The tight hamstring debate

Posted: January 6, 2016 in Uncategorized

 

How many people think they have tight hamstrings? Ca’mon, raise your hands, I know you think your hammies are stiff. I hear this from my patients all the time. When I ask them to do multisegmental flexion (touch their toes) many will automatically say ” I haven’t been able to do that in years” or “my hammies are way too tight to do that!” I’m here to say that yes, some people can have a physiological contraction of sarcomeres causing a shortened resting position of the hamstrings, which is what we classify as a truly “tight” muscle. However, it is my contention through clinical observation that most of the time this is not the case. I know this because I am often able to change their ability to touch their toes in a single session…something I would never be able to do if they truly had physiologic hamstring shortening.

A few weeks ago I had the pleasure of meeting up with my friend Erson Religioso while he was teaching in Toronto. Some of you might know him from his epic blog, The Manual Therapist…(if you don’t, please make yourself familiar by clicking on the link). On the course we used PNF type movements of the anterior chain to help increase length of the posterior chain. Some might call this reciprocal inhibition, other might say it’s simply a novel input to help reduce perceived threat thus allowing the nervous to relax it’s hold on the hamstrings. I am more inclined to believe that latter.. my explanation for why the following manual technique and subsequent exercise works is by reducing threat. I believe that hamstrings are generally felt to be tight to protect the lumbar spine, as many people with “tight” hamstrings also suffer from low back pain. The nervous system deems maximal lumbar flexion to be threatening to the spine so it creates neurologically mediated tone of the hamstrings to prevent full lumbar flexion…all in an effort to “protect” it. This might be good for those with an acute symptomatic disc bulge, but for many it’s overkill.

Here is a video demonstrating a pretty neat little technique you can readily do in the clinic to help ease tension in the hamstrings without having to stretch them (which might actually make the problem worse!).


If this technique works to help increase toe touch, the following home exercise is a fantastic way to help the patient maintain their newly found hamstring length…ahh the freedom!


Hope these tips help you in your clinical practice. Enjoy!

Let’s say you have two people who walk into your clinic with an acute episode of back pain after they fell off their bikes in very similar ways. Their pain location is the same as is their initial pain intensity. Both seemed to have muscle strains after physical assessment. After a few sessions, patient A is doing much better…pain is down and he is well on his way to a full recovery. On the other hand, patient B seems to be doing worse…pain is not going away and it’s starting to affect other aspects of daily life. This is peculiar to you because both had very similar objective findings when they first arrived to see you and both sustained very similar
injuries….what gives?!?!

This brief and overly simplistic story is common. The question that has been on my mind for the last several months has been what factors predispose one person to have chronic pain and another person to get better in a matter of weeks? Why do similar injuries lead to often very different outcomes despite good care?  What traits or factors do different people posses that lead them down the wrong road into the land of chronic pain?

In the world of social media where rehab gurus rein supreme, I would expect that some “expert” would give an intricate pathoanatomical explanation as to why patient B didn’t get better. I might hear such things as I should assess their rolling pattern, or that a certain muscle has become inhibited in the (insert random body part here). I would be told that I need to take this or that course to learn the next “game changer” technique to be better at my job. While con-ed is great and learning from peers online has been a blessing for me, I would say that what is not talked about are the less sexy causes for pain…the stuff we can’t assess with a movement screen or strength test.

I took a course a few weeks ago by a professor out of Western University that addressed the prognostic factors that lead to chronic spinal pain. Dr. Dave Walton might not be a social medial celebrity in the world of rehab/therapy, but that’s probably because he is too busy conducting real research out of his lab, The Pain and Quality of Life Integrative Research Lab.  This course, entitled “Prognosis- based approach to assessment and treatment of acute neck and low neck pain” was a 1 day seminar discussing the evidence behind the very question I ask on a daily basis….what causes chronic pain?

We talked about the roughly 25% of people who suffer an acute injury that becomes chronic and what similarities they had.  For whiplash:

High confidence of risk factors for chronicity 

High confidence of no effect on outcomes

High pain intensity >6/10 Angular deformity of the neck
High neck-related disability Impact direction
Post-traumatic stress symptoms Seating position
Catastrophizing Awareness of collision
Cold hypersensitivity Head rest in place
Mechanical hypersensitivity (distal >local) Older age
Vehicle speed

(Walton et al. 2013)

I find it funny that many of the more anatomical categories such as position of neck and impact direction have very little to do with the onset of chronic pain. This continues to beg the question of the relevance of biomehanics in the treatment of the chronically pained patient.

