Applying Extremity Tendon Loading Research to Isometrics in the Spine

Dr. Jordan Berry // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, Spine Division lead faculty member Jordan Berry discusses the top 5 reasons to begin to utilize more isometric exercises for the spine: they can be scaled based on any level of irritability, they produce a lot of natural pain-killing chemical, allow for the "stress-relaxation" phenomenon, allow for specific targeting of weaknesses, and are easy for patients to replicate outside of the clinic.

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. JORDAN BERRYWhat is up PT on ICE Daily Show? Good morning this is Jordan Berry lead faculty for cervical management and lumbar spine management courses. Today is clinical Tuesday and we are talking about isometrics for the spine specifically the lumbar spine but really any area we're talking about isometrics for the spine. Now before we dive into that, I just wanted to mention a couple of the courses that we've got coming up to end the year. We've got, let's see, we've got one more cervical management course that is going to be in Hendersonville, Tennessee, and that's this coming weekend, December 2 through 3. We also have two options for, well, one option left for lumbar management. We've got Charlotte, North Carolina this weekend as well, December 2nd through 3rd is sold out, And then we also have Helena Montana has just a few spots left, also December 2nd and 3rd. So we've got three courses for the spine division coming up this next weekend. And then the first chance to catch cervical management in 2024 is out in Wichita, Kansas. That is February 3rd through 4th. And then lastly, the first chance to catch lumbar management in the new year of 2024 is January 27th through 28th in Rome, Georgia. ISOMETRICS FOR THE SPINE All right. So let's dive into our topic today. We're talking isometrics for the spine and why I believe that this type of exercise for the spine is underutilized across the board for a bunch of different presentations and, a bunch of different levels of irritability. I want to chat just for a few minutes about how we can use this effectively in the clinic. So just to make sure we're all on the same page, when we're talking isometrics, we're talking about a hard, prolonged, sustained muscle contraction. with no movement of the joint. And when we think about using this type of exercise, we're pretty comfortable overall using it in the extremities. You know, we've got tons of research now showing the benefits of isometrics in patellar tendons and Achilles and glute med glute men and rotator cuff. So a lot of those main, you know, tendons and tendinopathies that we're seeing every day in the clinic, we're utilizing quite often some variation of an isometric. But in the spine, however, it's used significantly less. And, you know, there's not as much research geared towards specific tissues in the lumbar spine. with isometric loading, but we can take some of the concepts that we see in the tendinopathy research in the extremities and apply them to the lumbar spine. So I want to chat about our top five reasons why I believe that isometrics for the spine is a go-to exercise in the clinic. ISOMETRICS ARE APPROPRIATE FOR ANY LEVEL OF IRRITABILITY Okay, so number one, they're appropriate for basically any level of irritability. So obviously when someone comes in and they have really severe, really acute back pain and the irritability is really high, you're not gonna have as much freedom for exercise selection, right? You're gonna have to find things that are appropriate for that specific individual. And when someone's super flared up, it can oftentimes be really hard to find an exercise that not only what we're going for is relieving symptoms, but that doesn't flare that person up, And we try to get around this by using really low-level exercises like the cat-cow, like the bird dog, like the bodyweight glute bridge, which is not necessarily bad. I mean, oftentimes for acute low back pain, those can be really good movements to keep that person moving, to decrease fear during the first few days, but it's typically the movement of the spine if anything, that's gonna flare the person up. And so what I see is that we can potentially have not only more aggressive exercises early on, but more of a pain-reducing effect by utilizing isometrics. So again, imagine the person that comes in two or three days of really acute flared low back pain, where the actual movement of the spine, whether that be flexion, extension, side bend, whatever, is the thing that flares that person up. Well, we could use something like a Chinese plank. where the person is laid out in that reverse plank position across two benches, two boxes, two objects, and they're just holding a really hard, sustained contraction. They're contracting the glutes, they're contracting the hamstrings, they're contracting the lumbar spine. Or a back extension machine where you're locked in and you're just holding your back in a set position. Or the reverse hyper. We talked about the benefits of the reverse hyper a few weeks ago, but what about just getting in the position and holding in a straight line in that reverse hyper machine or even something like a GHD holding your body out in a straight position these are all examples of isometrics and what you'll find is that even individuals that have higher irritability they can tolerate a form of an isometric because it is the actual movement of the spine that flares their symptoms. We eliminate that problem entirely here. They get the benefits of the load, they get the benefits of the blood flow, but they don't get any of the potential negative side effects of taking that irritated tissue through the full range of motion. So number one is it's appropriate for any level of irritability. Now obviously if someone's lower irritability, we have a lot more options. We can do it way more aggressively, but usually, it's the higher irritability that can be more challenging to find an appropriate exercise for. PAIN-REDUCING EFFECTS OF ISOMETRIC EXERCISE This leads us to point number two, which is the pain-reducing effect of isometric exercises. And so again, we're going to take some of the research that we've seen in some of the extremity tendon loading research studies like the patellar tendinopathy research around the 5x45 is what so many people either use as a starting point or are basing some of their exercise prescription on. In the older study, they were utilizing five sets of a 45-second hold at somewhere around 70% MVIC. And what they saw in that study for the patellar tendon is that progressive sets decreased the pain significantly. By the end of those five sets, we saw a really significant pain reduction but we did not see that in the other forms of exercise. And so clinically, I'm taking that research and applying it to the spine. And so when someone starts that isometric loading, they might have some pain. You know, let's take the Chinese plank again, that reverse plank as an example. When someone's got significant lower back pain and they lay over those two objects, two benches, two boxes, whatever, that first