There Will Be A Way

“Push to Walk is an organization that provides individualized workouts and resources to people with spinal cord injuries and other forms of paralysis to optimize current quality of life and to prepare for future medical advancements.”

That is the mission statement of Push to Walk, an organization I have worked at for over three years and have proudly been the Program Director of for the past year and a half.  On the surface, we are a gym that provides intensive exercise for people with central nervous system injuries and disorders, including but not limited to spinal cord injury, multiple sclerosis, traumatic brain injury, and stroke.  Through our intensive training and exercise, we hope to maximize the health and subsequently, current quality of life of our clients, as our mission states.  The second part of our mission statement, “and to prepare for future medical advancements”, always seemed like an afterthought, even to the most hopeful of optimists, such as myself. 

While most of our clients may experience functional gains, intensive exercise is not a cure for any severe neurological injury or disorder.  Most scientists and clinicians accept a cure will be some combination of intensive exercise and physical therapy combined with some kind of regenerative medicine –i.e., “future medical advancements”.  I used to think that those future medical advancements were a long way away, and that people of today needn’t concern themselves about things being studied in the lab right now becoming widely available anytime soon.

Now I think I was wrong.  It is perfectly fitting that it is now 2015, the year that Doc Brown and Marty McFly travelled to “the future”.  I think the future is now.

Last year, we were introduced to a few significant advances in the science of treating injuries to the central nervous system.  These included:

•  Dr. Susan Harkema’s lab in Loiusville, KY published a paper detailing four men who had chronic, complete spinal cord injuries who had electrical stimulators implanted on to their spinal cords.  Long story short, after the stimulators were implanted, the published paper showed that the men could voluntarily control their legs, with evidence of voluntary ability to control their trunks as well.  Anecdotally (i.e., the information wasn’t in the published paper, but the subjects or scientists talked about it anyway) the men reported that they experienced significant increases in bowel, bladder, sexual, and autonomic function.  All four of them are also reported being able to stand as long as they hold on to something for balance, and despite not being able to walk, the muscles in their legs respond to walking training, which did not occur prior to the implantation.  The Christopher and Dana Reeve Foundation is currently raising money to get more subjects implanted with epidural stimulators so that they can formally study the autonomic gains that have been reported anecdotally.
• In October, a story was released to the world about a paralyzed man from Poland regaining an unprecedented amount of motor, sensory, and autonomic function. This single subject got was a surgical implantation of his own olfactory ensheathing cells, plus a peripheral nerve bridge across his injury.  This trial was based on the work of Dr. Geoffrey Raisman of King’s College London, who has been studying olfactory ensheathing cells for a very long time.  Barring some limitations of the research design, we have a proof-of-concept that someone with a spinal cord injury can regain a significant enough amount of function that his life is impacted.
•   Another study we learned about in 2014 was a clinical trial recently completed in China by Dr. Wise Young from Rutgers University in the USA.  Although his results are not yet published, I mention his study because it is another study dealing with chronically injured, functionally complete spinal cord injuries.  While we are all awaiting official publication of the paper, we learned that the majority of the 20 subjects in the trial experienced some significant degree of walking, functional, and/or autonomic recovery.  Dr. Young has said that the results of this study only bring up even more questions which warrant further investigation, but at least we are moving in the direction of human clinical trials.

Now at this point, you may be thinking, “So what? These studies are for ideas that are in their infancy.  Who knows how long it will be before treatments like these become common? I’m not going to worry about any of it until it becomes widely available and I can get it.”  Fair enough.  Hold on to that thought.

We also heard a lot about robotic exoskeletons last year.  While I personally am skeptical about the neurorehabilitative effects of them, they do allow people to be upright, out of their wheelchair, and move around their homes/neighborhoods in a way that is as close to walking as possible right now, which does have plenty of health benefits. 

Last month, ReWalk, the first company to receive FDA approval for their robotic exoskeletons, came to Push to Walk to evaluate whether or not an interested customer is an eligible candidate to use a ReWalk.  Unfortunately, the customer was not eligible to purchase and use a ReWalk, because his posture was weak, he lacked adequate range of motion and strength in his arms to use crutches to balance himself, and his ankles were too tight to fit into the foot plates.