For lower back pain, the results of a large scale meta-analysis from 2010 by Chou and Shekelle,  which was published in JAMA showed the following

Current evidence for LBP

Strong evidence of risk Moderate evidence of risk No clear evidence of risk
Nonorganic signs (Waddell’s signs) Non-supportive work environment History of prior LBP
Maladaptive coping behaviours High baseline pain Demographics (age, sex)
High self-report functional impairments (e.g RMQ) Presence of radiculopathy
Presence of psychiatric comorbidities
Low general health status

The conclusion of this article stated:

The most helpful components for predicting persistent disabling low back pain were maladaptive pain coping behaviours, nonorganic signs, functional impairment, general health status, and presence of psychiatric comorbidities.

The other key aspect of this course was the introduction of evidence backed outcome measures for pain and disability. These are used so we can actually measure objective change in pain and disability over time without the subjective conjecture of “oh you’re getting stronger and moving much better”. Having validated measures to use such as the Brief Illness Perceptions Questionnaire, the LEFS or Neck Disability Index (NDI) are great ways of helping us get a clearer picture of the patients pain and how it specifically effects their day to day life. It also helps us understand the patients beliefs around their pain and why they think they have it and how optimistic they are about recovery. Knowing this information going into an initial assessment really helps me get a clear picture of what I need to do with the patient. Maybe they believe their doomed to lifetime pain or maybe they have very few yellow flags. Knowing this drastically changes how I communicate and even what I do with the patient on the initial visit.

Overall, my tune has changed quite a bit over my 5 years of practice in that I used to be very quick to label peoples pain as anatomy related…”your back pain is due to your locked S.I joint or you have a twisted pelvis creatng muscle spasm”. I now cringe at thinking all the ways I scared patients and made them feel fragile and broken. As it stands now, my practice strives to rule out the bad reasons for pain (the red flags) and to find ways of modifying my patients pain to hopefully help them see that they have the ability to get better without excessive treatment. Education is a cornerstone of my practice…sometimes I think I talk TOO much to my patients about how robust their bodies are!

To hear from a physiotherapist I strive to emulate please take the time to  watch this interview from Prof. Peter O’Sullivan, a world renowned expert in treating chronic pain:

                          Let’s go Raptors!

A few weeks ago I had the pleasure spending the weekend immersed in something that has increasingly become a fascination of mine since I left PT school. It was a course run my a former classmate and friend of mine, Dr. Greg Lehman. Greg has a very unique perspective on the rehab profession at large because of his triple threat training as a researcher (did a masters of biomechanics with Pr.Stu McGill), a chiropractor and a physiotherapist. Coming into and directly out of physio school I must admit that I did not give much thought to the nature of pain. I knew people had it and I thought I would acquire all the tools in the world to fix it. I would mobilize stuck joints, release tight muscles, and give exercises to strengthen peoples cores. I would CURE people! I took courses in manual and manipulative therapy (Canadian System), acupuncture, soft tissue courses etc…all in an effort to get rid of peoples pain. Whenever I helped someone in a single session I thought I had the magic touch…what an idiot I was ;)

In my attempt to keep this prelude brief, I will say that as I moved forward in my practice and kept a skeptical mind about what I was doing and what I was taught, I began to realize that I could do any number of different techniques and people would still get better. I reasoned that it was just as much as what I said to my clients as it was what I did that made all the difference. It was then that I realized I needed to become better at what I said was the cause of peoples pain. I needed a way that didn’t make patients feel dependent on me to align them or make them feel like they’re fragile. I used to do that… a lot. I struggled mightily with this paradigm shift because it’s SO EASY to tell somebody they have a rotated pelvis causing their back pain. It’s tempting because it necessitates more therapy and it’s easy for the patient to understand. It also makes the therapist look like a genius for finding this flaw that can be fixed. The problem for me came when I was forced to realize that twisted pelvis’s, stuck cuboids, or tight muscles were not the sole cause for peoples pain. In fact, they were actually relativity minor players in the pain game. The PhyisoFundamentals course was about talking about the other players in the pain game…namely The biopsychosocial model.

Instead of giving a bullet point list of what was discussed, I think it would be far better to do this as a small case study to demonstrate how the content of this course would change how I handled a patient with good old fashioned knee pain.

Mr. Jones is a 65 y.o male with insidious onset medial knee pain on the right of 4 months duration, He thinks he developed this pain from playing “too much” tennis over that time period and has since stopped playing due to pain and fear of making it worse. He owns a large manufacturing business, which is quite stressful for him to manage. He complains of pain with prolonged sitting >30 minutes and with any pivoting motions. He saw his GP who ordered him an X-ray showing moderate to severe osteoarthritis of the medial compartment, which he now believes is the cause of his pain. 

