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Biomechanical Screenings for Preventive Care

By Rich Joseph
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Before reporting to medical school this coming August, I spent a portion of my final “summer vacation” in Santa Barbara, California. OK, I know how it looks, but in fact, I was not there for the perfect weather, the attractive people, and the lively beach scene. Well… not entirely for those reasons at least. I ventured west for a short internship at the Peak Performance Project—P3 for short (http://www.p3.md/). P3, an elite training facility for college and professional athletes, is the brainchild of Dr. Marcus Elliot, a Harvard-trained physician who has devoted his life to optimizing the physical and mental performance of athletes. As soon as you step in the door, you hear music blasting and see an army of athletes jumping, swinging, and pumping in unison. Anyone with a background in exercise science would recognize that this is strength and conditioning at its best—a thorough assessment for each athlete to pinpoint strengths and weaknesses, cutting edge technology to measure force production, and some of the most creative exercises strung together in complexes based upon the latest research in kinesiology. These trainers are the best of the best and the athletes that they produce come equipped with an arsenal of strength, power, and flexibility that leaves minimal chinks in the armor. In only a few weeks, I expanded my training skill set and had the privilege of working with some of world’s greatest athletes.

Given my experience as a personal trainer and my future career in medicine, I often found myself scheming how this training methodology could and should be incorporated into preventive medicine. Thankfully, the new health care law shines a much-needed spotlight on power of prevention to reduce chronic conditions, a major contributor to rising health care costs. Insurance companies must now cover all recommended screenings, preventive care and vaccines, without charging co-pays or deductibles. Those individuals whose care is covered by Medicare will get free annual physicals. These and other measures are certainly steps in the right direction.  Now, as the tide begins to turn, we must ride the prevention wave and innovate so that medical professionals are poised and primed to contend with the chronic conditions that cripple this nation physically and financially. Based on the knowledge I gained at P3, it seems to me that physicians, those in primary care in particular, would benefit from a working knowledge of biomechanics to assess and correct movement patterns and structural imbalances that predict future ailments.

Biomechanics involves the application of mechanical principles to biological systems. While this knowledge has largely been confined to those interested in athletic training and physical rehabilitation, a greater flow of ideas between those in the exercise world and those in the medical community could enhance care for the general population. Indeed, many of the chronic conditions that afflict patients each and every day stem largely from muscle imbalances and postural misalignments. Lower back pain, for example, afflicts one half of all working Americans each year. Not only do American’s spend $50 billion each year to treat back pain, but it is also one of the most common reasons for missed work and the second most common reason for visits to the doctor’s office (http://www.acatoday.org/level2_css.cfm?T1ID=13&T2ID=68).  The painful irony is that most cases of lower back pain are mechanical, and hence preventable in nature. While we sit at an office desk for hours on end (as many of us do), we fail to engage certain muscles like the glutes and hamstrings. In order to compensate, the hip flexors and erector spinae become over-engaged and tight with time. Shortened iliacus and psoas muscles deep in the lumbo-pelvic-hip complex tug at the top of the pelvis and the lumbar spine. This postural imbalances place tremendous pressure on the lower back, which can cause chronic back pain, slipped disks, and nerve impingements. Likewise, tight ankles hamper dorsiflexion, which refers to the degree to which you are able to point your toe up to your knee. Dorsiflexion is necessary for proper running and walking stride as well as for many strength-training exercises such as the squat. Limited dorsiflexion places a tremendous shear forces on the patellar tendon of the knee and can result in tendinitis and persistent knee pain.  And the list goes on…

In addition to more comprehensive training in nutrition, primary care physicians should integrate biomechanical assessments into regular checkups alongside screenings and other preventive measures.  A simple overhead squat test, in which a patient holds a dowel overhead and squats as low as possible while maintaining an upright torso and planted heels, provides a wealth of information of ankle dorsiflexion, hip flexibility, and thoracic extension. Simple depth jumps and lateral hops show how one’s feet interact with and contact the ground, which dictates forces on the knees and lower back. For those with physical constraints or limitations, appropriate substitute testing batteries are available. A simple sit to stand test indicates lower body strength, poor performance on which is correlated to falls and fractures in the elderly. And a walking speed test not only captures a snapshot of cardiovascular endurance, but can also be used to assess gait speed, an important indicator of muscular power and functionality in activities of daily living (Guralnik JM, et al. J Gerontol Med Sci. 1994;49:M85-M94).

These muscular and movement imbalances predict future aches and pains in the same way that a blood cholesterol test foreshadows cardiovascular disease, a blood glucose test monitors diabetes, or a bone density scan indicates osteoporosis. Hip instability and poor lordosis are pathologies associated with chronic and costly conditions just like high blood pressure. Hip flexibility and ankle dorsiflexion are important medical needs that improve health outcomes and reduce downstream costs if identified and corrected. Simple stretches and corrective exercises that target such needs and pathologies could then be prescribed before time takes its toll and makes corrective surgery and physical therapy the lone option. It must be noted that there is, however, one important distinction between biomechanical screenings and preventive tests currently used in a medical setting. These assessments are time-efficient and cost-effective! These are the exact strategies and techniques that we should be seeking and adapting in order to design smarter, quality-driven, and coordinated medical care.

Dr. Elliot attended medical school and translated knowledge from the biomedical sciences to optimize the performance of athletes at P3. He has now contributed a wealth of knowledge to the world of exercise science and rehabilitation that the medical community should eagerly adopt and translate to preventive patient care for the general population.  With open-minded and collaborative leaders in both fields, these two worlds could forge a powerful partnership. After all, when our years playing competitive sports come to a close, we are all still athletes at heart, training for the toughest sport of all—life. Once health care professionals—physicians, dieticians, physical therapists, and athletics trainers alike—live with this mentality and embrace kinesiology as an integral component of health care, it will be only a matter of time until the fitness infection spreads.

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