This article is not going to be about manual therapy, exercise prescription or reviewing recent literature. Today I want to share with you some of the key concepts I have learned over my first 2 or so years as a Physiotherapist. This article was inspired by a bright young physio student (soon to be physio) named Dave Leyland… read his latest article for some motivation in case you feel like you might be lagging behind. In essence, this article will just be me talking about what I have changed and what I want to change as a physio since graduating almost 2 years ago.

I started practicing September 8th, 2010. I remember my very first patient like it was yesterday (to those who have been in practice 20 or 30 years, I bet 2 years ago does actually feel like yesterday!). Her name was Nancy and she had an MCL and medial meniscus tear. She was a great first patient to have started my career with…friendly, nice, open to having a newbie work on her…she was a pleasure. I treated her with “the best” care I knew how to provide at the time. She got better and I felt like a super star…. Until my 2nd patient! My 2nd patient (ever) was the son of a relatively famous former NHL hockey player. He had a full AC joint separation after being hit in the boards during hockey. I remember going home at night a researching “the best” rehab protocols for such an injury. UnlikeNancy, this young man had been to other, more experienced therapists and actually knew a thing or two about therapy. He questioned me insensately and his surgeon called me to inquire about exactly what I was doing, why I was doing what I was doing, and what were my objective outcome measure after each session…these are all valid questions, but as a new grad I was forced to be very on the ball… it was rough…it was then I realized that knowing what I knew was just not going to be enough…and the more I learned, the more I realized that what I knew was just not going to cut it in this field…not by a long shot.

Over the past 2 years I have made huge gains in my skill set. I am more confident as a therapist. I am better able to recognize clinical patterns, and I know I can help most anything that walks into my door. Here is a list of the most important concepts I have learned over the pat 2 years in practice.

Looks a bit like me after work some days

1) I learned nothing in physio school! Well alright, maybe that’s a bit dramatic… but in reality, coming out of physio school I knew just enough not to hurt anyone. I thought I knew a lot, but when what I was doing as a physio wasn’t providing consistent and positive results I realized I needed to step up my game. The second I embraced the fact that the learning only really starts after you get the degree was the second I became better at what I did.
 

 

2) “The foot bone is connected to the leg bone… the leg bone is connected to the hip bone”. Remember that song from back in the day? Well who would have thought it would form the basis for my philosophy as a therapist. I learned only after school just how interconnected our bodies truly are. The “joint by joint approach” or regional interdependence model of care is now a corner stone of my practice. Simply put, most times pain in one area has contributing factors from other areas as well. This sounds simplistic, but it has and will continue to take me years to figure out all the reasons why people develop pain.

3) Patients do not care about the letters after your name. They only care about results. I used to think that having “MSc.PT” after my name made me credible in the eyes of my patients. I now know that they couldn’t care less. They care about how much you know to get them feeling better. They want to feel taken care of and that their problems are meaningful to me as a therapist. I am currently in the manual therapy stream of courses held by the orthopaedic division of the CPA. Once I complete the entire syllabus system I will get the designation “FCAMPT”…and will a single patient care? Probably not. I do these things for my knowledge and skill set…if you do them to impress patients you will be surely disappointed.

4) Confidence is king. This relates to my 3rd point, but clients need to know that their therapists knows exactly what is going on and how they will “fix” them. They need a game plan to follow and someone to coach them along the way. This is hard to do as there are some times clients that walk in my door that have very odd conditions. And I for one will not lie to a client and make something up just to give them an answer. That would be the easier route, but I rather tell them I don’t know but will figure it out. Does that always work? I’m not sure, but at least I can go to bed knowing I’m 100% honest with all my clients. The #1 way I have learned how to gain confidence is to LEARN! Always read, ask questions and then read some more. So much info is out there…you just have to wade through the B.S to find it.

5) The over arching theme I have learned over the last 2 years is that I will never be comfortable knowing what I know and leaving it at that. The second you become stagnant is the second you become obsolete as a therapist. Having an internal drive to know more is a gift I guess. I force myself to stay up to date and read as much as time always. Blogs, books, webinars, articles…I always wind up getting something from everything I invest time into. What you get out what you put in is never truer than with my career as a physiotherapist.

