I like mornings – our energy and brains are clear and the day spans before us, however, I have never been a “morning” person. Once up, there are the daily list of things to do and the race to leave the house. If I wake up late, I am rushed and frantic and settle down over time. Finally these past few weeks since returning from my yoga retreat I have changed my pattern, which has felt thrilling. My new ritual involves getting up a full hour earlier, making coffee, feeding the birds, spreading out my yoga props and doing 45 minutes of yoga before the house wakes up.
Sometimes I listen to NPR or sometimes in full silence. I can begin fast or spend 10 minutes lying on blocks. The best of all is when my partner wakes up with me, and we practice yoga perpendicular to each other alongside the kitchen table. He diligently looks through the books and though a beginner doesn’t pepper me with questions. I give him verbal cues infrequently and usually only when he looks like he might try to perform a regrettable feat. The household slowly wakes up and a positive mood has been established.
Here is a ten-minute version:
Lying on two yoga blocks; place one behind your upper back and the other underneath your head (the head one should be higher then the back one) and breathe into your chest area while rolling your shoulders towards the floor. Legs can be bent or straight.
Then stand up and place your hands on the kitchen counter and walk your feet backwards (hip width apart or wider if your hamstrings are tight) until your chest is parallel to the floor (or as close as possible) and breathe while you bend and straighten your knees. Try to reach your sitting bones back behind you as you feel the stretch in your chest area, back and the back of your legs.
Start your day!
The sciatic nerve innervates all muscles of the posterior thigh, leg and foot. It is as thick as a finger and is formed from the nerve roots that originate from the sacral plexus (groups of nerves) that emerge from the vertebrae between L4 and S3. It is actually two combined nerves, the tibeal nerve and common fibular nerve, which branch out in the lower thigh area and continue distally to innervate the lower leg. Sciatica often is a result of two causes: a herniated disc or piriformis syndrome.
A herniated disc can result in numbness with tingling radiating pain down the back of the leg.
Piriformis Syndrome is basically tight lateral rotators which can compress the nerve & cause pain.
The lateral rotators can be stretched with the following poses:
Uttanasana: standing forward bend with thighs parallel or internally rotated
½ Pigeon: with bent leg pelvis supported on blankets
Modified ½ pigeon with bent leg on table or low counter top
Marichyasana 3: Sit on support and twist towards bend leg
Ankle to knee: Sit on support with one leg straight or bend both legs (one or two ankles to knees)
Modified ankle to knee: sit in chair and place one ankle over other thigh. Bend forward from hips
Badha konasana: feet touching & close to groins
Tarasana: extend feet about 18-42 inches from pelvis, lean forward from hips
Please note that and an MD should be consulted if sciatica is suspected or pain persists.
Moore and Dalley (2006) Clinically Oriented Anatomy, 5th edition, Lippincott Williams & Wilkins, Baltimore, MD.
Lasater, Judith (2009). Yogabody: Anatomy, Kinesiology, and Asana. Rodmell Press, Berkeley, CA.
The deep layers of the gluteal muscles are also commonly referred to as “the rotators”. They are a dense strip of 5 muscles and are responsible for laterally rotating the thigh and helping to stabilize the femoral head in the acetabulum.
The piriformis is considered to be a landmark of the gluteal region and renowned because it is covers the sciatic nerve and can play a role in the developing and relieving of sciatic nerve pain. The piriformis originates on the anterior sacrum and attaches to the greater trochanter of the femur.
The obteratur internus and superior and inferior gemelli combine to form a three headed muscle and are sandwiched between the piriformus and the quadratus femoris. They share a common horizontal tendon, which runs from the superior ischial tuberosity to the greater trochanter.
All four muscles (pirifomus, obteratur internus and the gemelli) work together to rotate an extend thigh and abduct the flexed thigh and hug the head of the femur into the joint.
The short thick quadratus femoris sits at the bottom of this group of muscles and originates on the lateral ischial tuberosity and attaches to the top of the femur and is also a strong lateral rotator of the thigh.
The gluteal muscles are comprised of two layers, superficial and deep. The superficial muscles are what we commonly think of as our buttocks and include the gluteus maximus, minimus and medius and the tensor fascia lata.
Extensor and lateral rotation: The gluteus maximus is the largest muscle of the body. The maximus attaches to the back of the ilium (pelvic bone) and runs all the way down to the lateral sacrum and coccyx and its main actions are extension and lateral rotation of the leg. It is a strong extensor and is used mainly when the thigh is moving from flexed to straight such as sitting to standing and walking up hill. During static standing the maximus is not in use and when walking, it is used very little. Interestingly, when we sit down we are actually sitting on the tissue (and bursa) underneath our ischial tuberosity bones at the base of the pelvis, not the maximus itself.