In a nutshell, whether it is epidural stimulators, olfactory ensheathing cells, or umbilical cord blood cells, people’s bodies need to be healthy and strong enough to undergo the intensive physical activity that is going to be required in conjunction with any kind of regenerative cure that may be available in the coming years.  Even to take advantage of today’s technology, such as exoskeletons, people must meet physical standards to be eligible to use them in the first place.  If you’re thinking that all I’ve mentioned thus far is spinal cord injury studies, I will say that the mechanism of improvement in many of these studies will also have implications for other neurological disorders, such as MS and stroke.

What is my point with all this?  We all know exercise is important, but not just for health anymore.  My point is that there is technology available today that offers those who want it, a chance to get up and get out of their wheelchairs, even if only for a little while.  My point is that there are regenerative medicine techniques that have already been tested and thus fair been shown safe and effective in humans, not animals, with functionally complete spinal cord injuries. Since all of those techniques are, or have plans to be investigated further, it is no longer unreasonable to believe they will be more widely available sooner (years) rather than later (decades).  My point is keep your body as strong and in shape as possible so it is ready to function at a higher level.

I will never tell someone to undergo so much intensive training/therapy that it impacts the rest of their life.  Exercise should never interfere with friends, family, jobs, or come at such a huge cost that you can’t afford other things you need in your life.  With that said, if you have access to a standing frame, freaking use it. If you have access to functional electrical stimulation, make time for it.  If you can go to a gym, be it a commercial gym or an activity-based therapy gym, fit as much of it as you can into your life.  Do as much as you can to keep your body ready for those future medical advancements.  Because the future has already begun.

Research Review: A Case Study Examining Stem Cell Transplantation for SCI

DISCLAIMER: I'm not endorsing or condemning anything that was done in this article - rather, I'm trying to review the article presented,and give my perspective (and some critiques) from a scientific standpoint.

On facebook today, I came across a news article about a man who went to Panama for stem cell injections to treat his spinal cord injury.  The full manuscript, "Allogeneic and autogolous stem cell therapy combined with physical rehabilitation: A case report on a chronically injured man with quadriplegia" can be read here.

The article is a retrospective case report - simply put, it is a study with one subject that looks back at an intervention that was already done, and analyzes the results.  I'm actually hoping to do this kind of study with some of my clients at Push to Walk, but that's another blog entry for another time.  The case study reports on a 29 year old man with a C5 ASIA C spinal cord injury, meaning he was partially paralyzed from the neck down.  He had noticeable muscle contractions in almost every muscle of his body, but they were too weak for him to do things like walk, stand, or even sit unsupported or transfer himself on his own.  He went to Panama, had numerous stem cell injections over 5 weeks, came back to the US, and did 6 months of physical therapy and exercising in a gym.  The results he got after those first 6 months back were discussed.

Outcomes: The subject experienced an improvement in strength in 6 of 13 upper body muscle groups, and 8 out of 9 lower body muscle groups.  He also achieved 30 minutes of standing on a tilt table while maintaining blood pressure, and tolerating assisted ambulation in a body-weight support harnessed device.  He did not gain the ability to transfer on his own, but "increased the amount of effort he was able to contribute to these activities."  Perhaps most noticeable was that he had an increase in grip strength - his right hand increased from 5 lbs before the treatment to 22 lbs after the treatment, and his left hand went from 22 lbs before on the left to 36 after.  This increase in grip strength led to him being able to self catheterize, which he was unable to do before the treatment.  The subject was also significantly able to reduce his spasm medication, and moderately reduce his pain medication.

What I like about the rest of the article: the author (a physical therapist who is actually the sister of the subject in this paper) is good at pointing out that "success is not always translated from the laboratory to the clinic" when it comes to stem cell research.  She also mentions that since he got physical therapy and stem cells, it is actually impossible to say whether the improvements he saw were from stem cells alone, physical therapy alone, or a combination.  Were there to be a study with multiple groups - some receiving stem cells, some receiving physical therapy, some receiving both, and some receiving neither, we would be able to say with more certainty what was responsible for the gains.  Additionally, she points out that Manual Muscle Testing, which was the strength tests used to assess the subject's strength in this study, is not sensitive enough to detect small changes in strength that might lead to meaningful functional improvements. (Incidentally, this is one of the things that the new evaluation system we're doing a study on at Push to Walk seeks to resolve.)  The author concludes by saying that further investigation into stem cell treatments combined with physical therapy is warranted, since this one showed improvements in strength and health in somebody 7 years past injury.  Since this was a case study with just one subject (and therefore just one unique spinal cord injury) we can't say that what worked for him will work for everyone, but since it worked for him, we should see if it will work for other people.

