Located in Sterling, VA (703) 421-1200

September 2022

"Shoulder Pain? The Solution and Prevention" - A Book Review

John M. Kirsch, M.D., has practiced medicine for over 40 years and is a board-certified orthopedic surgeon. He served as a flight surgeon in Vietnam, and also worked with the Louisville Hand Institute. After a few years of using conventional surgical and rehabilitative techniques to correct shoulder injuries, Dr. Kirsch (accidentally) found a very simple solution that helps restore joint function, reduces and often eliminates pain, and restores quality of life. He has used this technique for nearly 40 years on himself and his patients to often avoid the need for risky surgery. The third edition of this book was written by Dr. Kirsch in 2012; I believe it was updated in 2019, but this was the only copy of the book that I was able to locate. What you'll find is a book full of useful information that is easy to grasp, along with anatomical pictures and illustrations that help us to better understand a very complicated joint.

We learn that the shoulder joint is primarily a ball and socket joint, or what is more specifically known as the glenohumeral joint. This is where the head of the humerus (upper arm) connects to the glenoid fossa (indentation) of the scapula (shoulder blade). However, the shoulder also includes acromioclavicular (AC) joint, which is where the scapula and clavicle (collar bone) meet. When football quarterbacks get diagnosed with a separated shoulder as a result of a hit, this is usually where it occurs. The acromion process, a part of the scapula, is a component of what is called the coracoacromial arch (CA arch), which rises over the shoulder joint and sits just above the rotator cuff muscles and the coracoacromial ligament (CAL). The artists' renditions and computed tomography (CT) scans show this beautifully. Due to the effects of time and gravity, the space below the CA arch can narrow, causing impingement, pain, and fraying of the rotator cuff muscles and tendon, as well as the condition known as frozen shoulder.

Dr. Kirsch recommends hanging suspended from a straight bar with your palms facing forward. This helps to reverse the effects of aging and gravity by opening up the space below the CA arch, and now that we know more about shoulder anatomy this makes perfect sense. The author notes that when we were children we did things like climb trees, swing, and hang with our arms overhead, but that we do less of that as we get older. Regularly hanging suspended from a high bar can help to relieve many shoulder issues, even if you have a rotator cuff tear. As the author explains, "95 percent of rotator cuff tears are caused by the subacromial impingement syndrome (SIS). This condition is caused by tightness or contracture of the arch of ligament and bone that covers the upper arm and rotator cuff tendons that lift the arm. The tightness or contracture of the CA arch causes painful and destructive 'pinching' of the rotator cuff. The cause of the contracture of the CA arch is unknown, but most likely related to disuse and gravity." CT scans and illustrations in the book show the difference in the CA arch when at anatomically neutral and hanging positions.

How can we implement this hanging exercise into our routine? Any secure straight bar will work, even the portable ones that you can hang in a doorway. The Nautilus Multi-Exercise machine that we have at Total Results works perfectly, but there are several less cumbersome options you can use at home. Dr. Kirsch recommends starting off by hanging for about 30 seconds a few times a day, depending on the severity of your shoulder infirmity. I must warn you that you will experience shoulder discomfort as you perform the exercise, but that is not indicative of further injury. As improvement occurs, you can decrease frequency. It's a good idea to start out with part of your body weight supported, and then gradually work up to where you are hanging completely suspended. Getting safely loaded into and unloaded out of the exercise is absolutely critical. Never jump to reach the bar or load yourself abruptly - this will significantly increase the risk of injury. Depending upon the height of the bar, use a step stool or ladder to load and unload. Try to avoid excessive swinging, although a little rocking should pose no problem. If you have trouble maintaining your grip, I would advise investing in a set of lifting hooks. Finally, maintain proper neutral position of the head and neck during the exercise.

This book is written for the layman, not the professional, and Dr. Kirsch does a good job of keeping things simple and not getting overly technical. If you're not interested in the anatomical descriptions, you can simply skip ahead to how to perform the hanging technique. I am typically against stretching as a means to prevent injury, and I maintain that belief in most instances due to concerns over joint laxity, but as we see in the book many shoulder problems are a result of excessive tightness, so I believe the reasoning here is sound. Contraindications for performing this technique are if you have unstable or frequently dislocating shoulders, or are suffering from osteoporosis. Another thing I like about this book is that Dr. Kirsch goes to great lengths to avoid having to perform surgery, and that he is honest about its efficacy. That means a lot, considering he is a surgeon by trade. Where the author and I part company has to do with the strength exercises he has chosen. I am not a proponent of using dumbbells in most cases, since it is much more difficult to control independent movement arms and impossible to increase weight in small increments. Dr. Kirsch does not understand the exercise principle of inroad, instead recommending an arbitrary amount of repetitions. Furthermore, there is nothing discussed about speed of movement or the dangers of excessive force. This is the primary cause of injury during exercise, and it is ignored by the author. Aside from that, I agree with the basic premise of the book.