Abduction and medial rotation: The gluteus minimus and most of the medius are underneath the maximus. Both muscles have the same proximal attachment at the external surface of the ilium and almost the same distal attachment; except that the minimus attaches to the greater trochanter slightly more anteriorly then the medius. Both muscles are used during internal rotation and when abducting the thigh. The tensor fascia lata is approximately 15cm long and enclosed by two layers of fascia and attaches to the front of the iliac crest (ASIS) and then runs all the way down the external thigh to the upper tibia. It works with the medius and minimus to abduct and medial rotate the leg, and also works with the psoas to flex the thigh. The muscle (tensor) part also assists in stabilizing the fascia (which runs down the leg) and holds placement of the femur on the tibia when standing. These three muscles also prevent the hip from sagging when walking so play an important role with all locomotion.
Hamstring muscles are active in all thigh extension – except when the knees are fully flexed such as in danurasana/bow pose. They also support trunk extension, and if they were to become paralyzed, our bodies would tip forward when standing. The hamstrings are also very active when walking on flat ground (city walking!) and are primarily used during the eccentric portion of a walking stride, right before our heel touches down. So what is the main job of each muscle?
Semitendinosus– is a long muscle and is named after the cord like tendon, which begins about 2/3 of the way down the posterior thigh. The tendon starts at the IT and attaches to the tibia portion of the inner knee area.
Semimembranousus– is named after its broad flattened attachment to the IT and its tendon forms near the mid thigh. The tendon has three attachments on the inner knee area, including the medial condyle of the tibia and the medial joint capsule.
Both these muscles work together, and when the knee is flexed 90 degrees because they attaché to the inner knee area they can medially rotate the tibia about 10 degrees. These muscles are considered to be “medial” hamstrings and are generally considered to be less “active” then the biceps femoris.
Biceps Femoris- has two heads (attachments) the long and short head. The long head start at the IT and protects the sciatic nerve as it descends through the gluteal region down the leg. The short head begins at the linea aspera (lateral thigh area) and both heads attach to the lateral knee at the boney head of the fibula.
When the knee is flexed 90 degrees the tendons of the biceps femoris and the IT band are palpable (and visible) and can laterally rotate the tibia, up to about 40 degrees.
Because the hamstrings are two joint muscles (hip and knee) when they concentrically contract they extend the hip and flex the knee. When walking they are used eccentrically, and with knee flexion, the hamstrings rotate the flexed knee. The majority of hamstring injuries occur when the tendons tear at the proximal attachment of the IT joint and can be a result of not enough warm up combined with a strenuous action.
Moore and Dalley (2006) Clinically Oriented Anatomy, 5th edition, Lippincott Williams & Wilkins, Baltimore, MD.
The hamstring muscles are a group of 4 posterior thigh muscles. The muscles are semitendinosus, semimembranosus, and the biceps femoris, which are considered two muscles due to their two distinct boney attachments. All muscles attach proximally to the ischial tuberosity except for the ‘short head’ of the bicep femoris, which attach to the lateral femur bone. The semitendinosus & semimembranosus muscles have a distal attachment to the superior medial tibia (bottom of the inner knee area) and the biceps femoris muscles attach to the head of the fibula (bottom of the outer knee area).
All the hamstring muscles are innervated by the sciatic nerve and are considered to be hip extensors when walking (the gluteus medius laterally stabilize) and when contracted they extend the leg, flex the knee and laterally rotate the thigh. Posturally, it is interesting to note that when the thigh and leg are fixed, the hamstrings assist the trunk in extension at the hip joint.
Exposing the Skeletons in the Closet of SCI Rehab
W. Brent Edwards, PhD.
•SCI associated with marked bone loss
•2x more likely to experience a fx due to minor trauma with small amounts of force
•Most valuable window is acute phase SCI rehab.
•No intervention yet has demonstrated complete or sustained recovery of SCI bone loss
Form Follows Function
•Bone is a dynamic tissue and constantly remodeling in response to it’s mechanical environment.
•Adapts to resist the load of habitual activity
•Mechanical Stimuli = Bone Strain. Called “Functional Adaptation” or “Wolf’s Law”.
(Bone remodels according to demands, grows and/or decreases in size and strength)
Three Rules for Bone Adaptation
1. Driven by dynamic, rather than static, loading
2. Only a SHORT duration of loading is necessary; extended loading durations have diminishing adaptive returns ( i.e. long distance running).
3. Bone cells get accommodated to customary loading (and thus less responsive)
Two Process of Adaptation
•Modeling: the independent actions of Osteoblasts (OB) & Osteoclasts (OC) change the size and shape of bone
•Remodeling: the sequential actions of OB & OC to remove old bone and replace with new bone
•OB- bone forming
•OC- bone absorbing
•Bone metabolism is out of balance: Osteoclast activity (they eat bone) outweighs the Osteoblast (which form bone).
