Over the past two months I have developed an adaptation strategy to ease this transistion into less supportive (and perhaps no) shoes and I have noticed some interesting outcomes. Before discussing this I will go through my program. I have divided it into phases of no-set timeline as I believe this is more specific to the individual than say- 3 weeks of this, then progress to three weeks of this etc etc.

The typical, highly-structured and regimented model, in its specificity, becomes specific to no-one. Dictating the length of the phase-time dependent on the individuals experience makes the program look more vague on paper but I believe lends itself to much more specificity to the individual. I hope that makes sense!

One more proviso- the program assumes that our normal lower body assessments and foundational progressions have been followed and can be completed well (leg loads, prone hip extension, hip-abduction, hitches, single-legged deadlifts etc, right up to a quality single legged squat, lunge and step up).

Anyway, the program.

Phase one: Barefoot ankle mobility drills, barefoot gym training (normal s&c training) and barefoot walking around the streets and paths. When the foot is feeling mobile (self-assessment and mobility drill ‘feel’) progress to phase 2.

Phase two: Continue phase one as part of a warm-up then add in squats with the heels off a box (forefoot loaded), barefoot skipping to help with proprioception as well as building endurance and resilience in the calves. I have been doing my skipping to pre-fatigue (just to when I feel them tightening) and keeping track of how long that takes. I have also been doing this only when I have recovered from the previous session. In the first week I needed at least two days between sessions but within three weeks I could train everyday and was able to skip for much longer before fatiguing. This will vary from person to person.

Also during this time I have been self-massaging, foam-rolling and stretching  my calves.

Phase 3: Continue with phases one and two, but now add in split squats with the front heel off a box and progressing this to a reverse lunge. I have also started single-legged skipping and some barefoot running out on the streets following the same principles of phase two. This is where I am currently.

Now for the interesting observation/s. Firstly, my gait has changed from a heel strike to forefoot strike (fifth metatarsal) without any cognitive effort, this has happened whilst wearing my neutral running shoes. Running this way just feels more natural for me now. Second, my hip flexors have not been pulling up tight after a run which is remarkable. I used to always pull up sore and tight through my hip flexors (ablog about the possible reasons for this will appear soon). Third, I have gotten rid of my orthotics completely when running, and that ‘jamming’ feeling in my subtalar joint is completely gone. I have trialled weening myself off of my orthotics by wearing them at work 3 times per week, then two, but I am finding that whenever I wear them, my foot feels jammed up again. So I have gone cold turkey and feel great for it (another blog about this will not be far away!).

So I will continue to develop my program and trial it on myself. But first, a couple of things you must remember if a program such as this is of interest to you:

• I have trialled this program on myself, not a client. I will not be implementing this program with any of my clients until I am convinced of my own adaptation and have taken some colleagues and friends through it successfully as well.
• I have made the call on my orthotics because they are MINE, and I have also made this decision in consultation with my Podiatrist. I do not make decisions or even suggestions about my client’s orthotics as this is not my job or area of expertise. I ALWAYS consult with my client’s podiatrist.

UniSA City East Campus, Playford Building

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Pre-exercise screening creates a foundation for safe, effective and client focused training.

Considering the increasing health needs of the population, and the opportunity for these needs to be addressed in fitness settings, being able to identify the level of cardiovascular and metabolic risk of new clients will ensure that exercise programming can appropriately match those needs, as well as facilitate well educated referrals to medical and allied health practitioners.

A brand new Screening tool has been developed that can be specifically used by the fitness industry, by a collaboration between Fitness Australia (FA),  Exercise and Sports Science Australia (ESSA), and Sports Medicine Australia (SMA).

This is the first workshop of its kind in Australia to train and equip you to use this screening tool. At the workshop you will learn:

1. The process taken to develop the screen to ensure its specificity to the Australian Fitness Industry
2. The extensive background to each of the questions to ensure you understand their implications
3. How to conduct each of the measurements and tests included in the tool
4. how to apply the results obtained based on various case studies.
5. How to refer when appropriate – to the right practitioner, and in the most effective way.

The workshop will be headed by Professor Kevin Norton, who was the chair of the development group of the tool. He will be supported by a number of Exercise Physiologists, including Nicole Lewis and Belinda Norton (from the University of South Australia), Dr Nathan Harten (iNform Health and Fitness Solutions) and Max Martin (Corrective Exercise Australia).

To ensure the broadest access to this workshop possible, the it will be worth 6 CECs, and the registration cost has been kept to a minimum due a subsidy by Fitness Australia.

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When: Thursday 21st July

Time: 9am (registrations) for 9:30 start – 4pm

Where: University of South Australia – City East Campus. Playford Building – Level 6, Room  P6-19

Catering: mid morning and afternoon tea provided.  Can bring lunch or purchase from near-by cafes (Uni Cafe + Rundle Street, etc)

CECs: 6

Cost: $45

Allow time to find carpark and room!

