Core strength is critical for everyday activities such as placing heavy grocery bags into the trunk of your automobile, carrying a gallon jug of milk from the refrigerator to the dining room table, and even walking to the mailbox. When your core strength is diminished, even bending over to pick up a pencil may result in a serious spinal injury. Weakened core musculature causes simple, daily physical activities to be problematic. When standing up from a seated position or getting into a car causes you to experience twinges in your back, you may be sure your core muscles are not working in the manner for which they were designed.
Your core muscles consist of the four abdominal muscles – the transversus abdominis, internal obliques, external obliques, and rectus abdominis – and back muscles such as the erector spinae, longissimus thoracis, and multifidi. The most important core muscle may be the transversus abdominis, a sheet of horizontally oriented muscle that lies underneath the other abdominal muscles and provides deep mechanical support to the low back and pelvis. Similarly important are the multifidi, a group of small, powerful, deep spinal muscles that interconnect pairs and series of vertebras.
In times past, when the concept of work meant actual physical labor, there was no need to pay attention to training the core. In those days, your core muscles were being trained all day long by lifting, carrying, pushing, and pulling loads with heavy resistances and/or bending, digging, hoeing, planting, and raking. Working on a farm or in a factory provided more than sufficient exercise for the core. But in today's developed world, farming and manufacturing jobs have been greatly reduced and the large majority of work is done in the so-called service sector. In the 21st century, people living in developed nations spend the largest portion of their day sitting at a desk. In such circumstances the core musculature will weaken drastically, unless specific attention is paid to training these muscles.1,2
The good news is that a wide variety of exercises are available for training the core. Most of them require no equipment. Many of them may be done at home and do not even require a gym membership. For example, yoga provides thorough and complete exercise for core muscles. Self-motivated persons might only need a yoga DVD and a yoga mat, minimizing financial cost and doing their yoga training at home. For others, taking yoga classes at a gym or yoga center might be more appropriate. But yoga is only one possible solution. Numerous highly efficient core exercises may be done on a physioball. Dynamic exercises such as the plank provide substantial core benefit and the only equipment requirement is a mat. Other dynamic exercises include squats, gluteus bridge, lunges, jumping jacks, and the grapevine.
When you spend the time to make sure your core musculature is strong, daily physical activities begin to be done with ease and grace. Back pain and other mechanical aches and injuries fade into memory.3 The overall result is a body that works efficiently and optimally. Thus, a strong core helps provide for a lifetime of health and well-being.
1Kumar T, et al: Efficacy of core muscle strengthening exercise in chronic low back pain patients. J Back Musculoskel Rehabil 2014 Dec 2. [Epub ahead of print]
2Granacher U, et al: Effects of core instability strength training on trunk muscle strength, spinal mobility, dynamic balance and functional mobility in older adults. Gerontology 59(2):105-113, 2013
3Huxel Bliven KC, Anderson BE: Core stability training for injury prevention. Sports Health 5(6):514-522, 2013
Many adults begin to develop shoulder pain, even though they may not have sustained a specific injury. It's important to pay attention to such shoulder issues, as a healthy shoulder joint is the key to full function of the upper extremities. We all know at least one person whose ability to perform normal activities of daily living has been significantly compromised by chronic shoulder pain. Conservative treatment may be of benefit, but the key, as always, is to prevent these problems before they occur. The primary prophylactic intervention, as is the case for most musculoskeletal conditions, is exercise.
We all agree that the human body's design is magnificent. Every component has a purpose, down to the smallest cell. Every system is deeply interconnected with every other. Miraculously, the whole is much greater than the sum of the parts. And yet, there are a few "gotchas" built-in to this ingenious design. With respect to the shoulder, the "gotcha" relates to the shoulder joint's extraordinary mobility. The shoulder joint has the greatest range of motion of all the joints in your body. But this extreme mobility comes at a price, that is, the shoulder joint is not a particularly stable joint. For example, shoulder dislocations comprise approximately 50% of all such injuries.