Whether your shoulder problems are recent and due to a singular event, or are chronic and a result of overuse, I believe that this hanging technique can make significant improvements in shoulder function, pain, and quality of life. This is a passive exercise that requires very little effort or time on your part, and can pay significant dividends in short order. It is certainly a more desirable alternative to surgery and lengthy rehabilitation.

Posted September 30, 2022 by Matthew Romans

The Value of Regularly Testing Yourself

We live in a world of relative abundance compared to our ancestors of just a couple of generations ago. Even though we face some uncertainty in regard to inflation, our energy resources, and supply chain, in contrast to what Thomas Hobbes said in Leviathan, life is no longer necessarily "solitary, poor, nasty, brutish, and short." Our life expectancy, in spite of skyrocketing rates of chronic disease, is also higher than a couple of generations ago, although it has dipped slightly since Covid. People are living longer and have more leisure time than ever before. Life is not nearly as difficult for us as it was for those of the G.I. generation. Modern conveniences are great; believe me, I wouldn't want to live in a world without air conditioning and indoor plumbing. However, this easier life has dulled us and made us less resilient. Now all that we have to do is press a button on our phone and whatever we want (especially food) shows up on our doorstep in mere moments. This can do a number on us psychologically, much like what happens to lottery winners with sudden unearned wealth.

How can we maintain proper perspective, enjoy the good things in life, and still maintain mental toughness? Test yourself. Many of us don't challenge ourselves on a regular basis; we're just trying to get through life the best we can. I suspect that a good number of Americans are content with their current capabilities and don't regularly do difficult things to find out exactly what they're made of. I believe this is a huge mistake. Each one of us is capable of accomplishing great things if we have the right attitude and mindset. Performing tasks that are demanding will help you to stay mentally and physically tough, and will also create a huge sense of accomplishment when they are completed. Nobody wants to find themselves in dangerous or truly adverse circumstances, but if you do hard things when the stakes are low, you will build up the ability to deal with difficulty if that time eventually comes.

What are some ways that you can test yourself?

Practice intermittent fasting. Many of us think we'll starve if we don't eat every few hours. This is utter nonsense. Older generations ate very sporadically, due to a multitude of factors, and managed to not only survive, but thrive. Try a 24 hour fast just for the challenge. I guarantee you will learn something about yourself and you'll come out better on the other side. Stay metaphorically hungry.

Read a challenging book. Step out of your comfort zone a little bit. Sometimes a book's genre or subject might not initially be attractive to you, but as you read further you end up being pleasantly surprised. Other times, it was just as bad as you initially thought, but there is value in sticking it out until the very end. Either way, it might just open up your mind to something new.

Exercise. Pursuing a meaningful metabolic experience is not designed to be fun. It is hard work that involves discomfort and occasional mental anguish. How you mentally approach a Total Results workout makes all the difference in the world. If you go into it with fear and anxiety, it will be a big hurdle to overcome. If you embrace the challenge, realize that the workout will be brief, and give your best effort, it will be incredibly rewarding. I have not experienced too many greater feelings of accomplishment than the one that occurs after an outstanding workout. Doing this every week maintains good habits and keeps you mentally tough.

Take a cold shower. I learned this from reading former Navy SEAL Dan Crenshaw's book Fortitude. It sounds like a crazy idea, but if you have ever taken a cold shower in the middle of January, you know it's typically an unpleasant experience. When you get up early in the morning and you're still shaking off the cobwebs of sleep, the cold water hits you like a ton of bricks. After the first few minutes, it gets easier. The way I look at it, you're starting the day off by overcoming some adversity. You can then face the rest of your day with confidence.

Sharpen your focus on an important task. Focus seems to be in short supply these days, with the multitude of electronic screens we stare into and the general approval of the concept of multitasking. It's much harder to focus on one thing and do it well rather than have pots going on multiple burners at the same time. Anything worth doing is worth doing right. Concentrate on completing one task to the best of your ability and don't worry about anything else until that is done. Lock your phone in a separate drawer or room until you have finished what you started. This is not easy, of course, but the question is how badly do you want it?

To paraphrase author Ryan Holiday, if you can't do something challenging when no one is watching, how will you do it when it truly counts? Regular challenges and personal tests are what keep us moving forward, give us perspective, and keep us humble. If you do these things when the stakes are relatively low, you will be ready when the ante is upped. Find out what you're truly made of, and you will be on the road to knowing yourself and truly finding inner peace.

