Last week on my blog I wrote about what I had learned in my 4th year of practice. One thing I mentioned was that I now use dynamic or rhythmic shoulder stabilization exercises much more then ever before. I now use them as much if not more than good old fashion concentric-eccentric cuff strengthening. This quick video post is going to explain this almost too simple to work exercise and why I think it helps.

The reason I like this so much is that the test becomes the exercise. If I do this band assisted stabilization exercise and it makes immediate changes in pain free AROM of the shoulder, I have instant patient buy in and then prescribe a variant of it for home use.  The next time you have a patient with a painful shoulder arch or too much upper trap activation with abduction, lay them on your treatment table and preform this exercise with them for 1-2 minutes  and then re-test their AROM. I have done this in clinic with some pretty great results. I love the “wow” factor patients have because something so simple and quick can change their pain…and the best part is that you don’t even have to do any manual therapy. I often complement this exercise with the explanation that if it helps it means the patient has full control over getting better and they don’t need any fancy manual techniques to improve. How liberating is that for the patient?!

I explain in the video why I think it works, but that is just an educated guess. If you have another explanation I would be more than happy to hear it!

Thanks and best of luck

What 4 years has taught me

Posted: November 17, 2014 in Uncategorized

 

It looks like it’s that time again. Time to summarize what my 4th year of practice has taught me. It’s been another busy year, but also a transformational year for my practice. I’ve settled into my clinic in Toronto, adjusted a few paradigms and am happy to report I still love what I do everyday. Being a physiotherapist is truly the best choice I have ever made.

So without further adieu, here are a few select things I learned in my 4th year as a physiotherapist:

1) Paralysis by analysis: reading too many blogs can be a bad thing: This might sound weird coming from a blog, but I have slowed down how many blogs I read (I say that every year, but this year was especially true). Reading 100 different opinions on any given topic can make you nuts. There have been times this year when assessing a patient I have a blog post from Reinold, Lehman, or Erson in my head and although I learn so much from all of them, it can still screw you up with the patient in front of you. Have a system and stick to it!

2) Quick clinical point that has really been great for me this year: Rhythmic stabilizations and reactive neuromuscular training is better that pure strength training for shoulder rehab. I have got MUCH better and quicker results by teaching the shoulder to resist movement by centrating it in the glenoid than I ever did with good old fashion side lying external rotations. Patient has pain at 120 degrees abduction before treatment, do 2 minutes of theraband assisted rhythmic stabilizations , and their pain is usually gone or at least better in most instances (not all, but always worth a shot). I will get a video up showing you what I do for this.

3) You can cherry pick research to justify pretty much anything in rehab. Anyone can use google scholar to find anything that validates just about everything…I’ve seen articles that validate some pretty wacky things. As a clinician, you have to take it upon yourself to have a cursory understanding of research methodology, statistical analysis, and levels of evidence. This helps you see through the bullshit.

4) Research has advantages over real life practice in that a patient in front of you in pain is not pre-screened using specific inclusion and exclusion criteria. It’s up to you to piece it together to help who comes to your door. As much as I love research and use it as much as possible, I have also come to learn that real patients don’t all fit into nice little boxes where we can do treatment ‘A’ and expect a certain result. Not everyone fits into a clinical prediction rule and we must treat the patient and not the condition.

5) Don’t feel bad for using treatments that many say don’t work. If I decided to stop doing all the treatments that such websites as sciencedbasedmedicine.org and saveyourslef.ca said are ineffective there would be very little I would be able to do as a physiotherapist. I really enjoy these sites and read them often, but I have come to learn that if something is of low risk and has some possibility of helping, it’s worth a shot. I’ve bashed craniosacral therapy before for its biological implausibility and lack of any research for its use. However, I also know there are subsets of patients who really enjoy it and respond well to it. I don’t for a second think the therapist is actually moving skull bones around or normalizing the flow of CSF, but I do think they are providing some great therapeutic touch, which we know down regulates the CNS, which can alter the sensitivity of the nervous system. The risk is small so I say live and let be when it comes to stuff like that. Just don’t say it can cure cancer okay? :P