What I didn't like about the article:  the author says that "almost all people that sustain a SCI will achieve some recovery of motor function...occurs in the first 3 months after the injury, but the individual can continue to improve up to 18 months after the injury." She goes on to say "...many patients with chronic SCIs do not recover strength so many years post injury with physical therapy alone." She cites one paper to back this fact up, which modern research has pretty much proven to be untrue.  Some research has shown that it can take up to 30 months to reach a stable ASIA score.  One only needs to look at the recent studies published by the NRN to show that people as far as 20 years post injury can experience a return of function with aggressive, high volume therapy.  She also mentions it is hard to say whether the subject in the paper had a truly complete injury or not, even though she shows the results of his pre-stem cell Manual Muscle Tests in the paper, which show us he had some motor function, if only slight, in almost every muscle below his injury. This conclusively shows he was an incomplete injury to begin with - if he were truly neurologically complete, he would have had nothing below the injury!

She also says there is "not a lot of evidence for chronically injured individuals recovering motor and sensory function over 2 years post injury with any type of treatment."  This, once again, has been shown to be completely false, by peer-reviewed scientific research.  The NRN studies have shown this to not be true.  There is also published research on NRN style therapy plus direct electrical stimulation of the spinal cord returning locomotor function, voluntary muscle control, and sensation in chronically injured individuals (4+ years post injury).  She does point out there is a study of a man who went from an ASIA A to ASIA C injury from 5 to 8 years after injury by doing "activity-based recovery", but says this activity based recovery consists primarily of FES cycling (cycling on a stationary exercise bike that directly stimulates the muscles of your legs, so the muscles actually contract).  Activity based recovery is (or really should be) so much more than FES cycling, and generally includes locomotor training, mobility training, balance training, significant amounts of weight bearing, and general strengthening.  The author does say that activity based recovery could be a valuable component to add to the post-treatment phase of stem cell patients, but it seems the author needs a better understanding of what activity based recovery truly is.

My scientific critiques: the subject in this article hadn't done any kind of physical therapy or exercise at all since leaving his outpatient therapy after he was injured.  Therefore, for almost 6 years he did nothing besides some stretching and range of motion exercises, yet the article does not state how frequently.  Therefore, it is very plausible that if he had done his physical therapy and gym exercise (2 days/week of each) without stem cells, he would have seen gains.

As the author said, there is no way to know for sure how much stem cells contributed to his gains now, but if we look closer there is some evidence.  The subject had function in almost every muscle of his body, and hadn't done physical therapy or intensive exercise in 6 years - this means he had lots of strength to gain everywhere in his body.  Additionally, axons in the central nervous system (the wiring that lets muscles communicate with your brain and spinal cord, and vice-versa) grow very slowly - the same speed as human hair at the fastest.  Therefore, it is unlikely that lots of new connections were made in only 6 months after the stem cell treatments.  It seems more likely to me that the gains he made were mostly from physical therapy and exercise, and less from stem cells.  Physical therapy and intensive exercise have been shown to reduce spasticity, increase strength, and in some cases, increase function.

A smarter way to approach this would have been to do physical therapy and exercise first, before ever receiving stem cell treatments, for a number of reasons.  One, stem cells cost tons of money, as do plane tickets and lengthy stays in Latin America, China, or Europe.  You're better off seeing what kind of gains you can make on your own before spending all that $$.  Number two, once you've maximized all your abilities on your own, if you do get stem cells, then you will know how much they really helped.  A lot of "stem cell tourists" get these injections after not having even attempted to regain function on their own for a number of years, then go through physical therapy or aggressive exercise, then see gains.  So how do we really know that stem cells were the catalyst for those gains, and not just the therapy or exercise that someone is engaging in for the first time in years?  Its basic exercise physiology that if you haven't exercised in years, then start exercising, you're going to see improvements.

