Maximize your Gains by Working the Antagonists

Maximize your Gains by Working the Antagonists

We are all familiar with the saying “you’re only as strong as your weakest link”. Typically this phrase will be used with team sports, leadership, or work metaphors. However from a therapeutic standpoint were basically always trying to find “weak links” (or rather “restrictions” or “kinks in the hose”) that negatively affect movement efficiency as well as movement competency.  Often times, what we find as movement specialist are several weak links due to imbalances of position, tone, and muscle firing. Which often begs the questions from patients what led to all of this?  Which a novice to an experienced therapists answers “ repetitive movement in one direction and altered posture (or however we word it)”; or simply bad habits.

Let's hit on one really bad habit that is consistently occurring in patients pursuing athletic endeavors, the fact that they are not training/strengthening their antagonists and not taking their antagonistic muscles serious enough. Today I want to talk on the importance of training the antagonistic muscles in regards to muscle balances, function, motor control, and maximizing performance gains. Then we’ll focus on one important strategy to incorporate  antagonistic training. But wait, there’s more. We’ll finish up with a few training session examples for you to try and see the importance of training the antagonists!

First, let's define antagonist in regards to muscles; not a shakespearean play or movie script(...hope I didn’t lose any readers).
The antagonist is defined as the muscle “that opposes a specific muscle group of movement”. That may be not the best definition because it doesn’t get the magnitude and importance of the antagonists role.  Rather than just opposing, they also control (eccentrically) the movement.

Controlling the movement ensures:
  1. Adequate joint alignment and position
  2. Limits higher unnecessary forces and torque.
  3. Which means it's preventing stress and strain on soft tissue
  4. Which means it's preventing injuries
  5. Which means you can continue to workout.
  6. As well as controlling rhythm and smooth interactions with other joints up and down the chain
  7. which means you are more durable and can last longer (in bed)
  8. As well as have Higher strength production
  9. Which means you perform better.
  10. Which means you're awesome
So here's the actual point we need to make on the antagonist: “you’re only as strong as your weakest link”. And we don't want the antagonists which are so crucial for correct mechanics and stability to be our weak link. Unfortunately, the antagonists are indeed the weak link and that weakness is leading to some serious breakdown and injury. Let me break it down:

Having agonist and antagonist strength is fundamental to fitness and performance.  It's the base of the pyramid. You can't build performance of fitness without it.

But we often try to build that strength without the other half of the base.  This leads to total collapse!The pyramid will collapse without a foundation of some strength and control form the antagonists.  Even a small amount of antagonists strength can lead to imbalances and a faulty foundation that will still lead to the pyramid to tilting over and collapsing on itself.

Further, performance and skill can only reach to a certain size with a small base. Want more strength and corresponding performance, make for a larger base to ensure ability to build up higher work capacity and then skill:

There you have it. An easy white board drawing to convey the importance of muscle balance specifically with the antagonist muscles.

PART 2: Therapeutic Strategies to Improve Muscle Antagonist Strength

If we are lucky (and that's a big if) this is what I get from most for my athletes: “ Oh yeah I make sure to do 5-10 minutes of foam rolling and/or stretching before I start the WOD”. They take their antagonist strength training about as serious as I take anything happening with the Kardashians, which is zero to NONE. While an active warm up is very important the fact is mobility drills and the likes are not doing anything to build antagonistic strength and a solid foundation, actually they are just trying to stop the pyramid from crumbling!  Trying to do a small amount preventive work before and after the WOD typically isn't enough...
Therefore, antagonist strength programming should be programmed within ( ! gasp !) the WOD, not before or after.

Ill let you catch your breath for a sec, because I know what you’re thinking “But bro are you saying I should do Fran with Y+Ls and hamstring hells???, that's gonna kill my time?!?”