Posted September 16, 2022 by Matthew Romans

Six Factors of Functional Ability

One of the logical goals of pursuing a comprehensive exercise program should be to be able to perform daily activities (and other physical tasks) safely and with greater ease of effort. Dr. Doug McGuff has talked about something called maximum physiological headroom, which is essentially the difference between the most that one is capable of doing and the least one is capable of doing. When the most and the least are equal, death is the result. There are six factors of functional ability that determine how well we perform physical tasks of varying degrees of intensity. Two of these factors are genetically predetermined, four are within your power to improve, and one is specific to the nature of the activity you are pursuing. Ken Hutchins discusses these six factors in "The Renaissance of Exercise", a 2011 updated version of the original Super Slow Technical Manual, and I have found that most exercise enthusiasts and "trainers" are either grossly unaware of these factors, or lack the ability to articulate them. I mention the factors here because they provide some context to the Total Results exercise philosophy.

Neurological Efficiency. This is the percentage of muscle that can be contracted in a maximum effort, and usually falls somewhere between ten and forty percent. This is genetically predetermined by birth and cannot be changed by exercise. If an exercise subject has difficulty maintaining a smooth movement and performing subtle turnarounds, it is likely that they are neurologically inefficient. Such clients can still make considerable physical improvements but may progress more slowly.

Bodily Proportions. These include bone length, muscle belly length (between tendons) and tendon insertion angle. One's body proportions often play a big role in what sports or activities a person decides to pursue. Think about former Olympian Michael Phelps: he has long arms, long legs, big hands, and wide shoulders. You probably couldn't pick a better prototype for an elite swimmer. There are numerous other examples of top-echelon athletes, but his example really sticks out. Bodily proportions are also genetically predetermined.

Cardiovascular Efficiency. This describes how effectively the heart, lungs, and blood vessels transport nutrients to the working muscles and remove waste products from them. Steady state (largely aerobic) activity is relatively inefficient for accomplishing this, and carries with it a high risk of repetitive stress injury. Improving cardiovascular efficiency is best accomplished by performing intense exercise for the skeletal muscles (a Total Results workout). Remember that the cardiovascular system can accomplish nothing on its own; it needs mechanical loading of the skeletal muscles. If there is a greater demand placed upon the muscles, then the aforementioned structures will have to work harder in order to keep up, thus creating a reason to adapt.

Skill Proficiency. Improving your ability to perform certain skills or tasks requires regular repetitive practice of those specific movement patterns. If you want to get better at tennis, practice the shots that the sport requires in conditions that are as close to or identical to a competitive match. The same is true for playing a musical instrument. If you are giving a piano performance on a Steinway baby grand piano, it doesn't make sense to practice on a Casio portable keyboard. This allows your muscles to function as efficiently as possible when performing these skills.

Flexibility. I believe that too much importance is placed on this factor. Flexibility can be improved to a certain degree, but it is highly overrated in my opinion. Many people do unsafe things to improve flexibility and often get injured in the process. Things like ballistic stretching, PNF (proprioceptive neuromuscular facilitation) stretching, and other types of flexibility training needlessly raise the risk of injury with very little reward. Hockey goaltenders and ballerinas use extreme degrees of flexibility, but this is something that is required to excel at their endeavors. This is not recommended for regular people; all one needs is a functional range of motion for everyday living. For my money, flexibility is most safely enhanced by performing proper strength training through a safe and pain-free range of motion on our Super Slow Systems and Med-X machines.

Muscular Strength. Skeletal muscle is the one type of muscle tissue in our body over which we have volitional control. Muscles produce force to enable movement. It should surprise nobody that the main reason for a loss of independence by the elderly and infirmed is a decrease in muscular strength that comes with age. Working to increase strength has both a direct and indirect effect on other physical improvements (fat loss, insulin sensitivity, resistance to injury, etc.) because all of the body's other subsystems are subservient to the skeletal muscles. Total Results exercise is the safest and most efficient way to improve one's muscular strength.

When we talk about functional ability, please do not confuse that with so-called "functional" training. Functional training involves performing a series of everyday movements with added resistance. Not only is this practice extremely dangerous due to high forces, it completely violates principles of motor learning. It's also important to differentiate neurological efficiency from neuromuscular adaptation. As Ken Hutchins says, "This (neuromuscular adaptation) is not in the sense of the all-out effort, but in the recruitment of motor units as the muscle progresses through a set of multiple repetitions." While your distribution of muscle fiber type is genetically predetermined, you can improve how efficiently each fiber type is recruited during the course of exercise.

Understanding the factors of functional ability can give you a better sense of how your body works, and what can and cannot be improved through training and practice. Much of what is required to perform at a high level every day and for many years to come is within your power to change. I often go back to what the Stoic philosophers have said for a couple of thousand years, and that is to understand what you can control and what you can't. Great physical and mental improvement can be made if you are willing to put in the work and apply the knowledge passed along to you by your instructor. We want to see you succeed, but it is largely up to you.

Posted September 02, 2022 by Matthew Romans