Shoulder pain in the absence of a specific injury often represents damage to the rotator cuff. Again, the design of the shoulder joint and surrounding soft tissues is implicated in these rotator cuff problems. The blood supply to the bones, muscles, ligaments, and tendons of the shoulder is consistently compromised during normal motion of the shoulder above 90º, as in placing an object on or taking an object down from the top shelf in a kitchen cabinet. If much of your day is spent with your arm elevated above 90º to the front or to the side, over time you may develop nagging shoulder pain. Worse, with persistent repetitive motion above 90º, nagging shoulder pain may become chronic pain that restricts activities.
The best approach to shoulder problems is to become aware of the rotator cuff's well-known tendency to develop degenerative changes. We can be proactive by doing strength-training exercises for the shoulder and incorporating these exercises in our weekly exercise program as soon as possible.1,2 Beginning such exercises in the teenage years would be ideal. For those of us who are older, the right time to begin shoulder strength training is now. Shoulder exercises stimulate growth of new muscle fibers, increase the size of muscle fibers already in existence, and stimulate growth of nerve fibers bringing information to and from all shoulder girdle structures.
Shoulder exercises should be done once or twice a week as part of your overall fitness program. As with all exercise that's new to you, start slowly and gradually increase the level of difficulty over time.3 The result of all this activity is a dramatically improved blood supply to the shoulder region and a dramatically reduced tendency for rotator cuff degeneration and injury.
1Choi SH, Lee BH: Clinical Usefulness of Shoulder Stability Exercises for Middle-aged Women. J Phys Ther Sci 25(10):1243-1246, 2013
2Saltychev M, et al: Conservative treatment or surgery for shoulder impingement: systematic review and meta-analysis. Disabil Rehabil 37(1):1-8, 2015
Another example of a common issues
3Daenen L, et al: Exercise, not to exercise, or how to exercise in patients with chronic pain? Applying science to practice. Clin J Pain 31(2):108-114, 2015
Most of us have experienced a painful bout of low back pain brought on by a seemingly innocuous movement such as bending over to pick up a pencil or a dropped set of keys. These painful episodes may last a couple of days or be more severe and last more than a week. We're left wondering, "What exactly happened?" After all, we weren't trying to pick up a 100-pound crate. When our chiropractor asks what caused the problem we say, "I don't know. I didn't do anything." For the patient, the mystery often remains unsolved. But it's important to know there is an answer. The deep background to these unexpected, troublesome back problems is loss of viscoelasticity.
Viscoelasticity is a physical property of both materials and soft tissues. When these structures undergo deformation, they exhibit properties of viscosity and elasticity. Materials and soft tissues that demonstrate viscoelasticity resist shearing forces when a stress is applied (viscosity) and strain when stretched or compressed and quickly return to their initial state after removal of a transient load (elasticity). For viscoelastic structures, the relationship between strain and stress depends on the factor of time.
In terms of spinal biomechanics, viscoelastic structures include joint cartilage (for example, intervertebral discs), ligaments, and tendons.1 If a substantial load is placed on the low back when viscoelastic properties of intervertebral discs and spinal ligaments have not returned to optimum, injury to low back muscles and ligaments may result.2 For example, if you've been sitting for more than 15 minutes the soft tissue structures of your low back have been compressed for that length of time. Standing up and bending over to retrieve something causes your low back to attempt to support all the weight of your torso and head. If you haven't prepared your low back to receive this substantial burden, that is, restored viscoelasticity, you will likely suffer an injury that may be not only very painful but also inconvenient in terms of time and resources spent on recovery.
Injury prevention in these circumstances largely depends upon understanding.3 Being aware of the requirements for maintaining viscoelasticity will help you remember to "wake up" the soft tissues of your low back prior to any load-bearing activities such as bending over or twisting and turning. A simple way to restore viscoelasticity is to pause before suddenly changing a position you've been in for a while, such as getting out of a chair after working at your desk for 30 minutes, and gently rotating your torso from side to side eight or ten times. These rotational movements immediately restore viscoelastic properties to baseline and increase circulation to intervertebral discs, muscles, and ligaments. The result is a spine that is ready for action and prepared for the demands of new physical work. As always, proper preparation and attention help prevent injury.