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Suddenly our ideal ’corrective’ exercises are suddenly not only useless, they may be reinforcing dysfunctional patterns already present! 

Let me give you two pieces of information that may ease your frazzled mind.

1) As an Exercise Professional, it is not your job to diagnose. In fact, as a Personal Trainer or Exercise Physiologist diagnosis exists outside of your scope of practice.

2) Regardless, diagnosis of the specific injury is superfluous to what you actually need to do for effective shoulder rehab.

For a shoulder to be happy, healthy and functioning beautifully you really only need to tick three boxes.

They are: Good resting postural alignment; correct stabilisation of the scapula on the thorax throughout movement ranges; and adequate scapulohumeral rhythm. Trust me, if you can be excellent in prescribing (and ensuring excellent execution of) exercises to address these three things you can rehabilitate almost any chronic or acute shoulder complaint and you do not need an accurate diagnosis to get started.

The question I get often get asked at this stage is ofcourse ‘so what exercises do I do to fix what I see?’ First of all you need to fully understand what it is you see and how that compares to an ‘ideal’. An analogy that Max uses, that I’ll steal is that investigators into counterfeit currency spend their careers becoming faultless experts in ‘real’ currency so that they can pick faults in counterfeit notes. We must be experts in anatomy if we are going to great assessors.

From here we can move onto corrective exercises.

Remember those boxes we needed to tick? Posture, Stability and Mobility. We could address those with; Prone Thoracic Extensions; Four-Point Single Arm Lifts; and Overhead Dumbell Presses. Easy.

But what if, for those respective exercises we allowed our client to; Hinge the spine from the L2-L3 level whilst keeping the thoracic level rigid during thoracic extensions; wing their scapulas during four-point; and drive overhead pressing via coupling the levator scapula and upper trapezius resulting in a hitch with restricted upward scapula rotation?

Suddenly our ideal ’corrective’ exercises are not only useless, they may be reinforcing dysfunctional patterns already present! 

Those exercises are invaluable, only if performed well. So we need to be excellent assessors and excellent at prescribing exercise appropriate to your assessments. But didn’t I say shoulder rehab is easy? It is if you are equipped with a small number of very simple assessments and exercises.

The anecdotal evidence from runners who claim to have cured themselves of chronic foot, ankle, lower leg, knee injuries from ditching their shoes is intriguing, but not conclusive.

There is a complete lack of evidence corroborating shoe manufacturers claims that more support and guidance under our feet will reduce injuries and improve performance. Actually wait- I don’t remember those claims being made by shoe companies at all. They often claim their new model is the lightest, or most advanced. But they don’t make claims more specific than that. So where does that message come from? That’s another blog, I have digressed.

The lack of scientific support to, um, support the use of, supportive (sorry) shoes is compelling in itself. The anecdotal evidence from runners who claim to have cured themselves of chronic foot, ankle, lower leg, knee, hip and back injuries from ditching their shoes is intriguing, but not conclusive. So I have decided to do the only thing I could. Conduct my own scientific study!

As with all scientific studies, its flaws must be communicated openly. There are a few. My sample size consists of one, me. There is no control group. There are no blind data gatherers, I am also the data gatherer. So I may not get published in Nature just yet, but its a start.

So the subject: 29y.o. very amateur runner, currently running about 40km per week with an aspiration of completing a 50km run in 15 weeks or so. No significant injuries, but does experience ‘jamming’ of the left talus when running in supportive shoes with orthotics.

My first test was comparing foot strike on a treadmill at 14kph in shoes and barefoot using the time honoured method of ‘listening’, a method preferred by horse trainers the world over.

The sound difference was immense. My heel strike gait in shoes made the sound it always made, barefoot was unbearabley loud and sharp, and quite distressing for other gym users at the time. As you can probably guess, my heel was still striking. Contrary to the theory, I did not automatically adjust my gait to ’protect’ my foot, I just ran the way I always had, or at least had since I started wearing shoes.

I was however, able to cognitively change my gait- softening the noise by pointing my foot more downward on foot strike and effectively foot-striking somewhere around the distal section of metatarsals 3-5. As I did this something encouraging happened.

I started to accelerate into the front guard rail of the treadmill. I was speeding up, and it was happening effortlessly. This alone warrants further inspection.

This did not all happen without consequence however. The following few days I experienced DOMS in my calves of biblical proportions. I had also almost ground the skin under my 3rd to 5th metatarsals almost away to the bone. That is not a surprise, that skin was probably as delicate as tissue paper due to the labour-less life it had led up until this point.

