Saturday, March 19, 2011

Got a side stich? Might be time to check your Thoracic Mobility. Most folks who've gone for a run - sometimes a bike or horseback ride - have had a side stich, or cramp in the side. Turns out there's a formal name for this experience: exercise related transient abdominal pain (ETAP).  Numerous theories have been proposed about the cause of ETAP, from blood flowing into the diaphram (nope) to ligaments among viscera getting shaken (nope), to muscle cramp (amazingly not). These theories are reviewed in an overview of ETAP from 2009 (Muir09). Turns out, the clearest connection for ETAP is thoracic mobility - or the lack of it.

Back in 2004 (Morton04), a letter in the British Journal of Sports Medicine suggested that the stich effect could be induced by palpating vertebrae T8-T12 (lower part of the thoracic spine - pretty much middle of the back and connected to abdominal muscles). Trying to figure out why thoracic issues might be the cause, the authors write
The extent to which the thoracic intercostal nerves may contribute to the experience of ETAP is worthy of further investigation. It seems plausible that, in some cases mechanical compression of the nerve root may refer pain distally, resulting in abdominal pain. Alternatively, irritation of the nerve may sensitise it to stimuli such that the threshold required for activation is lessened. Hence, in this study, palpation after the pain had been relieved may have allowed tissues innervated by the intercostal nerves, such as the abdominal musculature or parietal peritoneum, to recreate sensations of pain.
More recently in 2010, the issue of a possible spinal connection with ETAP resurfaced (Morton10). Two factors were considered: posture and body type. No correlation was found between body type (somatotype like mesomorph, ectomorph, etc). Where there was a connection, again, seems to be with the throracic spine. Indeed, the authors found what seems to be a correlation between incidents of reported ETAP and measures of kyphosis. As they note:
From a mechanistic viewpoint, increased curvature of the thoracic spine could influence the experience of ETAP either functionally and/or neurally. Functionally, kyphosis could affect rib cage mechanics, as asserted by Kugelmass,10 conceivably placing atypical stresses upon other abdominal structures. Kugelmass made this assertion to support his theory that ETAP was caused by compromised diaphragm function, which has since been convincingly discredited.[1], [5] and [6] From a neural perspective, the abdominal region is innervated by spinal nerves arising from thoracic vertebrae T712.19 Notably, abdominal pain similar in nature to ETAP has been evoked by lesions and compression of these spinal nerves.[12], [20] and [21] Further, we have been able to reproduce symptoms of ETAP by palpating sites adjacent to T7 through T12.4
So what's the Fix? Breath deep and Move the Spine
The authors note that in previous work by I.N. Kugelmass (1937), kids who practiced static posture work and breathing exercises eliminated occurrences of stitches. The authors note however that "the relationship between dynamic posture and the experience of ETAP remains a topic for further investigation"

In the interim, the authors suggest that "posture-corrective exercises may be considered a strategy for preventing the pain."


Movements to reduce Stitches - before they come on
Based on these findings, it may be possible to put together a few simple movements and breathing drills to help an athlete reduce stitches by getting the thoracic spine to a happier place.

It might be helpful to note that these kinds of stitches seem to be age related (morton 02): they decrease (1) with age and also, it seems, (2) with increase of training.

So - thoracic mobilization. There are many ways to help the thoracic spine to move better. Brett Jones and Gray Cook use the thoracic extension work of the Turkish Getup (overview). The familiar RKC Arm Bar also discussed in Jone and Cook's Kalos Sthenos (kettlebelss from the ground up) is another thoracic extension movement that works as a kind of antidote to too much flexion of the thoracic spine (aka going all hunched shoulders), while also helping with shoulder mobilization and strengthening.

Adding In Lateral and Circular Thoracic Work
The thoracic spine however doesn't just move back and forth. It also moves side to side. And really, it moves circularly. The more we practice the full range of motion of these joints, the better we are able to take advantage of that movement.

The anterior/posterior thoracic drills are covered in detail in the R-phase DVD, the Neural Warm Up 1 DVD (Rphase is overviewed here) and in the Quick Start DVD.
a seated variant of the thoracic posterior glide, from the Quick Start DVD

Here's Master RKC Geoff Neupert of kettlebell muscle fame demonstrating the above glide AND the RKC arm bar

The lateral (side to side) glides are covered in the R-Phase and Neural Warm Up 1 DVDs, as are the full circle thoracic movements.

Focus focus focus. These simple drills are fabulous for focusing one's attention on *just* the thoracic spine: can we move that part of our body independent of other joints  - like the shoulders.

Lateral Thoracic Glides
Once we can get the side to side and front to back, getting to circles is inevitable.

I can say with pretty good confidence that when i started doing Z-Health i'd stand side on to a mirror and try to do thoracic glides - it felt like something was moving long before i saw anything moving.

Circles to me seemed impossible. After a month of daily drills with the thoracics though, circles came. I remember RKC Team Leader at the RKC II last year saying how "flexible" my thoracic spine was. Ha, i thought, i guess it is down to perfect reps. It still stuns me.
R-Phase Neural Warm Up

One of the powerful moves in the progression from R-Phase to I-Phase (I-Phase overview) is the relaxation/breathing drills at the end of the Neural Warmup 2. These are called Front and Side Openers.

I-Phase NWU2
These openers combine a bunch of R-phase movements with I-phase load (loading explained in the I-Phase overview): toe pulls, ankle plantar flexion, hip extension, lumbar rotation and extension, thoracic mobility, shoulder flexion, wrist extension and breathing.

The position adds loading to these postures. The focus is yoga-like in that it focuses on relaxing into this posture while working the movement actively.

These are great progressions to help get the thoracic spine to regain its *full* range of motion and control that range of motion. And if the thesis of the various ETAP reviews are correct, for runners, cyclisys and riders with much jolting, these moves will also help reduce incidence of side stitches.

If you suffer from the occaisional stitch, and you try these drills, please let me know how it goes.

Related Posts

Morton, D.,  Callister, R. (2010). Influence of posture and body type on the experience of exercise-related transient abdominal pain Journal of Science and Medicine in Sport, 13 (5), 485-488 DOI: 10.1016/j.jsams.2009.10.487

Morton, D. (2004). Runner's stitch and the thoracic spine British Journal of Sports Medicine, 38 (2), 240-240 DOI: 10.1136/bjsm.2003.009308

MORTON, D.,  CALLISTER, R. (2002). Factors influencing exercise-related transient abdominal pain Medicine & Science in Sports & Exercise, 34 (5), 745-749 DOI: 10.1097/00005768-200205000-00003

Muir B (2009). Exercise related transient abdominal pain: a case report and review of the literature. The Journal of the Canadian Chiropractic Association, 53 (4), 251-60 PMID: 20037690

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