In Conclusion: The biggest thing I got from this article is that this subject had no adverse health effects from the stem cells.  This is a good thing because I have heard about people who have gotten worse after receiving stem cell treatments.  So if anything, this case study shows us good evidence that someone 6+ years post injury can go through stem cell treatments and physical therapy and exercise with no adverse health effects.  Other than that, not too many conclusions can really be drawn as to the efficacy of stem cells themselves from this case study.  Yes, further research on stem cells is warranted, but they are not the only hope for regeneration after a spinal cord or other central nervous system injury anymore.  I encourage everybody to stay up on their regenerative research and be aware of all the things being investigated that are offering hope to those with paralysis.  And, if you ever do think about getting stem cell treatments, please make sure you've exhausted all your other options first, such as physical therapy or aggressive weight bearing exercise to attempt to make gains.  While stem cells may work, there are almost always other options that could be effective that are most likely cheaper and much closer to home.

Don't search for an answer without regard to validity...

Let the Research Begin!

So the last bullet point in my doesn't-do-the-last-year-of-my-life-justice blog entry talked about the research that I will be doing at Push to Walk. At least as soon as I have the time to begin data collection!  Here is a link to a  press release we did about it.

In a nutshell, for a long time we have needed a better system than what we have been using to assess the strength and progress of our clients.  However, as a small non-profit, we don't have the money for expensive equipment or access to facilities that have them.  So what do we do?  Buy a relatively non-expensive piece of equipment called a muscle testing dynamometer and invent our own way to use it to evaluate our clients.

But how do we know that the system we come up with is any good?  By testing it out.  We will have multiple trainers evaluate multiple clients, and compare the results each trainer got to make sure that no matter who evaluates a client's strength, the same results are obtained.  Using statistics (yay, fun!) we can establish whether or not the new evaluation system is reliable.  That is to say, we will see if the new evaluation system accurately and consistently measures the change (or lack thereof) in strength of our clients at various joints in the body.



It was important to get our study approved by an Institutional Review Board, or IRB.  Why?  The main reason is because doing research on human subjects and attempting to get it published without IRB approval is illegal!  IRBs exist to protect any human research subjects.  Before we could embark on our research, we had to write up a proposal outlining our research, what it entailed, how we would ensure the safety of our subjects, and many other details.  The IRB at William Paterson University agreed to oversee our research, and they approved it!

So in a few weeks, when we have enough trainer staff to test out new system on clients, we'll begin our research on the reliability of the NIMS test.  I have a ton of other research ideas I want to discuss, but in the interest of keeping my blogs short and readable, I'll save those for another entry.

Take three...

Well the "Tips of the Week" failed pretty miserably eh?  Last blog post was almost a year ago.  That is pretty weak.

At the gentle, friendly, constructive encouragement of my younger brother, I have decided to try yet again to maintain a somewhat regular blog.  If the last year is any indication, writing a blog entry every week for the sake of writing a blog every week probably isn't going to happen.  And its better that way, because if I write only when I'm compelled to, I'll write better entries anyway.

So what has happened since my last blog post?  Here is a list, in (attempted) chronological order, of things that have happened, most of which I won't elaborate on enough to show how significant they were:

• I went full-time at Push to Walk, and eventually became the Program Director.  I still LOVE my job and couldn't imagine doing anything better.  I am now living the new American dream (I got a job after college.)
• I got engaged to my girlfriend of almost (at the time) two years, Mary.  I still don't know how I got lucky enough to have her in my life.  Every day with her is a blessing and I'm looking forward to spending my life with her.  You can read more about us at www.sutorfamily.com.
• I drove my new fiance insane with my obsessive following of the throwing events at the Olympics.
• I went to the Working 2 Walk conference in California, the annual conference that promotes advocacy and research for a cure for spinal cord injuries.  I got even more out of it than I did the previous year in Baltimore, made some new friends, and got tons of new information.  It reaffirmed my current passion for being a soldier in the movement to cure spinal cord injuries.
• I designed (with help from others at Push to Walk) a new system to evaluate the strength of our clients, and received approval from the Institutional Review Board (IRB) of William Paterson University to have their help and oversight as I investigate the reliability of our new system.  Hopefully this is the first of many studies that will come out of Push to Walk!