6) As much as I hate this, I have realized that my goals for patients don’t matter because it’s what the patient wants that ultimately dictates treatment progression. For example, if I see a patient with reoccurring low back pain and my goal is to teach them strategies for decreasing the rate of recurrence, I will do an SFMA and work on their DN’s which may include some serious strength training. However, the patient may just want pain relief from this specific episode and not care about prevention strategies. I will always try and explain that they need to do x,y and z to get better and stay better, but if they choose not to listen I have to respect that and just help them with pain relief. I sometimes believe this involves economic factors that I have no control over as well. In summery, if a patient just wants pain relief then that’s all I’ll give them. Can’t want to help someone more then they want to help them self.

7) Patients need to know you have a plan for them and seeing patients more often is better for their outcomes. I used to think that patients respected you more when you wanted to see them less (and I still think that is true to a degree). However, to really integrate proper exercise into daily life or to calm down nervous system output in the form of manual therapy, a patient needs to be seen a little more frequently at the onset. I now see new patients at least once a week for 3-4 weeks, sometimes twice depending on the nature of the condition.

8) I don’t think we can make permanent changes to people’s static posture and I’m okay with that. I am WAY less posture oriented this year then I ever was before. I don’t completely exclude it as a source of pain, but I don’t think I am able to correct a kyphotic thoracic spine to any appreciable degree…and I don’t think it even matters that much anyway. I now teach the mantra “motion is lotion” when clients ask me the ideal posture…the best posture is the next posture!

saveyourself.ca

 

9) Lastly, we need to have a framework to treat patients. There has to be a standardized method used to assess and treat and it needs to be patient centred. This has proven challenging for me as many of the “frameworks” from which I was taught to view the human body have proven wrong in the world of evidenced based practice. For example, I was taught tests for SI joint movement and stability (gellet etc) and then was told to treat based off those assessment findings. This kind of structuralism methodology formed the bases of my physiotherapy education and much of my post-grad education. Now, a few years into practice I can safely say that I have almost had to relearn what I do for a living due to fact that I can’t ignore the massive amounts of research showing we can’t palpate multifidus, detect movement at the SI joint or ascribe the cause of back pain to a leg length discrepancy (these are just examples off the top of my head). Integrating pain science into my practice was and continues to be a challenge… Patients really want you tell them they have a fixable structural problem. They almost need it to help them feel like they got a thorough assessment. Changing patient’s expectations in this area is a work in progress to say the least.

Are we really doing what we think we are doing?

 

So there you have it. An inside look into what has been going through my mind this year. Hope you enjoyed it!

 

Today I wanted to share some practical exercises I give to many clients who come in with all sorts of issues from knee soreness to lower back pain. As many of my readers know, I am a very big proponent of gluteal strengthening for many lower body issues. In fact, I would go as far as to say that if I could only give one exercise to all my patients, it would most likely be something that targets the gluteal muscle group. This muscle group consists of the gluteus maximus, minimus and medius. All 3 of these muscles have different, yet very integrated roles in lower body  stability and mobility.

The gluteal muscles as a whole are responsible for:

  • Hip extension
  • Hip abduction
  • Hip external rotation and internal rotation
  • Raising the body up from a forwardly displaced position (think deadlift)
  • Lifting the body out of the stooped position (think squat)
  • Femoral, patellar and tibial alignment (knee pain? check the butt!)
  • Stabilizing the lower back and sacroiliac joint via its attachment into the thoracolumbar fascia (Back pain? check the butt!)
  • Keeps the pelvis level for walking and running

….This can get to be a pretty exhaustive list!

The following is a great quote from fitness expert Mike Boyle that perfectly explains why the gluteal muscles are so important and how their function can become “lost”:

“The truth is that glutes are essential to survival. Low back pain expert  Professor Stuart McGill , author of Low Back Disorders, describes the loss of glute strength and size as gluteal amnesia and goes on to implicate lack of strength in the glutes for the debilitating back pain that afflicts so many. The cure for gluteal amnesia is an addanasstomy.  The truth is we sit too much, we take too many elevators, we skip too many stairs. The result…Loss of glute function and the relative disappearance of the bodies most vital muscle. Then to top it off we go to the gym and do what? Of course, we work on our upper body. No wonder everyone’s back hurts.