1Troyer KL, Puttlitz CM: Nonlinear viscoelasticity plays an essential role in the functional behavior of spinal ligaments. J Biomech 45(4):684-691, 2012
2Freddolini M, et al: Stiffness properties of the trunk in people with low back pain. Hum Mov Sci 36:70-79, 2014
3Mörl F, Bradl I: Lumbar posture and muscular activity while sitting during office work. J Electromyogr Kinesiol 23(2):362-368, 2013
"There I am," a very fit patient is saying, "out on my five-mile run, motoring my way up a steep incline. Suddenly, I feel a throbbing pain in the middle of my right shin. Oh, no, I think, not again."
As things turned out, the patient recovered from the shin splints1 quickly, but he knew he'd dodged a bullet. "Why did I get hurt?" he wanted to know. "I wasn't doing anything wrong.…What can I do to make sure this doesn't happen again?"
All very good questions. One answer is - basically − we need a plan for exercise. A powerful strategy that helps us train smart and train safe. When you're working this way − training smart and safe − then you can also train hard.
Training safe and smart means paying attention to what's happening in your body as you do your workout. "Paying attention" is a learned skill. It requires focus and repetition. Visualization is an important part of focus ─ and, if you're working on visualization, you're definitely paying attention!
You can visualize when you're running, too.
• Visualize an erect, fluid spine and strong abdominal muscles.
• Your head is upright, you're looking forward and slightly down, and your chest is open.
• Your arms are active yet relaxed, and your shoulders sit comfortably on your rib cage.
• Visualize a long stride, a soft landing, and a strong pushoff, with your leg kicking straight behind you.
Training smart means trusting your instincts, rather than listening to your ego. This is a tough one. At the time, it seems so important to do that last rep. Now, you can do that last rep if you maintain your form. Form is everything. If you have to sacrifice form in order to do those last few reps, you may get an unexpected, unwelcome result.
Likewise in running. When your form breaks down, that's a signal to slow down and recover your good mechanics. If your training is done with attention to proper, effective form, you'll be more likely, when the time comes, to run a good race at a good pace.
And, of course, we want to do these things to be healthy and well. The American College of Sports Medicine2 states, "Resistance training, particularly when incorporated into a comprehensive fitness program, reduces the risk factors associated with coronary heart disease and non-insulin-dependent diabetes, prevents osteoporosis, promotes weight loss and maintenance, improves dynamic stability and preserves functional capacity, and fosters psychological well-being."
As in much of life, there's a fine line between training hard and overtraining. Remember, the benefit of training is for the long term.
1Couture CJ, Karlson KA: Tibial Stress Injuries: Decisive Diagnosis and Treatment of "Shin Splints". Physician and Sportsmedicine 36(6):29-36, 2002
2Kraemer WJ, et al: Progression Models in Resistance Training for Healthy Adults. Med Sci Sports Exercise 34(2):364-380, 2002
You're driving to work and stop for a red light. You're minding your own business and - bam! - your car rocks forward and backward, slammed in the rear by another car driven by some guy yakking on his cell phone. Or you're a passenger in a New York City taxi. The driver's cruising down Fifth Avenue when a teenager suddenly dashes into the intersection, running across the street against the light. The cabbie slams on the brakes and your head rocks forcefully backward and forward.
Or for reasons known only to yourself you decide it's a good idea to go bungee jumping. You dive into space, the cord extends, and finally the cord is fully played out. Significant physical forces blast through your body as you helplessly bounce back and forth, dangling in the air like a gaffed flying fish.
The result of each of these demonstrations of Isaac Newton's First Law of Motion? Later that day, or possibly within several days, you begin to experience neck pain. You might also have shoulder pain, headache, nausea, dizziness, and pain or numbness traveling down one or both arms. You have whiplash - a traumatic injury to the muscles, ligaments, and spinal joints of your neck and upper back.1,2
If you're lucky you'll get better in a few days. If the injuries are moderate or severe the various complaints will linger and may even get worse. As with any injury or illness, if you're not getting better right away you need to see your doctor. As you've suffered an injury to your head and neck, it may be a good idea to see your doctor as soon as you can, in any case, even if you think the injury is mild.
Your chiropractor is an excellent choice for examination and evaluation of injuries due to whiplash. She will be able to determine the nature and extent of the damage to muscle, ligament, and bone. Taking an x-ray series is a very important part of the evaluation of whiplash, as even seemingly modest forces can result in fracture of one or more vertebras in your neck. Evaluation of nerve function, including both spinal nerves and cranial nerves, is critically important. Pain and/or numbness radiating into one or both arms suggests injury to a cervical nerve root and needs to be thoroughly assessed.