First off, bro, great antagonist exercise choices. Second off NO; Fran and other Benchmarks are to assess our skill and performance development, ie are we sure that the top of the pyramid is getting bigger. But a majority of WOD should not be benchmarks but rather strength and work capacity aquatistion. I would suggest that 75 to 90% of WODs should have antagonists exercises built within them! This strategy ensures adequate time is spent on acquiring strength in the antagonists. It will also ensure the athlete is consistent with the exercises. And lastly it makes it more fun to complete when under fatigue, and ensures proper recruitment and stability for the other movements within the WOD. Plenty of good reasons to put it in and no reasons not to!

Here's a few examples that incorporate antagonist training:
  1. objective: Strength
6 Rounds 5x Deadlift, then immediately... 2x Broad Jumps, then 5-10x Y+L @ 2.5#

  1. objective: Work Capacity:
10,9,8,7,6,5,4,3,2,1 reps for time: Renegade Manmakers @25#/15#, Box Jumps @ 20’’, wall slides or wall squats (ps: awesome post to expand on this topic)

  1. objective: Stamina
KB Complex: start from ground arm with the arm locked and packed, ie the start of the TGU position. Go to half kneel of the TGU position and perform 10x 1/2 kneel windmills, then stand and perform 10x rotation and push press, followed by 10x single arm KB swings and finally 10x single leg deadlift, ensuring you feel it in the glutes and posterior chain. complete on other side. perform for 15-20 minutes.

Try these out and see how you’ll have more muscle soreness from the antagonists than the actual big muscle groups.

7 things your Doctor and Therapist want you to know about your back pain (that you probably don’t)

Back pain is so common that it affects 80% of Americans in their lifetime.  However, even with such a high prevalence, many continue to have inaccurate beliefs (“thought viruses”) about back pain and how to go about fixing it.  In fact, many things you try to help back pain or actually negatively affecting it.  On that note, here are a few simple pointers to fix your back pain and prevent recurrences!

Start doing something for it sooner than later
Often times we are told wait for the pain to go away. However, the sooner you start to see a medical professional the faster the results can be. Usually the prognosis is pretty high (85+%) for a full relief.  As a therapist who seems patients with direct access, back pain can typically get under control within 1-2 sessions! So seek a therapist out after 7-10 days of back pain.

Start taking an active approach
Utilizing treatments such as heat, ice and ultrasound, can bring improvement, but their effect are usually temporary.  Mounting evidence continues to prove that taking an active approach to your recovery, including exercise and postural correctives, lead to faster recoveries.

In contrast, prolonged bed rest is unhelpful, and is associated with higher levels of pain, disability, poorer recovery and longer absence from work and return to your fitness pursuits. In fact, it appears to have strong correlation between the length a person stays in bed because of back pain, and the severity and length of the pain.

Start lifting properly (but don't stop lifting!)
Poor lifting mechanics can put excessive load on the soft tissue structures.  Find a movement specialist who can retrain your mechanics to ensure adequate load on the back and begin the process of building confidence and durability for lifting.

While initiating lifting can be scary, getting back to your prior level of function and fitness is important. Many people, after an episode of back pain, begin to move differently due to a fear of pain or a belief that the activity is dangerous. These altered movement can be unhealthy in the long term and can actually alter muscle activation and coordination, leading to movement compensations and guarding and thus longer episodes of pain.

Start finding movements that are good for you
While bending forward may have initiated the back pain, don’t assume other movement will be harmful. Often times the back has a “directional preference” after a back incident that helps calm the muscles and soft tissue down and allows for rapid pain relief. Additionally, movement is key to acute tissue healing as this inhibits guarding mechanics and gives feedback to the body that other painful movements can follow suit.  Movement regains strength, increases circulation and healing, and restores confidence in your back.  Physical Therapists specializing in movement can find the best movements to calm your back down.

Start exercising
Similar to moving, the return to a gradual exercise program will be helpful for back relief.  Although potentially scary at first, exercise reduces back pain. Find a therapist that can help you with this process and pick the right exercises, intensity, and progression for you.

Start finding a better work set up (fix your workstation)
Often times people want to fix the back pain without fixing the common cause of the pain: poor and/or sustained sitting postures.  Adding positives won't always work if we don't eliminate the negatives! Apply simple strategies, like limit sitting to 30 minute periods when at work, (as well as other helpful tips) to eliminate back pain all together.

