The Name of the Game is Progress

We have reached a milestone in the Alcorn household...Amelie is officially 1! Her first year has been truly incredible, as Amelie seems to be doing something completely new (and amazing) each day. It seems like only yesterday she was a tiny, little peanut that could not lift her disproportionately large head, and now we have progressed to this...

She is already a little rebel and has rejected the world of crawling, despite my lectures to her on the importance of closed chain activities to improve strength and control of the shoulder girdle.

On the heels of Balance the Shoulder (please check out my last post for details), I decided to follow in Amelie’s scootsteps and provide my progressions to the 6 foundation exercises in my shoulder program. The idea behind the next phase of the program is to progress in a step-wise fashion from pulling and pushing in a horizontal plane to a more vertical plane. Yes, you heard me correctly, I said pulling and pushing. We live in a world filled with pushing movements and we need to ensure that our patients are proficient in these movements. The Balance the Shoulder routine harped on pulling as the foundation of the program, and this continues to be the case, but what are we without progress?

10,000 Foot View - Adding levels to the pyramid of shoulder function through progression of  horizontal planes of motion -> vertical planes of motion. There is a tendency to see a breakdown in movement control of the shoulder/scapula as we progress above shoulder height so these progressions attempt to minimize the faults through a deliberate advancement from horizontal to vertical movements.

Disclaimer - these movements are meant to give you a sampling of the progressions towards better vertical pulling and pushing. They are not meant to be comprehensive in nature. 

The Movements – Horizontal to Vertical Pulling

1. Bent over row - Horizontal Pull to get the ball rolling (see video from last post)

 2. High to low row - Pulling from a position above shoulder height 

3. Pull-down - Pulling from a fully overhead position

4. Straight Arm Pull-down - Pulling from a fully overhead position with a longer lever arm

Horizontal to Vertical Pushing

1. Floor Chest Press - Pushing in the horizontal plane with a limited range of extension past the body (Note - this can be progressed to bench press to allow for a larger range of motion)

2. Land Mine Press - Pressing slightly above shoulder height

3. Land Mine Press with Lean - Achieves a greater range of motion overhead

4. Overhead Press - Pressing to a fully overhead position

The Prescription: Here is an example exercise prescription using principles from the American College of Sports Medicine’s Guidelines for Exercise Prescription¹.

1a) 2-3 x 10 Pull-down 

1b) 2-3 x 8 Front raise

2a) 2-3 x 10 Overhead Press

2b) 2-3 x 8 Shoulder extension

3a) 2-3 x 10 Floor chest press

3b) 2-3 x 8 Bent over row

4a) 2-3 x 10 Land Mine Press
4b) 2-3 x 8 Side-lying External Rotation

The Real World Application: This new crop of exercises can be added when there is proficiency with the foundation program and the patient demonstrates mobility and control above shoulder height. Remember, the basics are sexy (which is why I sprinkle the foundation movements throughout the program)! 

Onward and upward to stable overhead positions!

Resource:

1. ACSM. Progression models in resistance training for healthy adults. MSSE. 41(3):687-708, 2009.

Balance the Shoulder

When it comes to curiosity, nothing fills my cup quite like a good nerd-out session on the shoulder. I try to casually throw it into conversations with my colleagues and blurt out random shoulder factoids to passersby on the street, much like Amelie does with her favorite word, “dada.”

Slight digression – Amelie’s first word was “dada.” Hooray me! Reality check - Amelie’s word for everything in her environment is “dada.” Insert Debbie Downer theme music now.

Okay, back to the point of today’s message. The months of April-July, 2018, are like a perpetual Christmas/Hanukah/insert favorite holiday here, because I get the privilege of talking about the shoulder to captive audiences! My good friend and codependent shoulder partner in crime, Dr. Mike Kecman, and I will be teaching the Jackson Clinics Upper Extremity Series, speaking at the INOVA Sports Medicine Symposium 2018, and teaching a lecture on the upper extremity athlete to George Washington University’s PT school. In the spirit of all things curiosity about the upper extremity, and building on the momentum of these courses, I wanted to give you all a glimpse at how I treat the shoulder (Caveat – adjustments are made based on a formal assessment. This is not intended to be formal medical advice. Caveat # 2 - The Jackson Clinics PTs offer Free Movement Screens and accepts most insurancesJ). On with the show!