In clinical practice, I have found it hard to get some people to actually understand how to contract their glutes without substituting with other muscles (mainly the hamstrings). I think many reading this blog post  can relate when I say that teaching activation exercises can be a frustrating process when the trainee, who usually sits 5-7 hours/day at work, can’t contract the right muscles given the appropriate cues. The good news is that I have found the following exercises to be very helpful in getting my clients to “feel” the right muscle working so we can get them doing higher level activities without as big of a risk of injury or muscle imbalance.

1) Hip flexor stretch! 
As I state in the video, it maybe of little use to try and strengthen the butt if the client is sitting in excessive anterior pelvic tilt with tight hip flexors. This “lower crossed syndrome” type of client needs to get more optimal pelvic alignment before we can hammer away at glute activation drills….they won’t be able to do it. There may also be some reciprocal inhibition happening when you stretch the hip flexors to get more gluteal activation…might be a reason to explain how stretching the hips almost automatically helps some clients activate their glutes.

2) Prone figure 4 leg lifts
Do you have patients who complain of hamstring tightness or spasm even with a simple glute bridge? If so, try this exercise first and the see how their bridge improves! Only caveat here is that the client has to have enough hip ROM to get into the right position

3) Fire hydrants to monster walks
Great exercises to get the glute medius to fire and to teach the patient what it feels like to use these muscles.

4) Hip thrust
This is an exercise I give to many clients as it works better than a bridge to isolate the glute max muscle for the reasons I state in the video. When doing this exercise, make sure the client doesn’t substitute lumbar extension for hip extension…they have to be ‘ready’ to do this exercise.

So there you have it. Some of my go-to exercises to target many common issues I see daily in the clinic. What do you use to target the glutes? How do get those challenging patients to turn on their glute muscles?

Thanks for reading!

 

Research as shown that manipulation to the thoracic spine can be beneficial for neck and shoulder pain (see articles HERE  an HERE). So it only stands to reason that improving mobility at this crucial area of the spine can be helpful for a large group of orthopaedic complaints. Neurophysiological rational aside, getting more ROM through the thoracic spine has impact on areas upstream and downstream the body. If we look at the joint by joint approach, we see that the the cervical and lumbar spine are primarily designated areas of stability (sort of…), and the thoracic spine is the mobile area of the spine (again, kind of…). If we develop stiffness in the upper back, common sense tells that the areas above and below will have to compensate to achieve functional ROM. This is why so many people who drive a lot get neck pain…if you’re torquing out your neck to look at your blind spot because you can’t rotate through your upper back you will get neck pain.

I will be honest in saying that 99% of the people I treat will have their upper back mobility assessed via the SFMA model to some degree. Plantar fascists, PFPS, carpal tunnel…they all get their spinal mobility looked at. I may not always address it right away but it will be looked at. I just think it’s good clinical practice to get an overall sense of how someone moves and try to find non-painful dysfunctions before I jump into treating the painful area (yes, I treat the site of pain…and so should you!)

Here is a BRIEF video explaining how I assess upper back ROM using an SFMA framework.

For clients who have persistent lower back, neck or shoulder problems I usually send them home with at least one of these 3 exercises depending on what I find as being the biggest problem and what the patient can effectively do on their own. These are exercises that help maintain the gains made in therapy and for the most part, clients actually report the exercises “feel good” to do…which helps with compliance.

1) Open Books

2) Quadruped (on all 4’s) thoracic rotations with variations

3) Foam Roller Thoracic Extensions

I’m always looking for better and easier exercises that patients will like doing and that will help them with their chief complaint. I have had success with these 3 and hope to learn many more as time goes on. I hope these help you in your clinical practice. Please share what upper back exercises you like giving your clients as the best way to learn is through sharing knowledge.

Thanks for reading!

Are we getting too fancy?