STOP caring about the Diagnosis and Imaging
This one might be the most important of them all. 85% of back pain is “nonspecific” and can be fixed with the above corrections. “Nonspecific” also meaning it's not a single abnormal entity at the root of your pain.  Don't get caught up in “L5 herniations” or “stenosis”.  You are more than a static xray or MRI that has no real connection to your pain. Your pain is mechanical, meaning it's influenced by movement. Don't let a test that doesn't assess movement tell you what's wrong with you!

Imaging of your back often show things that are poorly correlated and have NO connection to your pain. In fact, studies have shown that even people who don't have back pain they still present with things like bulging discs (52%), degenerated discs (90%), herniated discs (28%) and 'arthritic' changes visible (38%).
Remember, these people do NOT have pain! Unfortunately, people with back pain are often told that these things indicate their back is damaged, and this can lead to further fear, distress and avoidance of activity. The fact is that many of these things reported on scans are more like wrinkles - an indication of normal aging and not an actual sign of pain generators.

The main benefit that a skilled therapist provides is the ability to test and re-test your symptoms following an intervention.  Our interventions are very efficient at alleviating pain but they do not magically abolish or fix a degenerated disc.  However when movement and pain improves one can rest assure that the degenerative changes were not the cause of the pain the whole time!  

A Comprehensive Guide on Training Proper Shoulder Mechanics

Teaching someone to move their shoulder with authentic and ideal movement can be a rollercoaster ride at times; sometimes it’s the most powerful reset and other times the most frustrating event of your day.  That’s because the shoulder in many ways can be the most complicated joint on the body because its very large freedom of motion.  When a joint has abundant motion like the shoulder, then it can be easy for the stability and support to be compromised.  Therefore, often times  we need to get the pendulum back to neutral by findings ways to build motor control and stability.

What’s most often involved with building motor control is the concept of a “packed” shoulder (i.e. engaging the rotator cuff and scapular stabilizers to ensure proper humeral head position on the glenoid of the scapula during any shoulder movement pattern).  

There are several techniques that can properly cue the shoulder to be “packed”, and help regain needed stability.  Here are a few techniques that may work well for you and your patients:

what a finely packed shoulder you have...
  1. Isolate the scapula then integrate with the humerus.   
It may be beneficial to isolate the scapula to improve the proprioceptive awareness, proper kinematics, and muscle recruitment needed for overhead motions.  The scapula is the driver for proper scapulohumeral rhythm.  Or another way to point it, proximal facilitation provides distal control.  What I have found to be a very effective technique is side lying PNF diagonals on the scapula. (PNF D1 replication or combination of isotonics[google it])
    1. Ensure proper body position and let your hips move the scapula.  You need to be “dancing” with the scapula.  Therefore be in the same line of the movement.
    2. Tactile cueing the inferior angle and infraspinatus gives the best kinesthetic feedback for the posterior depression (what the scapula usually needs more of to lock in the humerus). Try not to be too “handsy” and give conflicting proprioceptive information.
    3. “90% down, 10% back”. Stay close to 1 (or 11) oclock. Not 2-3 oclock. This is the biggest mistake most of my interns will make
    4. Once the patient gets a good idea of scapular motion then start moving lifting the arm into different angles (45, 90, 110, etc).  Watch and palpate the acromion. You and the patient should see and feel the humerus “drop” and gap right down. That ensures that the rotator cuff inferiorly glided the humeral head down (like a boss)
    5. Don't let the arm compensate by shurging, or elbow bending (long head biceps compensating) for the rotator cuff.  Even when the humeral head drops the wrist shouldn't!

  1. Use Analogies.  
Patients need to understand why we are working to pack the shoulder.  Otherwise, they will not be reinforcing and applying it outside of the clinic. For a patient to understand Sharmann's concept of PICR, or simply the correct force couple and ideal alignment of the shoulder on the shoulder blade should be broken into more simple ideas.