This post will focus on the foundational movements to start you on a path of optimizing shoulder health. Coming in for an ankle sprain? Great, you get the balance the shoulder routine (in addition to your ankle specific exercises, of course)! This routine heavily focuses on pulling movements to counteract all of the pushing movements that people tend to gravitate towards in the gym. How many times have you asked someone about their gym routine and they rattle off 12 upper extremity movements that target pushing/front of the shoulder? Bench press, incline press, decline press, push-ups, shoulder press, curls. What happened to the pulls?!

Are the muscles on the backs of our torsos suffering from the old adage: out of sight, out of mind? We can’t see these glorious pulling/back muscles so we forget about them? With this post I attempt to end an epidemic – Paltry Pulling Disease.

The Movements – Balance the Shoulder: The beauty of these movements lies in their simplicity. Anyone can do them (see caveats above) and you can make them challenging for any patient/athlete with minor tweaks to the volume. The goal is to get them to realize that the basics are sexy!

1. Shoulder Extensions: Pulling movement that targets the back and bottom of the shoulder.

   

2. T’s: Pulling movement that targets the back of the shoulder

3. Y’s: Pulling movement that targets the back and bottom of the shoulder

4. Bent-Over Row (DB): Pulling movement that targets the back of the shoulder

5. Sidelying External Rotation: Pulling movement that targets the back of the shoulder

6. Front Raises (Shoulder Flexion): Targets the front and top of the shoulder

The Prescription: Let’s rely on some help from the American College of Sports Medicine (ACSM) in this arena. The ACSM is a paragon of strength training and they derived these recommendations based on a compilation of > 300 references on the subject1. No sense in reinventing the wheel. The basics are sexy!

1. 1-3 sets - 1 set for untrained populations, multiple sets for trained populations
2. 10 repetitions per set - maximizes increases in strength, endurance, power
3. Establish 10 repetition maximum for each movement and working weight should be 60-80% of this number - You can also use a rating of perceived exertion of 6-8 on a scale of 0-10. ²
4. Utilize superset format – alternate between two exercises. These should target dissimilar movement patterns to allow for a rest period between sets. For example:

1a) 2-3 x 10 barbell hip thrusters

1b) 2-3 x 10 bent over row

2a) 2-3 x 10 stationary lunges

2b) 2-3 x 10 shoulder extensions

5. Rest intervals 60 seconds³ – this is built into the superset format. You are resting the shoulder while you perform an exercise for the legs or a different movement pattern.
6. Frequency: 2-3 x week – If you are working at an intensity of 60-80% maximum for each exercise, you will need a day of recovery between working days.
7. Duration: minimum of 6 weeks – change the volume every 6 weeks. After 6 weeks, the body will need a new stimulus to continue to adapt. One example is to switch to sets of 8 repetitions with a focus on heavier weight after you have some proficiency with the movements.

The Real World Application: If you are new to strength training, these 6 exercises can be your starting point. They primarily focus on movements that reverse the dreaded slouched position we see in every office, metro, and even gym (I’m looking at you, Mr. “nose in my phone while I use the elliptical”).

If you are a savvy lifting veteran you use these 6 movements as an active rest for your foundational lifts, as described in the superset portion of the blog.

The Tie-Back to Previous Blog Post: In my inaugural blog post (Please read if you haven’t done so. Go ahead and scroll down to the bottom of the blog post page. It’s only 3 articles so it won’t take long and I will still be here when you get back, I promise), I discussed Gray Cook’s concept of the pyramid of removing weak links and the foundation of the pyramid being movement⁴.  The foundation of treating the injured/weak/underperforming shoulder is moving it into a stable position no matter the movement. The Balance the Shoulder routine creates stable positions in movements close to the body, reaching out away, reaching overhead, and reaching through rotation. Whatever your ailing movement, we’ve got an exercise for that!