Posted: April 14, 2014 in Uncategorized

 

Earlier tonight I was watching an Inner Circle webinar from Mike Reinold. The webinar was discussing 5 common stretches we probably shouldn’t be doing and like anything else I’ve watched from Mike, it was a nice review with great content. During the Q & A part at the end, a physio asked if we are getting too fancy as new clinicians and favouring movement and neurodevelopmental approaches to assessment in favour of the basics? Are we jumping into Kolar and Yanda before understanding the basic work of Kendal, Magee, and Colby etc? In answering this young physios question, Mike stated:

“We’re seeing a lot of new grads coming out of PT school and they’re FMS certified, maybe SFMA etc. They’re doing PRI and DNS classes. They get all these funky things that they’re doing but they don’t know how to treat a joint. They can’t get people strong and mobile or much of anything else, yet they are trying to stimulate peoples diaphragms. It’s great to have the training in these things, but you must have the basics down first.”

- Mike Reinold, Inner Circle Webinar

I think this was an excellent reply from Mike as I also think social media has “pressured” us to take every con-ed course under the sun in the name of becoming “better”. But is taking seminar after seminar in the hopes of finding answers really making us better? Or is just making us more confused? I think taking con-ed is very important and have done my fare share, but I also think keeping the basics in mind is just as important. We have to understand stages of healing, true pathology, arthro and osetokinematics, normal ranges of motion and biopsychosocial care paradigms before we can start assessing crawling and rolling. These assessments are warranted and should be done, but not because we think we should to be “trendy”. They should be done only when you know exactly why you are doing it and how having that information will alter your subsequent treatment and exercise prescription. In talking to many therapists as of late, I have come to the sad conclusion that many do all kinds of movement’s screens and other fancy assessment techniques, but ultimately utilize the same interventions regardless of what their assessment tells them. Why? Because they don’t yet know what they should do with the information they have obtained. This could be because instead of truly mastering the basics, they have taken course after course but really don’t know what to do with the information they have been given. This may lead to confusion and frustration on the part of the therapist…sort of like paralysis by analysis. Personally I have chosen to slow down my course registrations per year because I believe it’s about quality, not quantity. I rather take a course and master it’s concepts to the best of my abilities before jumping into something else. I used to feel like I had to know it all now. I have a long career ahead of me and will take my time in getting these tools under my belt. I have actually found that I get better results when I stick with one form of care instead of jumping around from technique to technique in the hopes of finding that magic bullet.

I think having the desire to learn more is admirable and is something I can relate to. But I have come to learn that you can’t absorb it all right away. Learning through experiences via treating complex patients and even failing is what makes us better. As long as we are constantly being introspective about our practice and figuring ways to try and be better the next time I see nothing but a bright future for our profession!

Therapydia - Physical Therapy Discovered

 

Therapydia is once again doing their nominations for various physiotherapy related blogs. There are so many amazing webpages by dedicated therapists all around the world and I love being a small part of that world. If you enjoy what I put out and would like to show it, please take a second and nominate jessephysio.com for the chance to win a little reward!

You can access the nomination page here.  Also, be sure to sign up at bottom of page with your email so you can actually vote for the winner on April 14th!

Be better than a sit up…

‘Google’ core training and you will be inundated with all kinds of exercises, tips, “secrets”, and explanations on why any one method is superior to another. Now, I’m not here to say the way I like to do it and the way I give to my patients is best, but I do think it is well informed. Just quickly, the core does not just mean the 6-pack muscles. When I refer to the core for the purposes of this blog post I am referring to the rectus abdominis, transverse abdominis, internal and external obliques, multifidus, and diaphragm. The gluteal muscles can also be thrown in there but the exercises I show in the videos below don’t deal with that as much.