Two simple analogies are the golf ball on the tee (with this analogy they can understand the lack of structural stability that the small scapular glenoid provides for the large humeral head and the importance of the humeral head to be in the proper position so it doesn’t “roll off”).
Another useful analogy is the seal balancing the ball on its nose (here you can educate on the importance of dynamic stability that the rotator cuff provides when the ball moves).

  1. Start static but don’t forget to move dynamic
Lets face it, most of our patients aren’t performing for cirque du soleil so they may not have the best motor control in the world. Therefore, its probably best to start somewhere simple, with a unloaded and static technique.  
Begin with the patient in supine with your fingers and palm flat in a cupped position having your hypothenars contacting near the inferior angle of the scapula.  With the other arm begin to perform perturbations and rhythmic stabilization then progress to pulling on the arm with the cue “do not let me unpack your shoulder, even if I pull you off the table”.  Progress the intensity by pulling harder or letting them not know when you are pulling so they react quickly (this would be considered RNT).

  1. Teach packing on a 0-100 scale (and progress static to dynamic!)
Similar to slouch over correct technique, we may teach the shoulder being packed from very poor 0 position (superiorly shrugged, anterior tilted, and forward shoulders) and  to a perfect 100 position (chest open, post scap chain engaged, humeral head posterior and inferior).  It’s important for the patient to understand the shoulder doesn’t need to be a perfect 100 with all movements and in fact this may be a little overkill, but a 90ish is ideal and >50 will suffice. However anything 50 and below is clearly too inefficient and not preferred.   

A good exercise for this is the tennis ball drop-catch
Have the patient work in different planes of motions and diagonals, ensuring a packed shoulder with the movement . I love doing this in quadruped! Progress them from static packed to staying packed with movement.  If they drop below 50, they are awarded no points and may God have mercy on their soul.

  1. Incorporate open chain and “closed chain” exercises
Llearn how to move the arm around a fixed core (wall slides) as well as learning to move the body around a fixed arm (roll bar, Turkish Get Up)

  1. Put in a position that will easily engage packing
This can be accomplished by having the patient maximally rotate or “ twist and look over your shoulders”. This puts the shoulder in a great starting position and engages the posterior shoulder chain. It s a nice cheat and super simple to let the patient feel a properly packed position (say that 5 times fast!).

This is way longer than I wanted (take it from someone who is ADD). If you made it this far, consider yourself to be a scap packing ninja (with 6 ninja stars).  Oh, I never get a lot of comments, so let me know if some of this works, if you agree/disagree, or if you have other strategies that work well/better. Thanks!

Help me, Help you!

It has been refreshing over the past few years to see more emphasis placed on patient guided care in the physical therapy realm and even more refreshing to be more patient focused since the doors to Direct Performance opened last month in Virginia Beach. This desire for physical therapists’ to provide patient centered goals and care has been a recent hot topic as insurance standards continue to change. Our desire to become patient focused is one of the major reason we transitioned to private practice.
So here are Direct Performance’s Top 5 ways to stay Patient Focused:

  1. Listen to the whole story: The initial evaluation is important for building rapport with your patients and to having a true picture of that patient's injury and functional limitations. We all need to do our best to not interrupt during the subjective portions of the evaluation as the patient’s already have all of the pieces of puzzle for us to make a diagnosis. We have to be the ones to put the pieces together by asking appropriate follow-up questions. Build trust with your patients by allowing them to tell their story to an active engaged listener.
  2. What do you want to get out of therapy? I always make a point to directly ask the patient why they are coming to PT. Not why the doctor sent them here. Not what their injury is. Not why their parents are bringing them to PT. But “What is the patient’s goal for coming to therapy today?” Do they want to run farther, reach behind their back to tuck in a shirt, squat deeper to pick up their 3 year-old, walk without pain, sit at work without pain, etc.
  3. Build a Baseline: During the objective portion of your exam, pre-test the movement that the patient is struggling and help them record symptoms/issues so a baseline can be set for how well they move and how they feel during the movement.
  4. Post-test the Baseline: After you have delivered novel input in the system with manual techniques, stretching, modalities, corrective exercise or other techniques, you need to have the patient retest their squat, re-check internal rotation scratch test. Without the pre and post test you miss an opportunity to show the patient why they are coming to see you and how your treatment helps improve their functional deficit.
  5. Build PT goals around your Patient’s goals: Strive to make your goals focused around what the patient needs/wants to do better so that your treatment progression remains focused on why the patient is coming to you for help. Staying focused on the patient's goals with this format will in turn improve and heal the pathoanatomical issues that are at the root of their functional deficit.