Much more of this to come in future articles, but until then, let’s put the back in the forefront of our training priorities!

Resources:

1. ACSM. Progression models in resistance training for healthy adults. MSSE. 41(3):687-708, 2009.

2. Colado, JC, et al. Concurrent validation of the OMNI-resistance exercise scale of perceived exertion with theraband resistance bands. JSCR. 26:3018-3024, 2012.

3. Bunn J – Exercise Physiology in the PT Setting (2016) – The Jackson Clinics Residency Education

4. Cook, G. Athletic Body in Balance: Optimal Movement Skills and Conditioning for Performance. 2003.
5. Davies, G - A Master Clinician's Approach to Advanced Concepts in Examination and Treatment of the Shoulder Complex - 2016  *** Special Thanks to George Davies for the inspiration behind the Balance the Shoulder. His course was a truly inspiring course that I would recommend to anyone!

Running Away from Running

I have spent the better part of my lifetime involved in a rollercoaster of a relationship. With whom, you ask? She is a fickle mistress…running. Running is a polarizing term. To some (my father and my darling wife, Rebecca) it evokes the notion of the runner’s high, stress relief, a beloved pastime. To others (myself) it conjures up images of punishment laps in baseball practice, pounding the pavement, and too much time alone with one’s thoughts. My dad and my wife are two people whom I love dearly and I cherish the times I have had with both of them. A consequence of wanting to spend time with my dad and my wife has been that I too often find myself on the business end of a run that is well above my paygrade. The latest in this string of bad running decisions is a 10 mile trail race – The Fall Backyard Burn Running Series in Annandale, VA.

Why did I sign up for an activity that involves running? Well, the upsides are numerous: Spending time with my wife. Being outside. Trying new adventures (first trail race). The downside is the elephant in the room: it involves running.

The challenge: Can I complete this 10 mile trail race with Rebecca without having to run for my training?

This conundrum led me to book # 2: The One Minute Workout by Martin Gibala (a professor and chair of the kinesiology department at McMaster University who has devoted his career to researching the science of interval training).  This was an enjoyable read because it gave me hope that I could train for the trail race without actually running, and because it makes me think of 7 Minute Abs in “There’s Something about Mary.” The topic of High Intensity Interval Training (HIIT) has long been of interest to me. I have been an active participant in CrossFit (insert trademark symbol here), which incorporates these principles, had one of my students perform an in-service on interval training (shout out to Patrick Russo), and one of my favorite continuing education courses was “Exercise Physiology in the PT Setting,” in which I learned the science behind, among other things, interval training (shout out to The Jackson Clinics’ kick-ass continuing education).

10,000 foot view - What is interval training? Bursts of intense exercise separated by periods of recovery (can be either complete rest or lower-intensity exercise).

Why do interval training? The American College of Sports Medicine (ACSM) recommends 150 minutes per week of moderate intensity exercise to reduce the risk of cardiovascular disease or diabetes. Or you can do 75 minutes of vigorous exercise (HIIT), and this includes the rest time in your workout. You can reduce your risk for heart disease and diabetes with 10 minutes per day of exercise! Not only that, when compared to steady state cardio, HIIT provides similar changes in aerobic fitness (VO2 max), mitochondrial composition in the muscles (helps generate aerobic energy), and fat burning capacity during the workout (weight loss benefits). I am no math major, but deriving the same health and fitness benefits for a fraction of the time cost? Yes, please!

Why does interval training work? In two words - stress adaptation. In more words – you push your body out of its comfort zone, so it is forced to adapt. Gibala describes the following factors that contribute to the effectiveness of HIIT:

1. HIIT causes a dramatic shift in the rate of energy depletion in the body, when compared to steady state cardio.

2. Intensity and duration of the stressful stimulus impact the adaptation response.

3. Intensity of the stimulus is more important than the duration of the stimulus.

4. HIIT recruits more muscle fibers into the exercise – causes the muscle to use up available fuel sources faster. HIIT requires use of both fast and slow twitch muscle fibers, whereas endurance training primarily recruits only slow twitch muscle fibers.