Research tells us that repeated end range flexion is bad for the spine. Professor Stuart McGill from the University of Waterloo has shown in his lab that there are a finite number of cycles of compression a lumbar spinal disc can go through before it herniates. This number is variable between genders and age groups, but it is something to keep in mind. Therefore, I have long done away with sit-ups and crunches as my core exercise of choice. Why speed up the prospect of getting a herniation with my exercise selections? Those exercises aren’t “bad” per se but there are just more optimal choices to train the core functionally and reduce the risk of future injury (notice I didn’t say eliminate the risk…that’s impossible). I have stated before and will again that I believe the true function of the core is not to create movement, it’s actually to resist it. For example, if someone side tackles you while playing football your core doesn’t work to induce movement, it’s working to stabilize and limit how much lateral excursion your body is placed under during the hit. This is what we call reactive core facilitation. The core is preventing spinal injury by limiting movement that might be dangerous for the spine. This ability is trainable and should be for all people from those suffering from back pain to those looking to get stronger for elite athletics. All 3 exercises I will link to are modifiable to make them easier or harder depending on the ability level of the person attempting them.

One big caution: These exercises and their subsequent regressions or progressions should be prescribed to you only after an evaluation has been carried out. Every exercise is a test and if you fail the test with one of these (which is fine), you should be afforded the opportunity to be given exercises better suited to you. A good rehab professional or strength coach can do this…we should at least TRY to make things specific to the client as we can people…maybe a rant on that topic at a later time ;)

So here are 3 anti-movement core exercises that I like giving select clients at my clinic. Each one serves a different purpose and can for the most part be done at home with a band  or weight if a pulley system is not available.  Anecdotally I also like these 3 because clients can “feel” what I’m trying to accomplish with them  if done correctly. This helps with buy in and adherence. Enjoy!

1) Palloff press:

2) Supine single arm chest press:

3) Half kneeling chops:

For those that are super interested, this is an excellent teaser video from Gray Cook talking about side to side asymmetries in the chop pattern of movement. If you are good going to your right, but not your left then something needs to be modified. This is where the help of an expert in rehabilitation/exercise prescription comes in. Showing an exercise is easy… It’s modifying it for the abilities of the person in front of you that takes skill.

Hope you enjoyed.

The Cheerleader 3x3x3 exercise

Photo cred to Mikereinold.com

This is a video of a very simple exercise to help promote scapular retraction that I learned from Mike Reinold . I like exercises that are easy to teach and the patient can feel working almost instantly. This is also just a great exercise to get people out of the anterior tilt and rounded shoulder posture we see with the desk working community. The patient can literally have a band by their desk and bang out a set every hour or two…get that reverse posturing going! Also helps with those with impingement issues related to poor shoulder positioning.

All you need is a theraband and you’re set. As stated in the video, you just take the band between your hands and pull it across your chest, making sure to get a nice scapular squeeze at the end range. After doing 3 reps in the horizontal direction turn the band on an angle and repeat the same motion 3 times. Then turn the band the other way and do it…you guessed it, 3 times! Why 3? I don’t know, I just like it cause I call it the 3x3x3 drill (3 reps in 3 directions for 3 sets = easy for client to remember). This exercise mainly targets the lower trapezius muscle and rhomboids in a reciprocal fashion to pull the shoulders back and tip the scapula posteriorly. It’s cool cause it works both sides at the same time (less time for the patient to worry about exercising)

Again, this is a good exercise for developing posterior chain strength and endurance in the upper body. To get the most bang out of your exercise buck, have your client return the band to the starting position VERY slowly…this will promote great eccentric posterior cuff and shoulder stability…and the client will get a nice burn going.

Enjoy!

The WordPress.com stats helper monkeys prepared a 2013 annual report for this blog.

Here’s an excerpt:

The concert hall at the Sydney Opera House holds 2,700 people. This blog was viewed about 38,000 times in 2013. If it were a concert at Sydney Opera House, it would take about 14 sold-out performances for that many people to see it.

Click here to see the complete report.

