What Medical Students Can Learn from Strength and Conditioning Coaches and PT's

Medical students are renown for their arrogance and sense of grandiosity, like me. We think we know the best regarding the human body. The fact is that most medical students only know a bit regarding the various physical pathologies that can occur. Most of us do not understand the "functional" aspect of it. When it comes to back pain for example, medical students are clueless as to understanding the pathophysiology and management and the reasons behind it. The only thing we know is "don't bend over", "do more jogging", or the best yet, "kurangkan nasi (reduce your rice intake)".

Ever since I've started strength training, I've come to a greater appreciation for the work that people like S&C coaches, PT's, bodybuilders, and nutritionists/dietitians do, as these are the people that deal with optimization of human function. They have to put various knowledge together and integrate them. By optimizing function, they prevent or reduce pathologies. By knowing about the trees, they plant them to build the forest. Allow me to share the various knowledge that I've learned from them.

And in some cases, it is not the science that dictates the work; it is actually the work that dictates the science. And sometimes the science is several years late.

Injury Prevention:

There are 2 major injuries that occur in the public and athletes: shoulder and back injuries (almost 100% of people will have some form in some severity of it at least once in their lives). Shoulder injuries occur due to improper posture and muscular imbalances. Back injuries occur due to a lack of lower back stability. And unsurprisingly, many medical students know nothing and thus do nothing regarding their own back pain. If it's not due to TB spine/trauma, we're just clueless.

Understanding back injuries requires an understanding of a "joint-by-joint" basis of training. A joint may either be designed for mobility or stability. The only exception is the scapulo-thoracic joint (part of the shoulder joint complex), which is designed for both mobility and stability. And in most cases, theres is an alternation of stable and mobile joints.

Despite a lack of lumbar "ribs", the lumbar spine is actually designed for stability. This is especially noted following various research, some of which are done by Dr Gray Cook, a spine biomechanist. The easiest clue is to look at the orientation of muscles around the lumbar-anterior abdomen region: it is actually like a criss-cross of fibers, which is designed to act as a reinforcement. In fact, it is actually the thoracic spine that is designed for mobility, and along with the hip joint, are designed to have maximal movement as compared to the lower spine.

An example of immobile hip joints can be observed in 2 aspects - tight hip flexors (especially the psoas) and tight hamstrings. The former induces hyperlordosis, with a concomitant anterior pelvic tilt. The latter induces kyphosis of the lumbar spine, with a concomitant posterior pelvic tilt. When the hip cannot flex/extend due to this tightness, it is the lumbar spine which is forced to compensate.

In a patient with severe hip flexor tightness, standing will cause severe hyperlordosis, with excessive stress on the facet joints of the spine. Chronic stress can lead to spondylosis-spondylolisthesis. These people will have extension-based pain, worsening on standing.

In a person with severe hamstring tightness however, the patient's pelvis is always easily tucked under the spine when he/she flexes the hips, associated with lower back rounding (kyphosis). This leads to excessive stress on the intervertebral disks, and tension on the spinal ligaments. Excessive stress here may lead to disk herniation. Unsurprisingly, the pain thus occurs more on hip flexion, aka sitting.

In this case, when a doctor in the KK sees a healthy person with back pain, is pain meds the way to go? The solution might be as simple as assessing his/her posture. If the pain is worse on standing, and you find limited ROM in hip extension, teaching him/her to stretch the psoas, glute activation and abdominal bracing/core stabilization may bring a ton of relief.

If it's flexion based pain, as long as the disk hasn't prolapsed with neurological symptoms, prescribe him/her with hamstring stretching, along with proper movement patterns, aka moving with the hips, not with the back. As long as the person rests properly and rehabs himself well, the person can return to daily life pretty well.

To be continued...