•Bone loss is rapid and profound
•In two years: 25% in hip, 50% in knee
•Increased in areas below injury
•LE bone loss similar among para and quads
•UE unaffected in para, variably affected in quads
•Age, weight and gender not important determinants of bone loss
Fractures Source of Morbidity
•Only a small amount of force is required
•Common causes: falls & transfers from W/C & rolling over in bed
•Common location: proximal tibia, distal femur
•Fracture healing delayed
•Pressure ulcers (secondary complication)
•7x longer hospital duration
•High rate of D/C to SNF
How Do We Prevent This From Happening?
•Tailor programs secondary to preventing increased bone loss
•Rehabilitation: Weight- bearing exercise, Functional Electrical Stimulation (FES) and Vibration Stimulation
•Pharmacological: antiresorptive agents & anabolic agents
•In Acute SCI: most effective weight-bearing should be more dynamic and longer duration (i.e. litegait).
•In chronic SCI: static weight bearing (tilt table/standing frame) less effective.
•Vibration shows potential (while standing) 30 min 3-5x a week 1.5 years and with disabled children (CP, MD)
•FES shows most potential: with response limited to bone spanned by stimulated muscle (stimulated muscular forces carry more load to bone than gravity)
•Benefits not sustained after training
•Antiresorptive Agents (Bisphosphonates): Inhibit OC activity and evidence of efficacy in acute SCI and in chronic SCI no significant diff.
•Anabolic Agents (Parathyroid Hormone) effect number and activity of OC’s. Not been studied in SCI but in rats saw complete reversal of bone loss and has a synergistic anabolic effect on bone formation when combined with mechanical loading.
Summary of Interventions
•In Acute SCI rehab: Bone maintenance with sufficient mechanical stimuli or use of bisphosphonate therapy.
•SCI associated with marked bone loss
•2x more likely to experience a fx
•Small amount of force can create a fx (rolling over in bed)
•Most valuable window for intervention is in acute phase of SCI
•No intervention has illustrated complete or sustained recovery of SCI bone loss
One of the nice things about my job is that I learn new things. In late June, I was able to attend the 35th Annual Interdisciplinary Spinal Cord Course at the renowned Rehabilitation Institute of Chicago. It was just my second time in Chicago (the first over a decade ago for my cousins wedding), but both the city and the course turned out to be fantastic.
The course spanned three days and consisted of 12 hour long lectures related to evidence based treatment (best practice) of SCI and 3 afternoon lab sessions which focused on more experiential learning. The topics of the lectures I enjoyed the most were the Biomechanics of the Weight-Bearing Shoulder after Spinal Cord Injury: Implications for Clinical Practice by Sara Mulroy, PhD, PT. which emphasized strengthening the rotator cuff muscles to decrease shoulder pain from overuse due to chronic wheel-chair mobility.
The four exercises she recommends are performed with either dynabands or free weights: external rotation (infraspinatus) with the elbow at 90 degrees (8x), shoulder retraction with elbow 90 degrees (15x), thumb up lateral arm raises to shoulder height (supraspinatus, 15x with weights under 7#’s) and diagonal pull downs with straight arms (8x). All exercises can be performed w/c level or standing.
Another course called “Exposing the Skeletons in the closet of SCI Rehab” by W. Brent Edwards, PH.D, emphasized the importance of building bone density to prevent fractures in SCI due to rapid bone density loss: after 2 years 25% in hip and 50% in knees. An alarming 40% of SCI pt’s experience fractures in their lifetime the most common causes being transfers and falls from W/C’s or rolling over in bed. The two methods of reducing bone loss are with acute rehabilitation and pharmacology. Rehabilitation activities include weight-bearing exercises, Functional Electrical Stimulation (FES) and Vibration Stimulation.
Another of my favorite speakers, Jeri Morris, PhD, is a psychologist who emphasized the importance of teamwork to develop a relationship of trust with the patient in Facilitating Adjustment to Spinal Cord Injury: The Power of the Team. She believes that therapists must operate from a “position of benevolence” and understand (and deal with) why patients can be difficult and angry and above all learn to provide reality without taking away hope.
Lastly, I snuck half way through, into a lecture/lab given by Annie O’Connor, PT, OCS, Certified MDT called A Collaborative Approach to Seating: Importance of a Mechanical Therapy Approach. Basically, she specialized is pain (she says she loves it), and gets individuals whom are WC bound and in chronic, intractable, at the end of their rope pain, out of pain through careful analysis, evaluation, treatment and WC modification. It was thrilling to watch her work, a Dr. House of pain.