I'll cut myself off there for now.  I want to write a blog about the current research project we have coming up at P2W as well as other things going on at work, but if I write it now I'll just incoherently ramble on forever and nobody will read the whole thing.  So until then, I'm goin' for a walk...

Exercise Tip of the Week: Running is NOT Strength Training for the Lower Body!

On the left, 2008 Olympic marathon gold medallist Sammy Warinju.  On the right, 2008 Olympic weightlifting silver medallist in the men's 232 lbs weight class, Dmitry Klokov.  Who do you think has the stronger legs?

This one is for all my family, friends, acquaintances, and enemies who adhere to the belief that they do not need to do weightlifting for their legs, because they run, bike, or spend time on the elliptical.  If you spend time in the gym/weight room with the goal of getting strong, big, powerful, building endurance, or all of the above, you need to lift weights, or at least engage in some kind of resistance training, for EVERY part of your body.  Period. 

Running, biking, going on the elliptical, or doing some other kind of long duration aerobic work alone will not give you big, strong, or powerful legs, nor will it give you the other various benefits that resistance training will. Sprint training, however, is a good compliment to these things, but it works better when combined with weightlifting. Something you can get from aerobic work on these machines is local muscular endurance, so if that is your goal, than doing these things without weightlifting is fine, especially for endurance athletes.  Running, biking, or ellipcitcal-ing will not give you any of the other same adaptations as other types of resistance training.  Here's why, in a nutshell:

1. Long duration aerobic work does not elicit the right kind of muscle contractions to build size or strength.
2. Long duration aerobic training does not stimulate the type of muscle tissue that gets you big or strong as a result of resistance training.
3.Long duration aerobic training does not put the same stress on the body that resistance training does, and thus will not result in the same benefits.

Those are the main reasons that the treadmill, bike, etc will not give you the same results as resistance training.  I gave that short list because the scientific explanations behind those reasons are lengthy.  If you want a more in depth explanation as to why you need to suck it up and do squats, keep reading.

1. Lack of Eccentric Muscle Contractions.
An eccentric muscle contraction is one where the muscle contracts while actually getting longer, such as the phase of a bicep curl where you lower the dumbbell from your shoulder back down to arm's length.  Eccentric contractions are important because it is the eccentric portion of a movement in which the main stress is put on the muscle that will cause it to get bigger (and to a lesser degree, stronger).  When on an elliptical or cycling machine, there is no eccentric phase to the movement - in other words, there is no type of contraction that results in bigger or stronger muscles.  When running, there are eccentric contractions (they happen every time your foot hits the ground).  However, they are through a very short range of motion, they don't last the same length of time, and they do not bring forth as much force as eccentric contractions induced from resistance training do. 

2. Lack of stimulation to type II muscle fibers. 
We have two main types of muscle tissue in our body that cause movement - type I and type II muscle fibers.  Type I fibers cannot produce a lot of force and resist fatigure very well, so they are our main endurance muscle fibers.  Type I fibers also do not get much bigger, no matter what kind of training you do.  Sammy Warinju up top is chock full of type I muscles.  Type II muscles, on the other hand, fatigue quite easily, but can generate a ton of force.  They are the "fast twitch" muscles in our body, and they can grow considerably in size due to resistance training.  Dmitry Klokov is made up of mostly type II fibers.  Unless you are doing some kind of sprint training that requires short bouts of high force generation, no amount of time on the treadmill, elliptical, or bike is going to stimulate the type II muscle fibers in your legs.  As a result, no amount of time on the treadmill, elliptical, or bike will give you the size, strength, or power results you might be seeking during your time at the gym.

3. Lack of necessary stress to the body.
When I say "stress", I mean positive stress from exercise that is actually healthy for the body to endure.  Any weight bearing activity will cause adaptations to the body such as increased bone density, increased muscle strength, and enhanced tendon/ligament health.  However, the degree to which these adaptations takes place depends on such things as the loads put on the tissues/joints, or the range of motion through which they move.
Any movement we do on aerobic training machines rarely moves our hips, knees, or ankles through the same range of motion that many weightlifting exercises can.  Even if you do crank up the "incline" on the elliptical and you have to lift your knees really high, the force that our muscles must generate and that our joints and bones must sustain will still not be as high as when doing something like a squat or deadlift.
So yes, I'm saying the fact that a squat or deadlift stresses the body more than running or cycling is a GOOD thing!  When these exercises are done with proper technique, the stress on the body leads to our muscles, joints, and bones re-building themselves to be even stronger than they were before - not to mention stronger and healthier than aerobic machines can ever make them!