Based on this quick history, we could go several routes in both or physical exam and subsequent explanation of the cover page of pain workbookcondition. We could relate his knee pain to his twisted pelvis, creating a leg length issue thus placing more strain on the joint…how cool would that be if it were true?!?! Or we could do the following:

1) Explain that structure does not dictate function and that misalignments in the body have never been shown to cause pain. Our bodies adapt and there are many people out there with all sorts of anatomical peculiarities that don’t have any pain. This provides hope for the patient..he is not doomed to be in pain by his posture or alignment

2) We would NOT assess his pelvic orientation, how his L3 moves on his L4 or his inner unit timing and then relate it to the cause of his pain. What we would do is explain that while certain activities like tennis might make his pain worse, this is more of a neurologically mediated protection response than it is any knee specific problem. The brain interrupts the twisting motion as a threat and thus relays the message of pain to the brain. Slowly building capacity and confidence in the ability to move without pain will allow him to get back to tennis. We do this by manual therapy to desensitise angry nerves, explaining that he is not broken and the robustness of the body, and by graded exercise prescription specific to the tasks he wants to achieve.

3) We would be wary of making any correlation between his knee pain and his imaging findings. In fact, we would explain that he probably has the same amount of degeneration on his other knee and that many people get this and don’t have pain. Explaining how just as we age on the outside with wrinkles and grey hair, we age on the inside with degeneration and arthritis, This is a very important falsehood to correct because we know that if you believe the idea that your body is “degenerating” then you will naturally fall into behaviours that protect you. These “protections” are lack of use, hypervigilance and increased sensitivity to the area in questions…all things that promote the pain response.  Giving the patient the power to see past a static diagnostic image is both evidence informed and ethical. Personally, I question any healthcare professional who uses an X-ray finding to keep his/her patient coming back over and over again in the hopes of correcting whatever perceived misalignment or degenerative changes the image shows.

This course was unlike any I have ever taken before. There were no specific techniques taught and it was heavily based on language and evidence as opposed to palpation and guruism that so many other courses endorse. Greg made the strong point that we don’t have to change what we do with our patients on a day to day basis. If you like cracking backs, keep cracking. If you like prescribing the McGill big 3 or “releasing” muscles with an instrument, go nuts! All this course sought to do was re-frame the how and the why behind what we already do so well. And this is something I can get behind.

My personal comment: 
This course will be a hard sell for a lot of newer grads because they, like I used to, crave the “fix”. They went into the profession to help people and the promise of instant gratification is a powerful thing. There are many courses that promise quick fix techniques that seem very sure of themselves. The pain science movement doesn’t make itself out to be the panacea that many other courses seem to and this is why it might be hard for newer grads to reconcile. We want to believe we have magic hands and can move the body like a mechanic moves pieces of a car around to get it running perfectly again. This courses challenges those beliefs and might be a hard pill to swallow for some.

Overall I recommend this course to anyone who treats people in pain. We can do better and I think the content this course provides will help. I know it is still a work in progress for me to integrate all of this into my practice, but I will keep trying and make sure to assess my own interactions with each new patient I see.

Have a great week!

We see it all the time, especially over social media. Success story after success story. We see blog posts and facebook status updates detailing how a patient was miraculously cured of a chronic ailment in a single session because the practitioner was able to find what no one else was able to see. Often times when questioned about the assessment and treatment method employed to help such patient the inevitable response is usually “you must take my course to find out”. This blog post will be in direct contrast to that. This will be a quick case summery of a failed treatment of a patient I thought I could “fix”. We learn more from our failures than we do our successes so here’s hoping I’ve learned something from this.

About 2 months ago a new assessment came my way, referred to me by the Physiatrist in the clinic I work at. He was a 27 year old male with a chronic history of idiopathic low back pain. He walked into my office and I literally thought he was a neurological patient due to the sever antalgic and shuffling gait pattern. He was so far laterally shifted that he was losing balance while walking. In all honesty, once I realized he was a back pain patient I started salivating,..”this will be a great success story” I thought to myself. The more acute they are, the more of an instantaneous change I can usually make. It’s the chronic low grade back pain patients that take more time to see results. He explained to me that he has had multiple instances of his back going “out” on him over the past 5 years, but usually got better in a few days. This time was different in that he was in severe pain for over 2 weeks before seeing me.