 

Movement: it seems to me that this word has taken on a life of it’s on over the last few years. There was even a very popular book written by a prominent physical therapist with it as the title ‘Movement’.  In and of itself, the term is very ambiguous…what kind of movement are we talking about? There are so many types…off the top of my head:
– Passive range of motion
– Active range of motion
-Arthokinematic movement
– Osteokinemtaic movement
- Functional movement (whatever the hell that means…more on this later)
- Sport specific movement
- Single joint/double joint movement

This list is endless…

With so many avenues one could go with movement, how is one supposed to be a movement specialist? As a physical therapist I am supposed to be a movement specialist with the ability to assess and detect aberrant movement, which maybe causing a problem and then intervene with strategies to overcome these issues. Examples of this may include teaching someone how to walk again after a spinal cord injury, stretching a spastic muscle after a stroke, or teaching someone how to hip hinge so they can squat better. An old school chiropractor might say they are detecting subluxations which are causing a weak muscle thus limiting movement and then manipulate the spine. A Pilates teacher might try and isolate your transverse abdominus to help lumbar stabilization creating more optimal movement patterns. A personal trainer might teach you how to perform a proper pushup to facilitate better movement…again, this list goes on.

Here is the issue that I have with much of this ‘movement based therapy’ so many of us provide…I don’t think we know what the proper way to move is and really, is there even such a thing? Don’t get me wrong, I know that rounding your spine for a deadlift creates torque through the lower back and landing in knee valgus can cause ACL injuries. What I’m saying has more to do with screening of movement. I may use a combination of active range of motion via a selective functional movement screen to determine where I think a problem may exist while a massage therapist uses manual muscle testing to determine an inhibited vs facilitated muscle. We may come to very similar or dissimilar conclusions as to why someone has pain or “dysfunction” and our treatments maybe completely different for the same patient complaint…but we are both “movement specialist”…hmmmm

Imagine a patient with back pain… They can go to a physical therapist, chiropractor, and pilates instructor who all claim to be movement specialists. In my opinion, more times then not each professional will arrive at a VERY different diagnosis and treatment strategy. Who’s to say who’s right? Who’s wrong? And what is the standard we go by to make such determinations? The reality is there is not one standard of care in the movement based world of therapy. I know the FMS people are trying to make a movement checklist, which is good, but it has many loopholes. For instance, doing a movement screen of standardized movements will take two practitioners down very dissimilar roads of rehab. So in this case, the assessment maybe standardized, but the subsequent findings and treatment are most certainly not. I bet if a patient went to a 5 different dermatologist for acne the treatment would be pretty similar. When you see an orthopod for a torn ACL, the treatment is usually pretty standardized.  The same can not be said with the patient with back pain seeking conservative treatment. So are we truly specialized in the assessment of movement? Or are we all doing the best with what we know? (and there is NOTHING wrong with that)

So with so much ambiguity in the term movement, can anyone really be a movement specialist? A specialist by definition is someone who is highly skilled and has detailed knowledge in a specific area of study. As I mentioned earlier, there is no specific area of study in movement because it encapsulates so many different things.

So what is the point in all of this? 

With so much differentiation in how we treat and assess based on our individual training and philosophies, we must still utilize a common panacea to help us understand what it is we do. And my friends, that common panacea is something I like to call research (uh oh, research is boring and so un-radical—this is what I hear a lot!) Research asks a question, uses different methods to try an answer that question and then determines which method works best based on various outcome measures. It does not rely on personal bias, monetary gain from taking a guru course, or personal anecdote. So, remember that patient with back pain who saw a chiro, phyio, and RMT? Well, if each of these professionals utilizes research to guide their practice to at least some extent my hope is that similar conclusions would be drawn based on the existing body of evidence detailing why we have back pain. Of course clinical experience and patient preference play a roll in therapy, but at the end of the day, I want to know if I refer to another physiotherapist they will treat them in a similar way that I would…and they would do that because they to know what research says works and does not work.

There will always be charlatans and snake oil salesmen promoting their methods as the best cure for…whatever. This will never change. It is then incumbent on the evidence informed professional to do what is best for the patient and provide care that we know works. In general this means active patient participation in the form of education of condition, minimizing psychological threats, hands on therapy (again, very ambiguous term), exercise and reassurance. Will this get everyone I see better? Nope. Can I rest assured knowing I’ve done everything my skill set allows be to do while utilizing research to guide me…you bet’cha

In conclusion, I don’t think anyone is truly a movement specialist. I think we need to understand anatomy, biomechanics, physiology, pain science, exercise science and bring it all together using research to treat our clients. This is the kind of specialist I would like to be…