If no fractures have been identified, chiropractic treatment can begin immediately. Over time, chiropractic treatment helps reduce inflammation of injured muscles and ligaments. Over time, chiropractic treatment helps restore normal ranges of motion to your neck and upper back. With this natural form of healing you begin to make incremental, steady progress, recovering the ability to participate in all your daily activities with reduced levels of pain and discomfort.
Chiropractic treatment provides optimal therapy for whiplash injuries, allowing your body to recover and return to normal by utilizing its own restorative powers.3
1Kasch H, et al: Clinical assessment of prognostic factors for long-term pain and handicap after whiplash injury: a 1-year prospective study. Eur J Neurol 15(11):1222-1230, 2008
2Chen HB, et al: Biomechanics of whiplash injury. Chin J Traumatol 12(5):305-314, 2009
3Michaleff ZA, et al: A randomised clinical trial of a comprehensive exercise program for chronic whiplash: trial protocol. BMC Musculoskeletal Disord 10:149, 2009 (12/2/09)
We all know someone who has suffered a serious driving-related injury that had nothing to do with being involved in a motor vehicle accident. For example, turning your head suddenly and swiftly for a last minute check of your "blind spot" before changing lanes on the interstate could result in a painful neck sprain. Getting out your car in a crowded shopping center parking lot can often be awkward and may even result in a low back injury. Bending over to lift a grocery bag out of your back seat or trunk can even cause a herniated lumbar disc with very painful consequences. Thus, driving can be dangerous, even without taking account of your innumerable fellow drivers who are talking on their cell phones, texting, combing their hair, putting on makeup, or even shaving when they should be 100% focused on the road. Even if you're a highly skilled, appropriately defensive driver, doing driving-related things can cause real physical injury.
Why do such injuries happen? The cause is the same as for the person who, while getting dressed in the morning, bends over to put on his or her socks, stockings, or tights and experiences a sudden, sharp pain in the low back. Later on, that pain may worsen and radiate down one leg, and a likely diagnosis of a herniated disc may ensue. "But I wasn't doing anything wrong," the person exclaims to his chiropractor. "All I was doing was putting on my socks." But the chiropractor knows that the movement that apparently caused the injury was merely the last physical insult in a long chain of musculoskeletal and biomechanical deficiencies.
As with the person who injures his or her neck or back at home while engaged in innocuous activities of daily living such as housecleaning or taking out the trash, driving-related injuries that are not the result of an actual accident are caused by being deconditioned or out-of-shape. If your neck and back muscles, ligaments, and joints are not used to doing physical work while engaged in a full range of motion, suddenly putting them in mechanically stressful situations will very likely lead to injury. For such persons, the primary missing fitness factor involves the core muscles, the body's group of central, deep, sheath-like muscles that provide the base for almost all movement and motion.
Lack of core fitness is the culprit for most neck and back injuries that happen when you "weren't doing anything". The good news is that core training is readily available. You are training your core muscles whenever you do strength training or yoga. You are doing core training when you walk, run, bike, or swim, provided you are doing these activities effectively and efficiently. You don't need special equipment. All that is required is the willingness and persistence to engage in regular vigorous exercise. The many benefits are broad and longlasting, including getting more enjoyment out of the time you spend in your car.
1Rietveld AB: Dancers' and musicians' injuries. Clin Rheumatol 32(4):425-434, 2013
2Micheo W, et al: Basic principles regarding strength, flexibility, and stability exercises. PM R 4(11):805-811, 2012
3Steele J, et al: A review of the specificity of exercises designed for conditioning the lumbar extensors. Br J Sports Med October 2013: doi: 10.1136/bjsports-2013-092197. [Epub ahead of print]
All of us who’ve experienced a back injury of one sort or another have been told at some point to “avoid heavy lifting.” That type of advice appears to be a no-brainer or at least redundant, as no one whose back is hurting is going to try to pick up an air conditioner or even a 100-foot reel of garden hose. In this context, it’s important to remember the words of Shakespeare’s Cassius: “The fault, dear Brutus, is not in our stars, but in ourselves”. The problem isn’t the heavy lifting, as such. The real problem is in us, that is, in our overall level of conditioning or physical fitness.