So switching to barefoot isn’t, its seems, a magic bullet. At least not for the participant of my study. But it is an intriguing concept, founded in compelling logic. I am now developing an shoe-barefoot adaptation strategy, that I will elucidate in future editions.

After viewing the evidence, and much discussion about practical delivery of this information, a consensus was reached that the material delivered to Cert 3 and 4 students would need to change to  take into account the large body of evidence pointing to crunches and sit-ups as exercises that fail the risk-to-benefit test.

We discussed practical, useful, and functional ways to challenge the core/abs, and even to achieve that desired six-pack!!

I’m very excited, and feel privileged to have been able to be a part of such a meeting, and to be able to facilitate the technical discussions that were had. I think this is a huge step forward for our Industry. I also really appreciate the open and flexible attitude of the TAFE lecturers who are obviously very interested in providing the best possible information to their students!

The brief back ground of this client is as follows:

• Woman, early fifties, 20+kg overweight, has recently torn her left tibialis posterior tendon (overuse, with flat feet and excess wieght being causative factors). She was also experiencing low back pain and SIJ pain due to compensatory gait patterns. She hopes to reduce her foot pain sufficiently within 2 months as she is travelling to Europe for 6weeks with her family.

She decided to continue see me and her Podiatrist, and upon the Pod’s advice, saw an Orthopaedic Surgeon who has a typically conservative approach. The surgeon has advised staying off her feet as much as possible, losing some weight and wear the Podiatrist’s brace religiously. He has advised surgery if no improvement is seen.

 In response she has started a reduced calorie eating plan, hired an exercise bike and worn the brace day and night.

As a result she has already lost 3kg, her foot has improved dramatically and her back and SIJ’s are also feeling better. She has continued to train, and we have been able to do some pretty vigourous sessions with no risk to exacerbating her injuries. Due to the guidance of these two practitioners I have had the confidence to work her hard within safe boundaries.  

This, so far has been a great situation for everybody. What would her experience have been like if she had gone to the Osteo, and removed herself from this colaborative network? Who knows.

What I do know is that in the future, I would do nothing different, my client would do the same and she will have every confidence in the advice I give in the future.

I just wanted to point you towards a brilliant post by in-house nerd, Scott Wood, on how we deal with our pain.

This post is a great little insight into some of our typical reactions, and could apply to how we respond to so many areas of our life! Understanding that ‘pain’ is the way our brain interprets a multitude of factors is a key step to start dealing with each of those factors to change the way we feel and hence what we experience. Obviously this will give you some very useful tools to be able to coach your clients through their rehab process.

I definitely recommend a read of it! – it was posted in our iNform blog and facebook page, so click on the links to read it!

Enjoy!

Max

its easy to get a crush on sexy new information

We need to be aware that its easy to get a crush on sexy new information that may make a lot of sense when presented by a dynamic, convincing and well meaning educator (or two). The question I always ask myself is: would I be comfortable to introduce this sexy young thing to my friends (colleagues) and family (business and clients).

As we all know trends come and trends go. The pendulum of beliefs swings from one end to another. You know what I mean, don’t you? one day something is the MUST do thing, later to find out that it wasn’t so good after all, to then find out that… you get the picture. So its important to be able to discern those solid principles that guide good practice. On the other hand it is also necessary to be open to new approaches that arise out of our ever-growing understanding of this most amazing machine that is the human body.

So at Filex this year I witnessed the  pendulum swing right in front of my eyes, and I think its gone a bit far – as matter of fact it was accelerating rapidly last year. I’m referring to the ‘whole body movement – we are just fascial lines’ argument. Now, I risk putting a few people I respect off-side with this post if they read it, and if you know how we practice and what we teach, then you may be raising an eye-brow at the moment as well, So please let me explain:

The argument I refer to proposes that the best way to activate a muscle is to pre-stretch it, therefore the best way to ‘rehab’ a muscle that is ‘dysfunctiona’l is through exercises (movements) that put those muscles into a stretch. The proposition also states that focusing on the muscle in isolation contradicts the ‘rules’ of neuromuscular function. On face value this makes sense, as we know from PNF principles that we can create ‘reflex’ actions by the way we load muscles. We also know from plyometrics that if you stretch a muscle rapidly, a rapid contraction follows that is more powerful and efficient than if the pre-stretch hadn’t occurred.

Now, this is where I believe the weakness in the argument lies:

the context of the training application is important!

a reflexive loading of healthy and functional tissue for the sake of performance is different to re-establishing neuromuscular coordination and control.

Let me give you a practical example to illustrate my point: we know that a lot of clients present with a dysfunctional Glut Medius (which is functionally responsible for maintaining the pelvis level when standing on one leg – and for rotation of the hip). This typically results in what is called a trendelenburg posture, where the musculature on the one leg that is on the ground is unable to maintain the pelvis level, so the non-supported side  of the pelvis drops – imagine a model walking down the catwalk for an extreme example!