6) This will be my “rant” point off the list. I have come to realize that treating clients who are unmotivated is both physically and emotionally draining! I want to cure the world and make everyone 100% better, but I have learned that just isn’t always possible. The greatest exercise means nothing if the client doesn’t care enough to do it. This is an epidemic these days with some clients. I could write an entire blog on how everyone wants the quick fix, but that’s not the point of this article. Essentially I have come to realize that if I care more about my patients’ well being then they do, I will burn out quick! So I make a point of telling each new client I see that they have to be committed to therapy for optimal results to be achieved…it’s a two way street. Passive care is great, but it can’t all be that.

Can’t be all about the money

7) Money will come. I used to think I wanted lots of money right away and many of my decisions were based on how much money I could make. I’m lucky to have realized very quickly that money will come when I deserve it. Being the absolute best therapist in my client’s eyes is what creates value. This is something that takes time to achieve…you know, the whole “always learning stuff” I keep talking about… that’s what makes money. When people deem you to be so essential that they will spend their hard earned dollar to have you work on their body…that’s when money will come (more money that is).
 

 

8) I am a puppet on a stage EVERY single day I go into work. My patients don’t care how tired I am or how bad my night was. They have their own problems to deal with and are paying me to worry about their issues…not mine! Each day I go into work I have to put aside any and all problems in my life and become 100% sympathetic to my clients needs. There are no off days for me. I can’t afford to be indifferent with even one client because you never know who that client knows and how they might help your career one day. This was a hard pill to swallow because lets face it…as much as I love my job there are definitely days where I MUCH rather be elsewhere. Learning how to “act the part” day in and day out was tough…but that’s just the way it is!

 

9) Customer service customer service customer service!  Writing down the names of my patients kids, their birthdays, when and where they went on vacation, what their favourite sports teams are…these are the little “tricks” that really help solidify relationships with my patients.  Think about it…wouldn’t you love it if the next time you walked into your doctors office and he or she asked you how your trip to ‘insert destination here’ was? That little extra care really goes along way. I make a habbit of emailing clients videos of exercises to make sure they fully get them. I call clients back ASAP if they have any questions. I always tell clients to call or email me when and if they need me for anything physio related. That kind of selflessness is what drives customer service. If you do just this I think you are ahead of the game.

Overall, I am happy to say that I love my job and I feel honoured to be able to do what I get to do each day. It can be a hard job, but it can also be immensely rewarding! I can’t wait to see what I learn in the next 2, 4, 10, 20 years!

What have you learned since becoming a therapist? What tips do you have for newer grads like me to ensure success in a demanding industry such as ours?

Have a great week!

A face I’ve seen a lot lately

I personally have a love hate relationship with the shoulder joint. It’s a mysterious area with much interconnection with the rest of the body, yet there are multiple local factors that can make a good shoulder bad. Obviously there are the 4 muscles of the rotator cuff (supraspinatus, infraspinatus, teres minor, and subscapularus), the deltoid, teres major, trapezius….and then all the other muscles that attach from the ribs and neck to the shoulder blade….all of which can be pain generating sources.

Above all else though, at least over the past few months for me…has been the glenohumeral joint (GHJ) capsule. The GHJ capsule overlaps the joint providing an extra measure of stability to an otherwise very mobile joint. A tight capsule is one difficult entity to treat. Before I go on explaining why the joint capsule can suck to treat, let’s go through a basic arthrokinematic example talking about a tight capsule:

A tight anterior capsule will drive the humeral head POSTERIOR too soon with external rotation

A tight posterior capsule will drive the humeral head ANTERIOR too soon with internal rotation

A tight inferior capsule will drive the humeral head SUPERIOR too soon with abduction

A tight superior capsule will drive the humeral head SUPERIOR too soon with abduction (this one goes against the joint arthokinematics we learned in school)

I have had a recent influx of clients with chronic capsule tightness that borderlines on being diagnosed as frozen shoulder…but isn’t because they can still actively raise the arm up over 40-50 degrees in the scapular plane. A tight and fibrosed capsule is hard to treat because as a manual therapist, if can’t move their shoulder without pain, I can’t do a heck of a lot. One client I saw 2 weeks ago was so sore (for 8 months!!) that I couldn’t do PROM into ER or IR without a huge bout of rebound pain into the superior and anterior shoulder joint. In her case, both the anterior and posterior capsule was tight leading into multidirectional glenohumeral joint restriction. After clearing the cervical spine, I did tons of soft tissue work to the posterior capsule, quadrilateral space, pecs, lats, and traps…this helped with pain but unfortunately didn’t drastically change her AROM…she is possibly in the freezing stage of adhesive capsulitis.

