How Lady Gaga Can Optimize Her Hip Labral Repair Outcomes

How Lady Gaga Can Optimize Her Hip Labral Repair Outcomes

Today’s post offers a sneak peak of some of the concepts presented in my upcoming text on yoga in rehabilitation (Handspring Ltd, UK est. 2016). Keep up with the news about it on subsequent blogs and on my website, www.gingergarner.com

Lady Gaga recognizes the importance of a maintenance rehab program.

This picture was posted by Lady Gaga several weeks ago, highlighting how important it is to always continue doing maintenance physical therapy (PT) after hip preservation surgery.

I could not agree more with Lady Gaga.

I also applaud her for her dedication to, and advocacy for, physical therapy. I also appreciate her using her status and fame to bring awareness to the underutilized field of rehabilitation. Too many folks do not get the physical therapy they deserve and need after surgery. Worse, they often get substandard therapy that is too generalized (a stretch here and a strengthening exercise there) to get the best outcome.

What Lady Gaga and I share in common is that we need a healthy hip to do our job. Plus, yes I also (occasionally) take the stage as a vocalist.

I am a “hippie” (someone who has had hip preservation/reconstruction surgery) and a PT specializing in hip labral injury (HLI). At 1 year post-op I am still (and will always be) working to safeguard the integrity of my hip.

We must have enough mobility (via fascia, muscle, and nerve integrity and resilience) and enough stability (joint integrity, strength, motor patterning, and endurance) to enjoy any measure of quality of life.

The hip is the connecting point for the upper and lower body, and a major contributor to back and pelvic health. Without a healthy hip, you cannot sit, stand, walk, or even sleep well.

Have a Healthy Hip is Critical to Enjoying a High Quality of Life. Anyone who has ever lost function of a limb knows how important even 5 degrees of motion can be. If you can’t flex the hip enough, you can’t put on your own pants or lace your own shoes. If you can’t lift the arm enough, you can’t put dishes away or even dress yourself.

What Lady Gaga Can Do to Improve Performance and Preserve Her Hip Because every degree of motion counts in both matters of strength, fascia, and joint performance, I have some suggestions for Lady Gaga on how she can vastly improve the results she gets from the “go-to” post-op rehab exercise she is demonstrating: The Bridge.

First, Kudos On Using Yoga for Rehab

First, let me give you the down and dirty on what I consider safe and smart exercise, especially since the movement she is demonstrating is a yoga pose!

Second, Safe Yoga Prescription for Injury Prevention or Rehabilitation Depends On:

1. Centering through Breath Mastery – The concept of centering is based the theory that breath dictates health (Gandevia and McKenzie 2008); therefore, monitoring of respiration and mastery of a basic skillset in respiration is a prerequisite for yoga posture performance. Centering is a deliberate action the individual initiates to create mind-body connectedness throughout each of the five facets of what is known as a biopsychosocial practice (see figure at right). One of the most effective ways to affect centering is to teach breath awareness first.
   

   The BPS Model is a five-faceted pentagon of wellness based on the yogic panca maya model. ©2001-2015. Ginger Garner.

One of the clues I have that Lady Gaga needs some breathwork retraining is that in the photo her ribs are flaring anteriorly and laterally, most likely without employment of the respiratory diaphragm or its nearby cousins, the thoracic and pelvic diaphragms.

Lady Gaga Analysis of Respiration

• If she is inhaling, the diaphragm is likely being used paradoxically (meaning it is being pulled superiorly either actively or passively), instead of descending like during normal inhalation.

• If she is exhaling, again, there would not be a “hollow” vacuum in the mid-torso region, which is indicative of a lack of active trunk stabilization (no transversus abdominis use at all, which destabilizes the posture and compromises hip and pelvic stability). It is also indicative of a negative pressure moment which likely stems from again, not-our-friend, the paradoxical breath. Paradoxical breath would reverse normal kinematic function and physiology of the diaphragm, not to mention create adverse length/tension in the three diaphragms (thoracic, respiratory, and pelvic). Why is this bad? It is bad for autonomic regulation, alveolar ventilation, fascial mobility, and lumbopelvic stability. Specifically in Lady Gaga’s case, it is also bad for vocal performance (talking or singing) and endurance, vocal fold preservation, and overall cardiorespiratory endurance. As a woman, paradoxical breath is particularly bad for HPA Axis regulation and a little hormone called cortisol, which is implicated in everything from weight management issued to premature aging and depressed immune function.