The new swing of the pendulum says that the glut medius should not be addressed specifically, or in ‘isolation’, to improve its function. Rather, exercises would be prescribed that place the individual standing on one leg, with the hip in internal rotation (to stretch the gluts) and the pelvis in a trendelenburg position (to stretch the glut medius) – refer to the exercise picture.

Now, while I’m certainly attracted to the sexiness of this exercise and the concept behind it, I ask myself one question (and I hope you follow my logic): if all it takes to activate a muscle is to pre-stretch it, then certainly the model with the swinging hips should theoretically have the best glut medius development around – considering that she stretches each one with every single step she takes!…right??!

I think you would agree with me that the answer to that question is a resounding NO!

And the reason behind this is that people in pain or injury behave differently.

That’s right, we know that ‘normal/healthy’ neuromuscular patterns are disturbed by injury and pain – and this argument was very well presented by Prof Hodges at the very beginning of the Filex conference. Its important that we listen to the whole message!

My approach agrees strongly with Hodges’s theme for that presentation: the answer depends on the context! and the skill of the exercise professional is to determine the right approach! no stress, hey??!

So, my approach? Scientific evidence and clinical practice have shown me, time and again, that the first step to re-establish function in a muscle/pattern is to address that muscle specifically and to recreate appropriate neuromuscular function to that muscle. THEN, we integrate that muscle into complex, integrated, functional movement patterns – like the sexy exercise in the picture above – performed, by the way, by our program developer Scott Wood – so yes, we do believe in exercises that encourage whole body movements, and that load along fascial lines! – just in the right context!!!

He does not like his clients seeing practitioners from other professions as it makes it hard for him to gauge how successful his part of the treatment has been. Are you serious buddy?

I was compelled to write this blog after a conversation with a client today. She has been training with me for some time and also receives podiatry care and physiotherapy to help with issues around her feet and back. She exists in the rare, almost mythical world of Allied Health.

In our session today she commented that her friend has recommended that she see her Osteopath, who her friend swears by. The catch however is that this Osteo does not like his clients seeing practitioners from other professions as it makes it hard for him to gauge how successful his part of the treatment has been. Are you serious buddy?

That philosophy works great if you are designing a scientific study to determine the efficacy of Osteopathic treatment, but what about the client’s needs? In his approach, the primary beneficiary of his treatment is him, not his client’s. If they happen to improve under his care, they both win. If not, he learns, she suffers. Go and be an academic if that is how you operate in my opinion.

This mentality is not confined to Osteopaths of course. You probably know of the Doctor that advises avoiding Chiropractors at all cost, the Chiro who says Physio is a waste of time, The Physio who wants to play the role of Physio, Chiro, Podiatrist, Exercise Professional, Massage Therapist and Psychologist but does all sub-optimally, the Podiatrist whose gaze never ventures upward of the knees, and the Exercise Professional who avoids referring out to these practitioners because of the perceived risk of losing their client. If you are one of the above styles of practitioners, the following are the only assumptions that I can reach to explain why it is you practice in isolation:

• You are ignorant of the skills that other health practitioners possess and how they can complement your own services.

• You are arrogant and believe that your dabbling in extra-curricular education is sufficient for you to be both excellent in your own profession, but also equally skilled as other practitioners are in theirs.

• You are paranoid that your own inadequacies will be exposed if your client starts seeing other practitioners.

• You are greedy and want every dollar that your client’s spend on their health to go into your bank account.

As you can tell, I feel pretty strongly about this.

I am fortunate that where I work, a strong alliance exists between ourselves as Exercise Physiologists and Personal Trainers; three or four chiropractic businesses; three podiatry centres; two physiotherapy practices; three or four massage therapists; and numerous GP’s and Sports Physicians. I am a bit sketchy on exact numbers as they are fortunately, growing steadily.

Many of the practitioners in this network know one another and each-other’s strengths quite well; obviously they share a philosophy of a multi-desciplinary approach to client management; and also have no financial obligations or connections of any sort to one another at all. We work together because we know it is the best thing for our clients. As far as I am aware, this alliance is unique at least in Australia (I would love to hear if it isn’t!).

And here is the irony. This approach builds tremendous trust and loyalty in our clientele and that is fantastic for business. There are two other major benefits of this approach.

• I have never experienced this model failing to deliver positive client outcomes and my colleagues and collaborators would, I am sure, agree with that.

• I have learnt a tremendous amount from the practitioners that I have been fortunate enough to work with over the years and I know I am a better Exercise Physiologist for knowing them and what they do.

I deliberately have not named the AHP businesses that I have referenced as I do not want this blog to act as a branding exercise. I want only to promote the concept rather than the individuals driving it.

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