I'm not saying nobody should ever do cardio.  Trust me, I'm not one of "those guys".  Cardiovascular training is very important, and lots of people enjoy aerobic machines and should use them as much as they want to.  Just don't expect your legs to be as big, strong, or healthy as they possibly can be if cardio machines are the only training you ever do for your legs!


I almost forgot - resistance training results in LIFELONG health of the lower body!

Health Tip of the Week: Online food/exercise logs - to use or not to use?

In the quest to get healthy and meet health related goals, a lot of people have started logging their workouts or counting their calories using online exercise journals and caloric intake/expenditure calculators.  My girlfriend recently started using one herself, so of course I was skeptical (since I'm skeptical of just about everything) and had to investigate.  I will go through the pros and cons of such web sites by going over a few features of the food and exercise logs and calculators on http://www.livestrong.com/, as this is the one my girlfriend has been using and I have gone through with her.

Pros:

• It helps you meet goals you set: My girlfriend's main goal is simply to lose weight.  Putting her age, height, and current weight into a calculator on the web site gave her Basal Metabolic Rate, or BMR, which is the number of calories you burn simply from existing.  Then she picked her goal of losing one pound per week (which is a great goal, as it is healthy and realistic!).  Based on her BMR and her weight loss goal, she is given a target number of calories to consume each day to meet her goal.
• Calorie counting: The MyPlate feature of livestrong.com lets you enter the food you ate and tells you how many calories you get from carbohydrates, fats, and protein in that food. This makes counting the calories you consume through the day very quick and simple.  It also lets you see how much food (and how much of which foods) you ate, which helps you spot if you are eating too much of one thing or not enough of another.  You can even track how much water you drink throughout the day!
• Logging your exercise: The same feature on the livestrong web site lets you input what kind of exercise you did that day, and how long you did it for.  You can also input general physical activity, like gardening.  It then tells you how many calories you expended doing those activities.  This allows you to track your exercise and physical activity to see how much you really do from day to day.
• Showing the relationship between diet and exercise.  The coolest feature of the livestrong web site is that it calculates caloric intake from food and caloric expenditure from physical activity all at once.  It then shows you if you are over or under your goal for the day.  For instance, if your caloric intake goal is 1,500 calories a day, and you consume 1,700 calories but burn 300 calories throughout the day, your net caloric intake is 1,400 calories, and you have met your goal!  This is a great visual representation of how it takes BOTH diet and exercise to lose weight (or meet any fitness goal).

Cons:

• Body composition doesn't seem to be addressed. I didn't find anything on how much of your body is fat weight vs. lean weight (which is bones, muscle, skin, everything on your body other than fat.)  While there is no good way to assess one's body composition without using equipment in person, it would be good to at least have a mention of it somewhere.  When trying to lose weight, losing fat is good - losing bone, muscle, or fluid, however, is not!
• The numbers are not 100% accurate. It's necessary to measure exact serving sizes to get an accurate caloric measure of the food you eat, which most people don't do.  Same thing with exercise - its possible that even two people of the same size can expend a different amount of calories when doing the exact same exercise.  This is not to say that the numbers are wildly off-base, as most of them give you a general idea of what you have eaten or expended.  Just not an exact amount.

So are they good to use or should I not bother?
I think online journals and logs like this are great tools for someone who is just starting out exercising or changing their eating habits.  They let you visually see what you eat, what you don't eat, and how much exercise you do or don't do.  This is a great tool to have when trying to make lifestyle changes.  People simply need to keep in mind that when losing weight, they should try to focus on losing excess mass (fat) and not lean mass (bone and muscle).  The numbers from these sites also shouldn't be taken too literally, as they will never be 100% accurate.  But they can be very good guidelines that can set you on the right path to your fitness goals.

Meeting fitness goals is much easier if you can SEE what you are doing each day, and online logs make that convenient and easy to do.

Health Tip of the Week: The Importance of Trunk and Hip Musculature Endurance

Well, its a day late, but here it is, my newest health tip of the week!  This one deals with the importance of
muscular endurance as it relates to the muscles of the trunk and hips.