Most back injuries don’t occur as a result of heavy lifting, but rather are caused by a seemingly innocuous event such as bending over in the shower to retrieve a bar of soap that has fallen to the floor. Other likely pain-producing scenarios are bending over to place a bag of groceries in the trunk of a car bending over to tie a loose shoelace. None of these circumstances involved lifting extraordinary weight. Rather, the common elements are lack of flexibility and lack of appropriate muscle tone and strength to support the weight of your body in a forward flexed position.
The problem isn’t lack of big muscles. Picking up a bar of soap or positioning a 15-pound grocery bag doesn’t require bulging biceps or massive lats. The problem is lack of conditioning. Most of us no longer do actual physical work on a regular basis. We spend the large majority of our day sitting, either working, reading, or watching entertainment on television or other devices. The result of such lack of activity is twofold. Muscles lose strength and muscle fibers are replaced by fat. Additionally, tendons and ligaments contract and become tight, losing their necessary composition of elastic fibers. The functional loss associated with these physiological changes is profound. We experience these change every time we feel a twinge, or worse, in our backs.
The fix is easy and primarily focuses on building up core muscle strength.1,2 Core training is directed toward your deep abdominal muscles. The main such muscle is the transverses abdominis, which surrounds your entire waist, protecting and supporting your lower back. You can think of this critically important structure as your internal weight belt. Activation of the core muscles is required for all effective physical activity.3 Without this essential foundation, any minor attempt at work, even bending over to pick up a pencil, can lead to disaster in the form of excruciating back pain.
Core training includes exercises such as the scorpion, lying windmill with bent legs, pushups, squats, and the plank. Many good books and numerous online videos are available to provide instruction in the performance of core exercises. Your chiropractor is experienced in rehabilitative exercise and will help guide you to the training methods that are best for you.
1Inani SB, Selkar SP: Effect of core stabilization exercises versus conventional exercises on pain and functional status in patients with non-specific low back pain: a randomized clinical trial. J Back Musculoskel Rehabil 26(1):37-43, 2014
2Brumitt J, et al: Core stabilization exercise prescription, part 2: a systematic review of motor control and general (global) exercise rehabilitation approaches for patients with low back pain. Sports Health 5(6):510-3, 2013
3Wang XQ, et al: A meta-analysis of core stability exercise versus general exercise for chronic low back pain. PLoS One 2012;7(12):e52082. doi: 10.1371/journal.pone.0052082. Epub 2012 Dec 17
As we get older, rotator cuff injuries become more common, a result of the natural aging process. A similar mechanism operates in the discs separating the vertebras in your lower back. These cartilaginous structures lose water over time, becoming less flexible and more brittle as the decades roll by. In the case of the shoulder, the rotator cuff tendon is pulleyed to and fro as the arm swings forward and back and up and down. As the years pass, this constant motion may cause fraying in the rotator cuff tendon and inflammation in the muscles that comprise the rotator cuff. Eventually, partial or full thickness tears may develop in one or more of these musculotendinous units, causing pain and some loss of function. Importantly, conservative care may be all that’s needed to reduce pain and restore needed motion.
The shoulder joint is beautifully designed and a marvel of engineering. Its construction makes possible a full 360-degree arc of motion in both the sagittal and frontal planes. In other words, you can swing your arm in a complete circle from front-to-back and to-the-side-and-up-and-around. In the third, horizontal, plane, 180 degrees of motion is available. The overall combination of movements in three-dimensional space makes the shoulder joint the most freely movable joint in your body. However, as with all freedoms we enjoy in this life, there is a price. The shoulder joint’s great mobility is countered by its very limited stability.
The shoulder’s lack of stability needn’t concern us in our average day-to-day tasks. Protection to the joint is built-in by way of the rotator cuff muscles, which form a strong hood that envelops the intersection of the arm bone and shoulder blade. Falling on an outstretched arm may result in a dislocated shoulder, so we need to have some care in this regard.
