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The Best Assessment for Chronic Pain


Learning Objectives:

  1. Reader will learn why rotational torso mobility is vital to the alleviation of aches and pains.
  2. Reader will learn an assessment for testing the rotational capability of the torso.
  3. Reader will learn both non-exercise and corrective exercise strategies they can incorporate into client workouts to improve torso mobility. 

The key to successful integration of musculoskeletal assessments and corrective exercise strategies with any client is to know a few strategic assessments that shed a lot of light (for you and for your client) on your client’s musculoskeletal or movement dysfunction. If you can demonstrate to a client plainly through a simple assessment that they have an imbalance(s) that may be causing their pain, and that it will affect their ability to achieve their primary fitness goals (e.g., losing weight, getting fit, improving athletic performance and/or putting on muscle), then the client will be receptive to incorporating corrective exercises into their regular fitness program.  In this article you will learn one of the most effective assessment strategies for uncovering a common movement dysfunction that can cause chronic pain - the inability of the torso to rotate.  You will also learn techniques you can employ to correct this problem and help your clients feel and function their best. 

Why is this Assessment so Important? 

The torso (which consists of the spine, rib cage and shoulders) is an area of the body that is constantly put into an unfavorable position as a result of our modern lifestyle. People typically spend hours on end sitting with their upper back rounded forward at a computer, watching television, driving, and/or eating meals, resulting in most of the day spent with their spine slumped forward. This affects the function of the entire torso; specifically impacting its ability to rotate and transfer forces through the body’s center (i.e., the core) and out to the periphery through the hips to the legs/feet and shoulders to the arms/hands (McGill, 2002).  Therefore, assessing function of the torso and understanding the results of any misalignments you find in this area is vital to uncovering the cause of pain and dysfunction anywhere in the body.

What Can Cause Restrictions in the Torso? 

The movement capabilities of the torso can be adversely affected by mental and physical factors, and most people are constantly challenged by a combination of both these on a daily basis. One of the most obvious musculoskeletal adaptations to chronic psychological stress, for example, is using the muscles and joints for self-protection (Rolf, 1989). Since the primary purpose of the rib cage is to protect the internal organs, a person experiencing mental stress will instinctively drop their rib cage down and forward in an attempt to protect themselves from the perceived threat or source of stress. This dropping down of the rib cage at the front causes the upper back to round forward.  A person under stress will also typically bring their arms forward and across the front of the body as an unconscious form of self-protection. This movement makes the shoulder blades protract and the arms internally rotate. This positioning of the shoulder blades and arms causes the thoracic spine to round further and surrounding muscles to tighten up even more. Over time, chronic mental stress leads to immobility of the torso (Price, 2010). 

Many physical problems can also manifest in the torso and affect its ability to move correctly. One of the biggest culprits is overpronation. In today’s world of flat walking surfaces and prolonged sitting, most people’s feet overpronate (i.e., collapse inwards) when they are standing or engaging in weight bearing activities. This rolling in of the feet causes the ankles and legs to collapse and rotate inward toward the midline of the body.  This inward rotation of the leg changes the position of the hip socket, which in turn, causes the pelvis to drop down at the front and the lower back to over-arch (i.e., excessive lumbar lordosis). This excessive arching of the lower back leads to the upper back rounding forward to help the body maintain its center of gravity. Ultimately, this series of imbalances in other parts of the body show up as restrictions in the torso because of the interconnectedness of all our muscles, tendons, ligaments, fascia and joints (Myers, 2001). 

How Torso Restrictions Affect Whole Body Movement

Sufficient torso mobility is essential for the pain-free performance of any type of dynamic fitness activity. That’s because walking, running and playing sports all require that the arms be able to swing to help keep you balanced and generate momentum. As your arms swing (if everything is working correctly) they help turn the entire torso. However, since many people have some degree of immobility in their torso, the movement generated by their arms when engaging in such activities does not turn their spine and rib cage as it should, but instead places a lot of rotational torque on the other structures of the body, like the lower back, hips, knees, ankles, shoulders and neck. Over time, the body adapts to this increased stress to the peripheral structures by limiting the amount the arms swing when you walk or run. However, since performing these activities still requires the body to balance and slow down forces, this restricted movement in the torso and arms means that smaller muscles in the body must take up the slack and peripheral joints and structures can get hurt or injured as a result.

Torso Rotation Test 

The following test is designed to assess how much your torso can rotate. It is a quick and easy strategy to use with clients before, during and after their regular workout sessions.


Instruct your client to sit on the edge of a chair with a pillow or mat squeezed between their knees.  Ask them to hug themselves so their arms and shoulder blades are locked into a fixed position. This will ensure they do not “cheat” the assessment by trying to move their arms and shoulder blades. Now coach them to rotate to the left without bending their spine to the side. If they lack mobility as they rotate to the left, their right knee may want to come forward (or vice versa) in an effort to achieve movement by rotating their pelvis instead of their spine and rib cage. If you notice this, remind the client to squeeze their knees together to prevent this undesired movement. Once the client has completed the rotation to the left, instruct them to return to the start position and rotate to the right. Again, check that their shoulders are level and they are not bending to the side to try to achieve the movement. Ideally, the client should be able to rotate about 50° in either direction. 