Above all else, I feel one of the hardest parts of treating the shoulder has nothing to do with me at all. It has all to do with the patient. I often get fantastic results using manual therapy for some spinal conditions. However, the shoulder requires a lot of active care…meaning the patient can’t be lazy. Corrective and rehabilitative exercise is a MUST for the vast majority of shoulder problems. For athletes, this is great. But for a mother of 3 who works full time and barley has enough time in the day to eat, doing the required home exercise program is…well…hard. This is what they don’t tell you in school…they show you great exercises that get shoulders better…but they don’t tell you how hard it is to get clients to adhere to a graded home exercises program. Sometimes even giving 1 or 2 exercises is all I can do because giving all that is required to create needed mobility and strength in the shoulder is just too much.

So what’s the best way I have found to convince clients to do their exercises? You need to PROVE to them how important they are. Here is how I go about doing that:

1) Many clients with painful shoulders have a large kyphosis or sit in a hunched forward position (desk workers syndrome). This effectively closes off the subacromial space leading to impingement. Have the patient assume their normal poor posture position and tell them to maximally flex their arm. They will have decreased ROM with sooner onset of pain. Then have the client sit erect with scapula back and down and repeat shoulder flexion. This will produce increased ROM and later onset of pain (which hopefully is diminished in the new position). This teaches the patient how important it is to have good posture and strong scapular retractors….this proves to the client how important the exercises are.

2) I also do assisted scapular upward rotation to help clear the acromion and humeral head during arm elevation. If this diminishes or abolishes the shoulder pain I always tell the client that we have to make the muscles that my hands acting as to keep your shoulder feeling this good. Again, I’m proving to them how great they could feel if they put in the work.

A 2009 article from JOSPT did a great job of summarizing the proposed biomechanical mechanisms of scapular kinematic deviations. They are:

1) Inadequate serratus activation: Lesser scapular upward rotation and posterior tilt

2) Excess upper trap activation: Greater clavicular elevation

3) Posterior GHJ soft tissue tightness: Greater scapular anterior tilt and humeral head anterior translation

 4) Thoracic kyphosis or flexed posture: Greater scapular IR and anterior tilt with less upward rotation

(JOSPT Feb 2009: The Association of Scapular Kinematics and Glenohumeral Joint Pathologies)

So what do I do for painful shoulders? Here are some of the usual steps I take for most shoulders problems:

1) Address Thoracic kyphosis: Retraction and extension exercises, thoracic spine manipulation, soft tissue release, posture arch, spikey ball, posture education

 

2) Address scapular stabilizers: Strengthen serratus anterior (wall slides, push up plus, hugs, punches etc), lower traps (Y’s, Overhead pull aparts, chair dips), and rhomboids (rows and active scap squeezing)

 

3) Address soft tissue tightness (BIG ONE!!): Release levator scapula, scalenes, SCM, upper traps, QL space, subscap, pec minor, pec major, lats

 

4) Rotator cuff strengthening: Side lying ER, Isometric ER/IR, scapular plain abduction progressing to ER at various degrees of shoulder abduction, “W” squeezes ( a favourite of mine)

5) Capsular stretching: Door way ER stretch, horizontal adduction and sleeper stretch with PNF contractions being my favourites

Overall, the shoulder is a tough joint to treat because no one exercise or technique works for everyone. It’s a constant trial and error processes that is made easier by a good assessment that takes into account posture, the cervical spine, contractile and non-contractile tissue along with more distal and inter-systemic issues manifesting as shoulder problems. The one thing we as therapists need to remember is that non-acute shoulder dysfunction doesn’t happen overnight…it takes months of misuse before problems arise. Therefore, we shouldn’t expect shoulder problems to disappear instantly. It takes time, focus, and a considered effort on the clients part to get a shoulder healthy.

Do you have any tips for treating painful shoulders? What kinds of techniques do you use?

Have a great day!