Here is a bullet form list of what his exam findings were:

  • Severe lateral shift (pictures below…don’t worry, I got permission before posting this)
  • SLR of 20 degrees on right
  • +ve crossed SLR with pain only into the contralateral side of the low back
  • Absent right S1 reflex
  • Dermatomes within normal limits
  • No complaints of bowel or bladder signs, but had pain down to the right heel
  • Lumbar flexion to 20% of normal…couldn’t get his hands past his upper thighs
  • Lumbar extension to about 40% of normal
  • Basically all lumbar movement was classified as a DP (dysfunctional and painful)

Most other standard testing was not done due to the aggressive nature of his pain. At this point my diagnosis was in keeping with a severe right L5-S1 disc herniation compressing the L5 nerve root. He was already under medical management for this so I didn’t deem it prudent to send him for medical follow up. We started treatment with the idea of de-facilitating his sympathetic response. He was pretty wound up (understandably) so my clinical judgement lead me to work on crook lying diaphragmatic breathing, which did help slightly. For the first 1-2 sessions he couldn’t stay in any one position for more than 2-3 minutes before he had to move…suffice to say he was a challenge to treat. What he did respond to was aggressive lumbar traction in side lying. I had to use everything I had to traction his lumbar spine, which was exhausting for me but abolished his pain when maximum force was used. I basically just did this for another session or two, but results did not last at all. He would get off my bed as shifted as ever and in the same amount of pain as when he walked in. Many things were tried with him such as soft tissue release to his paraspinals and sciatic nerve pathway, thoracic spine manipulation, cervical traction, lumbar spine unloading tape jobs, side glides with over pressure, and many forms of self traction. He would always feel better after treatment, but the shift did not change and the results were very temporary. This was unacceptable to me. This client was talking time out of his busy day to see me and paying good money for my care…he should get at least some benefit from each session.

Homework consisted on breathing exercises, side glides in standing, crook lying core contractions, and self traction exercises of various degrees.

I treated him for 8 sessions using pain science education, traction and every type of self care exercise I could think of. With some initial progress but not enough, when he came in for his final session with me even worse than he had been before, I decided to throw in the towel and refer him back to our Physiatrist. At that point he was taking 12 percocets a day (!!!) and couldn’t work (even from home). The hard part was that he had no hard neuro signs and when we told him to go to the ER, they gave him pain meds and told him to come back if he had signs of cauda equina syndrome. He was stuck in limbo…too much pain to achieve therapeutic benefit and not enough to warrant a surgical opinion. He was given an MRI, which did show a large right sided disc herniation compressing the L5 nerve root. On a side note, it’s patients like these the remind me that imaging findings DO matter some of the time in that his pain was directly correlated to what his MRI showed. This is undeniable to all the pain science people out there.  This was a young man who desperately wanted to get better. He did everything that was asked of him and more. He just wanted to get back to work and resume his life. I can safely say this was a patient that kept me up at night thinking how else I could help him.

Our Physiatrist sent him to a pain clinic for injections in his back. The first one he had worked well and he achieved an 80% reduction in pan, but he went back for a second round the next day for more shots, which actually made him worse ($hit!). He was in agony again and back to square one. We are waiting for his symptoms to calm down a little before re-starting rehab and he is in line for a surgical opinion (finally).

This was written to remind you that there are just some patients we can’t help, despite doing everything we can. There is a tendency in the rehab/exercise social media setting to glorify outcomes, which I think make us as rehab professionals feel like we should be able to cure everyone who walks through our doors. As much as we want to, this is just not possible. But never stop trying and continually elevate your game to help as many people as possible. But also know that throwing in the towel is nothing to be ashamed of, as I feel It shows professional responsibility and a patient centred model of care. If I couldn’t help him, I wanted to find someone or something that could. I feel like I would enjoy reading this type of post if nothing else but to remind me that clinicians all over the place are working hard and not always getting the results they want. If you are struggling with some patients, seek out others for advice. Personally, I spoke over the phone with my friend and trusted colleague Erson Religioso about this case and he gave me some excellent advice. I went on a rehab group message forum to get suggestions from such people and Craig Liebenson. Just reach out and ask for help. It will serve both you and the patient well.

Here are the pictures of my patient so you can get a sense of how shifted he was:

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If you have any questions about this case (I know I didn’t give too many details) or any suggestions please do let me know. I think sharing troubling cases like this makes for an excellent learning opportunity and I hope you do too.

Thanks for reading

I’ve been asked to collaborate with a business in the U.K on this infographic about posture, pain and self help tips. The information is mine and the graphics were done by them. I think it uses best evidence that is easily understandable to the public. Any input would be great! I’m excited about this project and think it provides the public with an entertaining way of understanding how to self manage back pain from sitting too much…. And who doesn’t do that?

image

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!