If you’re a young athlete and have suffered a rotator cuff tear, surgery may be an appropriate option.1 But for the vast majority of people, especially for those over age 40, most rotator cuff injuries are chronic rather than acute and can be treated with rest and rehabilitative exercise. Again, if you’re a 60-year-old skier who has torn his or her rotator cuff in a downhill accident, surgery could be indicated. For the rest of us, rehabilitative exercise is the key.2,3
Four or five primary strength training exercises are involved in shoulder or rotator cuff rehabilitation. The three basic shoulder exercises are (1) seated overhead press, which trains all the shoulder girdle muscles simultaneously; (2) standing side [lateral] raise; and (3) seated or standing bent-over raise. The lateral raise specifically trains the middle deltoid muscle and the bent-over raise specifically trains the posterior deltoid muscle. Specific rotator cuff strength training exercises include internal rotation and external rotation on a flat bench using very light dumbbells. More painful injuries with greater loss of mobility may require (1) Codman pendulum exercises and (2) finger-walking (up a wall) to the front and to the side.
The goals of rotator cuff rehabilitation, as for any mechanical injury, include decreased inflammation, decreased pain, return to more full active range of motion, return to more full muscular strength, and restoration of function.
1 Plate JF, et al: Rotator cuff injuries in professional and recreational athletes. J Surg Orthop Adv 22(2):134-142, 2013
2 Escalmilla RF, et al: Optimal management of shoulder impingement syndrome. Open Access J Sports Med 5:13-24, 2014
3 McMahon PJ, et al: What Is the Prevalence of Senior-athlete Rotator Cuff Injuries and Are They Associated With Pain and Dysfunction? Clin Orthop Relat Res 2014 Mar 12. [Epub ahead of print]
The great TV classic ER helps teach armchair physicians to become amateur diagnosticians. He's in shock! She's got kidney stones! Rule-out pheochromocytoma!
But sometimes a little knowledge can be a dangerous thing.
You've learned somewhere - on the network news, in the Science section of The New York Times, or in a CPR class at your job - that shoulder pain can mean you're having a heart attack. Now, seemingly out of the blue, your shoulder begins to ache and throb. Very concerned, you rush to the local emergency room.
The resident's first question, of course, is "where does it hurt"? You point to your right shoulder and blurt out, "Am I having a heart attack?" The resident smiles, gently reassuring. "A heart attack might give you pain in your left shoulder," she says. "Have you been to the gym lately? This might be a rotator cuff strain."
The resident knows that heart attack symptoms usually involve chest pain (in two-thirds of cases), and may include faintness, shortness of breath, sweating, and a feeling of impending doom.1 Chest pain may spread to the back, jaw, and arms. Left arm pain may radiate to the inside of the forearm and the ring and little fingers. So, shoulder pain by itself probably doesn't suggest a heart attack.
She orders an MRI which shows mild damage to the right rotator cuff. What's going on? What exactly is the rotator cuff?
The rotator cuff is a muscular sheath that surrounds the head of the arm bone (the humerus) and the entire shoulder joint (really, two joints - the acromioclavicular and glenohumeral joints). The four muscles that comprise the rotator cuff help raise the arm to the front and the side and help turn the shoulder inward and outward.
If you're a sports fan, you know that rotator cuff injuries affect baseball pitchers, tennis players, swimmers, and football players. Such injuries are due to repetitive motion, and may also result from falling on the shoulder or arm or lifting heavy weights.
Rotator cuff injuries may also be slowly developing and chronic, related to arthritic and degenerative changes in the rotator cuff tendon and the two shoulder joints. Low-grade pain may develop, and the pain may become aching, throbbing, and chronic. Raising the arm may cause pain, and there may be loss of mobility.2
In the above-40 population, lack of exercise and chronically poor posture may contribute to rotator cuff problems. Sitting at a desk all day, with the neck jutting forward and slumped shoulders, places long-term mechanical stress on the rotator cuff.
Chiropractic treatment may be very useful in helping to rehabilitate chronic rotator cuff injuries. The chiropractic physician is expert in evaluating postural problems and associated spinal conditions. By providing effective treatment, postural corrections, and rehabilitative exercise, chiropractors offer a comprehensive therapeutic program to reduce pain, improve shoulder mobility, and regain function.
1Source: Cedars-Sinai www.cedars-sinai.edu
2Baring T, et al: Management of rotator cuff disease. Best Pract Res Clin Rheumatol 21(2):279-294, 2007.