My interval training program, as prescribed by Martin Gibala: 6 weeks - 3 x week - 4-6 sets of 30 second sprint on the AirDyne bike – 2.5 minutes rest in between sets.

The AirDyne Bike (AKA my Wedding Present to Rebecca, AKA our replacement for a living room chair, AKA the bane of Rebecca’s existence).

The result...

We did it!!

Until next time,

Running from running

Curiosity - The Antidote to Aging

Premise of the blog:

Curiosity – try to look at the world through Amelie’s perspective – specifically with regards to the shoulder, fitness/performance, professional development.

Focus on foundation - Principles over tactics

On July 13, 2017 I had the greatest honor of my life, becoming a father. My daughter, Amelie, has taught me countless things in our 6 + months together, but she continues to amaze me each day with her unbridled curiosity for everything in her world. This got me thinking, how could I be more like Amelie? How can I be more curious?

My wife and I try to read to Amelie every night before bed and this seems to spark Amelie’s curiosity. This gave me the bright idea – I can spark my own curiosity by reading everything I can get my hands on! I set a goal of reading 40 books this year and the spectrum is far reaching – biographies of American forefathers, behavioral psychology, fitness/performance, how to get your child to sleep, how to live on chronic sleep deprivation. Did I mention that Amelie doesn’t do much sleeping? I digress. My goal is to answer every burning question that I have in my head. Sure, I can GTS for a quick fix, but if I am truly channeling my Amelie curiosity I want to take a deeper dive into these subjects. Hence the topic for this blog – the curiosity addiction and how to feed it.

Book # 1 – I decided to start with Athletic Body in Balance by Gray Cook because it is a movement classic for healthcare and fitness professionals alike. Rather than give you a book report like my mom used to enforce each summer to complete my school reading list, I will word vomit my takeaways, the low hanging fruit, and pearls of wisdom that I took from this book.

10,000 foot view - how can we better balance the body, specifically with regards to efficiency and effectiveness? I have pilfered the definitions of efficiency and effectiveness from Gray Cook because they are simple, yet elegant. We tend to focus our efforts on effectiveness – yielding results. The ends justify the means. Why do the means get such a bad rep? Isn’t it the means (poor movement patterns done thousands of times in order to achieve the ends) that land people in PT in the first place? What about efficiency? Cook describes efficiency as action without wasted movement or unnecessary energy expenditure. Webster’s dictionary couldn’t have described that better! When someone has an overuse injury, they present with painful/dysfunctional movements that limit their energy expenditure.  If we can improve their efficiency of movement, we can solve the question of “why did the patient hire you?” My big take away from this book was: how can I maximize efficiency of movement to improve effectiveness of movement?

Pearls of wisdom –

1. Efficiency of movement can be improved by addressing (through assessment) and training the weaknesses in your movement patterns.

2. Pyramid of addressing weak links: Foundation of pyramid is movement -> next block is physical performance -> top of pyramid is skill.

3. Focus on the foundation (of the pyramid) – improve how the body moves.

4. Babies don’t need to compensate, because they do not lack mobility. They learn through trial and error and feel, and develop the stability through repetition of movement patterns. Learn through movement and focus on the foundation. Be like Amelie!

5. Deep squat starts with the toe touch – relaxes the lumbar spine (see video below) – babies first learn to squat from the ground up.

My weakness – I went through Cook’s Functional Movement Screen and tested out with the deep squat being my greatest weakness! This is Bad News Bears, considering I am trying to layer fitness and performance on top of a faulty movement pattern.

My curiosity – can I learn to squat with my daughter, Amelie?

To be performed every morning – 10-12 repetitions…

Time to practice what I preach – my patients have heard ad nauseam about a “brushing the teeth for the body” routine. Every morning, have a movement practice to undo this stiffness of sleeping. Every evening, have a movement practice to undo the stiffness of sitting behind a desk. The Japanese have been airing a radio broadcast of morning calisthenics since 1928 – time to bring that tradition to good ole’ USA! I will incorporate the deep squat progression, as taught by Gray Cook, into my morning movement practice and track my changes in the deep squat. Stay tuned!