Free Movement and Performance Seminar Tues, July 28th, at 5:30pm at Valiant CrossFit

Come Join us Tues, July 28th, at 5:30pm at Valiant CrossFit to learn mobility drills and corrective exercises that will:

Improve your performance & durability
Prevent risk of injury and pain
Establish more effective movement patterns

Fix poor mechanics that limit strength and conditioning
Identify and fix poor movement patterns
Receive individualized mobility drills 

    Correct muscle imbalances and compensations

    Hope to see you all out on this Tuesday Night!

    and Improve your overall Crossfit and Performance Pursuits!!!

    A Better Way to Treat

    I recently finished listening to a Freakonomics podcast titled 'A Better way to Eat' that interviewed Takeru Kobayashi, the Micheal Jordan of competitive eating. In it, they praised 'Kobi' on redefining the problem of competitive eating from "how do I eat more hot dogs" to "how can I eat one hot dog more effectively".  That simple tactic made Kobi one of the most successful competitive eaters ever and allowed him to shatter records (When he first competed in the Nathan's Hot Dog eating contest the record was 25. Kobi ate 50, doubling the world record!)

    A simple problem worth redefining in the physical therapy (and healthcare!) realm is instead of asking " how can we be more proficient or productive" or " how do we get patients better" maybe we should be asking it slightly different: "how can I treat one patient more effectively".  That simple alteration can be pretty impactful.  So now that I have changed the question slightly, here are my first thoughts:

    1. Its not (just) about your new, fancy technique or assessment. It's about how they respond to it.

    I'm sure you were just taught a new fancy technique that allows you to reposition the sphenoid or realign a counternutated sacrum.  And even the best, most researched techniques and assessments will be limited without testing than, retesting, another retest, and then one more retest to ensure stickiness (ie effectiveness). When patients see and feel the improvement that's gonna carryover to their confidence with any limitations they are working through.  The more consistent your retest, the better your patient's confidence will be afterwards.  And to build even more confidence make your retest as functional as possible. For example, retesting Shoulder PROM is good but retesting how you can now be more effective with a pull up will be better.
    Because whatever technique, all we are hoping to do is reset the nervous or muscular system and give a new input to the brain and muscles to move more effective with the patient's chief complaint. Sometimes you need to work up to a more functional retest.  For example, when you can perform a toe touch (my first retest) without any limits or points of restrictions then we can start training (and retesting) your deadlift. Regardless retesting should be a consistent aspect of care.
    2. Time

    Spending more time with patients has shown to improve outcomes.  I should stop there (but I'm not)  Spending time with patients allow you to be more emphatic. It allows you to fully assess and treat.  It allows the patient to be more interactive in their care and take more ownership of their condition. It allows additional time for education and reinforcement: If I can effect more of the patients choices outside of the 45-60 minutes I am with them, then the better we can fix postural of movement compensations causing the source of their complaint.  Increasing time with patients also decreases no show rates. Spending Time allows you to calm their concerns and better educate on what their condition is (and more importantly, what their condition is NOT). Oh, it also improves patient (and practitioner) satisfaction.  Boom.

    I am sure there's a lot more, but these are just the first two that pop up to me. How would you answer the question "how can I treat one patient more effectively"? And then go apply it.

    At direct performance, we are passionate about patient focused, highly effective care of our patients.  I hope you can come check us out.