2. Addressing Six Subsystems of Movement for Proximal to Distal Control – Yoga is a complementary therapy capable of addressing all six subsystems of movement due to its mind-body component (Hoffman and Gabel 2013, Deutsch and Anderson 2008) (see figure at right). As such, stability, as a general rule, should be addressed before mobility. Stability begins with lumbopelvic evaluation, followed by shoulder complex/upper quarter assessment and lower quarter assessment. Stability assessment is outside the scope of this post, but let’s just say I spend a great deal of time focusing on this concept in patient care.
   

   J. Hoffman , P. Gabel Expanding Panjabi’s Stability Model of Express Movement: A theoretical model. ©2013. Reproduced for educational purposes only.

Lady Gaga Analysis of Stability

In Lady Gaga’s case, there are too many degrees of freedom in the pose, which is putting other joints and joint complexes at risk.

• First, there is the surface where she is exercising. It allows for too much surface deformation, which means the cushion she is on (or whatever it is) collapses under her body weight and malaligns the posture. If you draw a plumb line from the ear to the hip, you can see that the head is forward of the plumb line – meaning, it does not bisect the mid-humeral shaft, trunk, and greater trochanter as it should.

• Second, there is the arm placement – the arms should be at the side, rather than under the head. The existing arm position exacerbates cervical shear and forward head posture and further distorts plumb line alignment and makes spinal neutral impossible without likely neural tension on the dura mater.
• Third, there is foot placement, which is unduly complicated by the soft surface on which she is exercising. The feet should be under the knees and the feet no wider than hip joint width, in order to maximize concontraction and balance of quadricep:hamstring ratio, as well as dial down the motor input of the psoas, which if she had an anterior tear (and labral tears are) or any past history of a snarky psoas, hypervigilant or reactive, or labral compression via the psoas due to dysplasia or other cause, then she is really going to need to mediate psoas contraction. This position would invariably increase psoas contraction and anterior joint load, but would also increase load transfer to the cervical spine (due to the knee extension moment that would turn on the quadriceps and turn off the hamstrings). Also, feet placement would also likely diminish TATD action, which is one of the chief reasons for performing bridge, other than gluteus maximus recruitment (which is a beginner goal for bridge pose). What is TATD action? TATD stands for transversus abdominis-assisted thoraco-diphragmatic breath, and it represents the conscious recruitment of all three diaphragms and the trunk cylinder (transversus abdominis, pelvic floor, respiratory diaphragm, and multifidus) in some varying degree of MVIC (maximum voluntary isometric contraction) (Garner 2015). I will save the details of TATD breath for another post.

Side note: Can bridge improve your sex life? Gluteal work only scratches the surface of what this pose could do if it was aligned properly. Advanced breath training (which could vastly improve vocal projection and endurance), advanced lumbopelvic stabilization (gotta have that for stage performance), and even improved sexual function are some of the many benefits Lady Gaga could reap from the way I align bridge pose.

What Does a Helicopter Have in Common with Lady Gaga’s Rehab?

3. Next, we need to consider doing a complete “Helicopter Analysis” of her pose. The Helicopter Analysis is a “ground-up and inside-out” approach that should be completed for every prescribed movement or exercise. It is an assessment of the yoga posture or breath in all planes of motion: 1) Coronal or Frontal (Lateral), 2) Sagittal (Anterior-Posterior), and 3) Transverse (Horizontal).

A Safe, Smart Bridge (setu bandha) Pose (or any pose for that matter)

Here’s what we should see in a Helicopter analysis of a therapeutically effective bridge pose.

• Recognize that fascia plays a major role in postural performance (Alfonse et al., 2010), breath, and alignment via variables including, but not limited to, muscle contractility through force generation (Sakuma et al., 2012, Schleip et al., 2005), force transmission (Findley et al., 2015, Langevin et al., 2011, Huing et al., 2007, Barker et al., 2004), viscoelasticity and plastic deformation (Chaudry et al., 2007, Schleip 2003), and tensile force capability (Chaudry 2011) which includes proprioception via mechanoreceptors, as well as nociception (Stecco et al., 2013).