Ask the client upon completion of the assessment which way they found more difficult to turn, or if both directions were difficult. If it is not obvious to you during the assessment, you can also ask if when they turn one way they find it difficult to breathe, while when they turn the other direction they can breathe normally. If their breathing is restricted on one side, this means it is difficult for them to turn that way and the muscles around the rib cage are tightening up. Also, if their knees have a tendency to come forward a lot during the assessment this can help you offer insight into why their hips, lower back, knees or feet and ankles might hurt by explaining that they are “cheating” with those structures to make up for immobility of movement in their torso.

Introducing Positive Strategies to Address Restrictions

Once you client has been made aware of the movement restrictions in their torso, the incorporation of corrective strategies into their fitness program will be welcomed. A good corrective exercise program should begin with a warm-up focusing on self-myofascial release techniques (American Council on Exercise, 2010). This provides a general warm-up for the body, but also addresses any chronic myofascial restrictions before beginning the work out. While your client is performing self-myofascial release on those muscles that need to loosen up to allow movement of the torso (i.e., erector spinae muscles, rectus abdominis, obliques, quadratus lumborum, etc.) you can discuss the following strategy for addressing mental stressors that might be contributing to their musculoskeletal dysfunction (Golding & Golding, 2003).

Stop, Drop and Roll:  As previously discussed, many of your clients are besieged by psychological stress. They may feel discouraged about their current weight or appearance, feel limited because they have pain that won’t go away, or think they aren’t good enough at a sport or activity they are competing in. The list of potential mental stressors is endless. However, the underlying theme is always the same. People create thoughts in their heads based on the information they seek out and deem important. For example, overweight clients typically compare themselves to people that are very fit or have model-like bodies in magazines. Athletes who come second in a competition usually focus on the person who came in first, rather than feeling great because they beat everyone else (Whitworth, 2007). These recurring negative thoughts cause a lot of harmful stress. 

An effective technique for helping clients create new, more positive thoughts about themselves is called Stop, Drop and Roll.  Coach you client that the next time they have a negative thought about themselves to “Stop” what they are doing, “Drop” the negative thought out of their mind and “Roll” into a more positive frame of mind regarding their situation. For example, if a client finds themselves worrying about gaining weight because their knee pain is stopping them from running, you can coach them to stop, drop and roll into a more positive mindset by saying to themselves, “My knee pain does not stop me from walking so I am still able to exercise. Furthermore, I am taking positive steps right now with the help of my trainer to make sure that I can run again in the future.” Teaching clients how to reprogram their thoughts gives them a concrete strategy for neutralizing stressful thoughts that can contribute to stress, torso immobility and chronic pain.

Incorporating Corrective Exercises

Once your client has completed their self-myofascial release warm-up activities and created a more positive frame of mind, you can prep them for their regular exercise session by integrating the following two stretches into their program. Utilize them as needed before or during their workout to help mobilize their torso. You can also recommend that they perform them for homework on a regular basis.

Doorframe Stretch: This exercise addresses the front and sides of the torso. Stretching the abdominals and lateral muscles of the trunk (i.e., quadratus lumborum, intercostals and obliques) will help free up the torso so that it can rotate with ease.


Instruct your client to stand in the middle of the doorway and grab the right side of the doorframe as they push their left hip away from their outstretched arms.  They can tuck their left foot behind their right foot to increase the stretch into the left hip and down the leg. Instruct your client keep their torso upright and not round their spine forward as they perform this stretch. Repeat stretch on both sides of the body.

Wall Rotation Stretch: This exercise increases the ability of the torso to rotate. The split stance position of the feet in this stretch will also help open up the hips.


Instruct your client to stand about 12-18 inches away from a wall on their left-hand side. Coach them to put their left foot forward and right foot back with their feet straight. Ask them to rotate their torso to the wall and use their hands to create more rotation. Your client should feel this stretch on the front of their hip and around their torso. As they are performing this stretch, you may notice their hips move and/or their spine bend to the side in an effort to achieve the attempted movement. You can correct this by pulling their right hip back gently as they are rotating their torso left (and vice versa if performing this stretch on the other side). Repeat stretch on both sides of the body.

Conclusion

Making clients aware of how torso immobility can impact the success of their workouts will make clients receptive to the idea of incorporating corrective exercise components into their fitness programs. In doing so, you can help them address the underlying causes of their dysfunction and alleviate their aches and pains. 

References:

American Council on Exercise. (2010). ACE Personal Trainer Manual (Fourth Edition). American Council on Exercise. 

Golding, L.A. & Golding, S.M. (2003). Fitness Professional’s Guide to Musculoskeletal Anatomy and Human Movement. Monterey, CA: Healthy Learning.

McGill, Stuart. (2002). Low Back Disorders: Evidence Based Prevention and Rehabilitation.

Champaign, IL: Human Kinetics. 

Myers, T. (2001). Anatomy Trains. Myofascial Meridians for Manual and Movement Therapists.  Edinburgh: Churchill Livingstone.

Price, J. & Bratcher, M.  (2010). The BioMechanics Method Corrective Exercise Educational Program. San Diego, CA: The BioMechanics Press. 

Rolf, I. P. (1989). Rolfing: Reestablishing the Natural Alignment and Structural Integration of the Human Body for Vitality and Well-Being (revised edition). Rochester, VT: Healing Arts Press.

Whitworth, L., et al.  (2007). Co-Active Coaching: New Skills for Coaching People Toward Success in Work and Life (2nd ed).  Palo Alto, CA: Davies-Black Publishing.