set might cause a bit of pain. But you'll see that progressive set, set two, set three, set four, set five when they're holding that 30 to 45 to a minute prolonged sustained contraction, that you see this oftentimes this nice pain-reducing effect with each set after. And by the end of it, they have significantly reduced pain by actually challenging and loading their spine. And what a very empowering type of exercise for someone with pretty significant pain to realize that loading the spine and actually challenging it in a way can actually reduce the pain. And so if we see that change in the clinic, I'll just tell the person, this is your new painkiller. Okay, this is your new ibuprofen, this is your new Tylenol. And the cool thing about isometrics is they can often be done not only daily, but multiple times throughout the day. So if you're feeling like the pain is increasing or something is making the spine a bit more irritable that you're doing throughout the day, you can use this as a tool, hit a few sets of these isometrics, those long sustained contractions to be able to reduce the symptoms. So number two is the pain-reducing effect. STRESS-RELAXATION RESPONSE Number three is the stress relaxation response. So again, we see this in some of the extremity tendon research, like the patellar tendon, where we see this, what's called the stress relaxation response. And basically what that is, is the benefit that happens with long-duration isometrics, specifically once you hold a sustained isometric for at least 30 seconds, you see the stress relaxation where the fibers in the tendon have this progressive relaxation until a steady state is reached, essentially the load is being dispersed throughout the entire tissue, throughout the entire tendon. And so the way I apply this clinically to the spine is to take someone that has either excessive or limited motion at a specific level in the spine. Think about your older, middle-aged, stiff golfer who really lacks motion in the thoracolumbar junction, the upper lumbar spine. or take the opposite where you have that young mobile gymnast who has a ton of motion in the thoracolumbar junction, the upper lumbar spine, almost a hinge point right into extension. So those areas in the spine That hinge point, for example, are getting a ton of stress. Oftentimes, a lot of the movements throughout the day, they're using that specific area to move. When you're utilizing these isometrics, you get that stress relaxation response where the load is now being dispersed throughout the entirety of those tissues instead of just moving at these specific hinge points. And so it's cool to now have an exercise to be able to not just isolate the spot that they're oftentimes over-utilizing, but now we can load the entirety of those tissues and disperse some of the force. SPECIFIC TARGETING OF WEAK AREAS Number four targets weak areas. So think about your person that comes in with low back pain and you're screening out the deadlift as one of their aggravating factors. And they oftentimes have this spot in the deadlift that's the weak point. That's the spot of breakdown where when either the technique fails or the pain occurs, it's because they have a weakness at a specific point in the lift. Well, we can utilize isometrics as well to eliminate those specific weak points. So you could have someone, for example, do a rack pull, and you're putting the bar right at the spot that's their sticking spot. You can have them perform isometrics in those specific positions to build strength where the technique starts to break down. And you could hit that at any point in the deadlift, right? It could be six inches off of the ground, right, when they're initiating the pull. We could hold that position. or we could do a rack pull right after the bar crosses the knee and they're struggling to get to that full lockout position. You could use isometrics at any point during someone's movement to build capacity and strength in that specific position to eliminate that weakness. ISOMETRICS ARE EASY TO REPLICATE OUTSIDE OF THE CLINIC Last, they're easy to replicate. So I'm always looking for exercises in the clinic that are easy to do, that you don't have to be at a specific location to do, and take minimal equipment. And isometrics will typically check those boxes. So again, let's take the Chinese plank as an example, the reverse plank that we've been talking about. You can literally do that anywhere. All you have to have is two things you're laying your upper back around your shoulder blades and your heels on. In the gym that could be two boxes, that could be two benches, that could be a bench in a box, it could literally be two tables, it could be a chair in an ottoman, it could be literally anything that you could lay your body across and perform that isometric. Same thing with a reverse hyper. Yes, the actual reverse hypermachine is the gold standard, but you can mimic the isometric anywhere. I mean, you could lay on a table and have your hips hanging off and just raise your legs, keep your legs straight, and hold that position. So I love the isometrics because they don't take any equipment. You can do them anywhere and they're easy to progress because you don't necessarily have to have weight, at least in the start, you can just increase the time. So someone could go from 3 sets of a 15-second hold to 3 sets of a 30-second hold, to 5 sets of a 30-second hold, to 5 sets of a minute hold. You can progress this HEP very easily without having to have equipment or progressively increase the weight. So those are my top five reasons why I am using isometrics very consistently, very frequently throughout the clinic. So just to review, number one, they're appropriate for any level of irritability. So from the lowest of irritability to the most acute and irritable. you can oftentimes find some variation of an isometric that not only is going to load their system and not flare it but oftentimes will reduce their symptoms, which is number two, the pain-reducing effect from isometric. So multiple sets you will oftentimes see a more powerful pain-reducing effect from each set. Number three is the stress relaxation response. So we see that stress disperses throughout the entirety of the tissues when we hit that 30-second mark. So we can load parts of the spine, parts of those tissues that aren't typically getting loaded throughout the day. Okay, number four, it targets weak areas. So if there are sticking points in any movement, we can use that to eliminate the weakness. And lastly, they're easy to replicate. Very little equipment, very easy to progress. That's all I've got, team. I appreciate you hanging out, sticking around, listening to that. I would love to hear from anybody about how you're utilizing isometrics for the spine, either in the clinic, from a rehab standpoint, or more from a performance standpoint, either on yourself or a potential client. Other than that, have an awesome day in the clinic. Thanks for sticking around for Clinical Tuesday, and if you're coming to a lumbar or cervical spine management course, I will see you soon. Thanks, team.

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