The kinetic chain of a bridge pose runs from the tips of the toes to the cranial crown. Bridge pose should be constructed form the ground up and from the inside out, given that fascia is “malleable, coordinates components of motor units in the myofascial unit and connects element between body joints by means of retinaculas. The fascia and the muscles act as rigging that guarantees verticality of our body.” (Findley et al., 2012, Stecco 2004., pg. 11).

• When aligning a posture from an orthopaedic perspective, work proximally to distally. In bridge pose, if the cervical spine, knees, or hips are comprised in the pose (which they are in her pose), check proximal joint alignment before attempting to change distal segment alignment. The thoracic, respiratory, and pelvic diaphragms should be untethered and fully functioning in the bridge pose.

From the picture, I can see they are not fully functioning. If I was Lady Gaga’s physical therapist, I would have her vocalize in bridge pose and relate improved phonation, articulation, projection, and endurance with the length/tension relationship of all three diaphragms.

The take-home message is, when you get multi-level diaphragmatic function correct – a new door to mindfulness and body performance opens.

Through careful postural assessment via the Helicopter Analysis, a therapist should identify dysfunctional neuromuscular, myofascial response, or abnormal recruitment patterns; especially since these variables are instrumental in pain management, increasing range of motion, and facilitating tissue healing (Hoffman and Gabel 2013).

Now It Is Your Turn

Now it is your turn to critically analyze Lady Gaga’s bridge pose. Keep in mind this pose is specifically for post-operative hip labral repair rehab and use these four critical components to evaluate her yoga bridge pose using this four-step “Helicopter Analysis” method (Garner 2015):

1. Optimal Kinematics – To properly assess postures, introduce single planar movements and limit the degrees of freedom allowed in a posture. Otherwise the diagnostic field can be muddied with too many variables for differential diagnosis. Note any presence or absence of reasonably normal spinal curves and extremity positioning.

2. Efficient Motor Patterns – Note initiation or isolation of an individual muscle or muscle (including the three diaphragms) group to facilitate stability, indicative of adequate load transfer and optimal movement strategy. Note if range of motion is completed in a smooth, coordinated fashion with both concentric and eccentric control. Note if momentum, rather than control, is used to complete a movement pattern, which would be considered a nonoptimal movement strategy.

3. Ability to Adapt to Imposed Stresses – Can the person maintain focus and a psychobiological “center,” e.g. calm disposition, even, smooth breathing at 12 or less RPM, and where applicable, maintenance of TATD breath for provision of safety in yoga posture performance? Are there changes derivative of a dorsal vagal response (Porges 2011), such as breath holding, shortening, emotional dissociation, changes in the voice, or fascial expression indicative of a fight, flight, or freeze response?

4. Tissue Extensibility and Sensorimotor Integration – Carefully attend to neurovascular and/or myofascial resilience and response.  Yoga postures can be used to assess cognitive status, body awareness, attention to task performance, attitude, cooperation, or the need for tactile prompting or other form of learning.
All myofascial lines (Myers 2009) would be relevant in this pose because they all have the capability of being on tension, in order to maintain a posture, especially if the theory of biotensegrity is considered. Myofascial restriction and identification of diaphragmatic impairment or contribution of other soft tissue or neural factors (hamstring or posterior fascia limitation, sciatic nerve tension) should be identified by observation or the clinician’s “listening hand,” as described through the work of Robert Schleip (2003). The entry point for this assessment is to complete real-time assessment of range of motion (osteokinematic motion) during posture performance and fascial and neural response to that ROM.

I hope this post has been helpful. In no way was it meant to be “nit-picky” or negative toward Lady Gaga’s hip labral rehab program. To the contrary, she is doing a fabulous job so far and I’m cheering her on and hope that she has found full relief from her rehab protocol. However, if she or you have not found relief from your hip rehab, then I would humbly suggest following the guidelines I’ve proposed here. And as always, my clinic door is open!

References

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