The muscles of the trunk and hips are ones that stabilize the spine, and all its related structures.  If the spine is not held in alignment for long periods of time, tissues can get damaged, nerves can get pinched, discs can slip/herniate, etc - in short, an unstable spine = back pain.

So what do the muscles of the hips have to do with the spine?  Well, the muscles of the hips are connected to the pelvis, which is the base of the spine.  Many muscles connect the pelvis to the spine as well.  Thus, it is possible to have a structurally healthy spine, but if certain muscles of the hips are too tight/too flexible, or too weak/too strong, the pelvis can be pulled out of alignment, which in turn will affect the spine as well. 

A few illustrations showing how many muscles attach to both the spine and pelvis, or the femur (thigh bone) and pelvis.  If just one of those muscles connected to the pelvis is too weak, tight, or loose, it can effect all the other connected structures!

Ok, so the spine, pelvis, and all connected muscles are interrelated.  Why is endurance of the trunk and pelvis musculature important?  We spend most of the day either sitting or standing up.  That whole time, our spine needs to be held in proper alignment.  All day.  Every day.  Hence, if those muscles that stabilize our spine are not able to work for long periods of time, they get tired, and can't hold our backbones or pelvis in the proper position anymore! 

I've heard that just the abs (or psoas, or multifidus, etc) need to be strong to alleviate back pain.  Is that not true?  It is not just one muscle that holds our spine and pelvis in proper alignment - it is ALL of the muscles on all sides of our trunk and hips that do this work! If one muscle is weak, tight, or loose, it can cause problems, but one specific muscle doesn't do all the work for one task. Our back muscles, obliques (muscles on our sides), our abs, and a whole host of deeper muscles (such as the psoas or multifidus) must all work together to brace our spine in a healthy position. 

Alright, so what exercises should I do to increase my trunk-hip muscular endurance?  Isometric exercises (exercises where you don't move) or, what I have begun to call iso-dynamic exercises (ones in which you are moving, but are trying to keep a certain part of your body still) are just as good as any type of sit-up, crunch, or dynamic trunk exercise, and they might very well be more applicable to what we do in the real world.  Lets elaborate:

Isometric exercises

The king of all isometric trunk and hip exercises is the plank and all its variations.  You can also do bridges, which target the lower back and the gluteal muscles (your butt). Different types of planks target different areas of the trunk and hips, but they all force your muscles to hold your spine, hips, and/or whole body in a straight line. Make sure to do different types of planks to hit your trunk and hips from all sides!

Iso-dynamic exercises

As I said earlier, an iso-dynamic exercise is one where you are moving your whole body, while trying to keep one part or parts of your body from moving too much.  Two examples are the bottoms-up kettlebell carry, and the overhead carry with a slosh bar. Both exercises invlove walking (the dynamic part), while your trunk and hips (as well as arms and shoulders) must hold the unstable load still while you are walking (the isometric part).  This static action of the trunk and hip muscles makes them work, which braces your spine and holds it in proper alignment.

So whats the best way to go about adding exercises like these to my workouts?

Here are the two ways which I believe are best:

• At the end of your workout, do two or more sets of different plank/bridge variations. Along the same lines, at the end of your workout, do two or more sets of some kind of iso-dynamic exercise, carrying the load for as long a distance as possible.  For the best results, do at least one type of isometric and one type of iso-dynamic exercise.  Whichever one it is, you want to be able to do the exercise for as long as possible, since that is what endurance is.  Therefore, you want to be able to hold that plank for as long as possible, or walk for the longest distance possible while carrying some kind of unstable load. 
• At the beginning of your workout, do these exercises as part of a warm-up.  By doing these exercises at the beginning of your workout, you "turn on" your trunk and hip muscles, and get them into "stabilization mode."  Be careful though, as you don't want to fully fatigue those muscles before going through the rest of your workout.  So you can still do two sets of isometric and iso-dynamic exercises, but don't go until failure.  Dial the length of your sets back a bit so that your trunk and hip muscles feel worked, but will still last through the end of the rest of your workout.

The moral of the story: having good endurance in ALL muscles of the trunk and hips that stabilize the spine and pelvis is important, both for the reduction of back pain and for long term back and hip health!