2 BIG Announcements

Posted: May 23, 2012 in Uncategorized

Hello Blog readers. Today I have 2 very exciting announcements to make that I’m sure will be of interest to all of you wonderful people:

1) I have joined up with www.physioanswers.com to help write small articles on real life matters related to your health and wellness. This site is simple it nature–it is just a bunch of very smart professionals from across the world who have come together to make an easy to navigate site with great articles for your health. And it is 100% free!!

2) Have you ever wished you had access to easy to follow, professionally made exercise videos for either yourself or your patients? There are a bunch on youtube, but they are of sub par quality and don’t give the viewer all the tools to really understand how to do a simple exercise. Well in the coming months, me and my colleague (and friend) Scott Stanger are teaming up to produce a first class website with exercise videos. Professionally shot, with text, video and voice to help fully explain exercises. This site will be easy to navigate and will surely help your patients out with exercises…because really, are the pictures on paper showing exercises really helping our patients understand what to do? I think not. Scott and I want to change all of that. Our site will show rehab exercises from simple clam shells and side lying external rotation to more complicated movements like single leg deadlifts or turkish get-ups. More information on this to come as we develop and fine toon it for its big debut.

Please comment with any suggestions you have for either announcement and I will be sure to listen!!

Manual Therapy in Canada

Posted: April 14, 2012 in Manual Therapy

This blog post will be a little different from ones I have written in the past. Today I want to explain the manual therapy system of education as I see it in Canada. This post will hopefully be informative and useful for both other young Canadian therapists and those abroad who have an interest in manual and manipulative therapy.

As I sit at my desk writing this post I am looking at my clock because in about 2 hours time I have to head to downtown Toronto to be a mock patient for the Orthopaedic Division intermediate manual and manipulative therapy practical exam. You will know exactly what that is once you have finished reading this article. I also chose to write this piece because I am currently a student enrolled in the level 3 upper manual therapy course…again, you will know exactly what that is momentarily.

Let’s take a step back and assess why someone would want to do MORE course work after just finishing almost 7 years of post secondary education to become a registered physiotherapist in Canada. I think the answer to that question is a personal one and many people will have different answers. For me it boils down to wanting to do better for my patients. As much as I learned in P.T school, I still feel I lacked the request knowledge to understand the gamut of clinical presentations I was seeing in practice. I know from having placements with manual therapists that have been through the system that their clinical reasoning (problem solving) skills were superior to those who did not do any manual therapy con-ed (just my opinion). So for me, it boils down to learning as much as I can about the field I have chosen to specialize in. When I know more I can treat more and get more people better…this makes for a much for fulfilling career as far as I’m concerned. Because applying ice, stim, and ultrasound to everything that walks in my door just doesn’t do it for me. It also gives me a great sense of specilization…that I have done more to boost my career to the level I want it to be at.

Here is a diagram of the manual therapy system in Canada taken from the ortho division website . It shows a schematic representation of the “level system” and all that needs to be done to navigate through it. I have NOT done the entire system yet as this takes years and I have only been in practice since 2010. However, I have completed the level 1 exam (you can do a course for level 1, but many just choose to do the exam), level 2 upper quadrant course and exam, level 2 lower quadrant course and exam and am now on my level 3 upper quadrant course. The level 2 courses take about 4 months each to complete (you are in class for one full weekend a month for 4 months). Yes, you heard me…an entire Friday, Saturday and Sunday of each month for 4 months is devoted to manual therapy. Each of the 4 weekends deals with a different body area (for example, the first level 3 weekend was dealing with the craniovertebral, mid cervical spine and cervicothoracic junction areas). Not only that but it is essential to study before and after each weekend because the amount of info you are given is overwhelming at times. Personally, I spend on average 30-40 mins/day looking at the notes, reviewing videos online, etc… If I didn’t I would be lost come course time.

Lumbar spine flexion Mobilization

The courses themselves and exams are what are needed to be done to be able to do the practical (hands on) exams. Oh wait, you also need to accumulate a crap load of mentorship hours with a therapist who has already completed the level system to be allowed to sit for the intermediate and practical exams….writing it all out like this really makes it look like an exhausting process haha.

As per the diagram, once you do levels 1-3, gotten mentorship hours, passed the intermediate exam, done levels 4-5, got more mentorship hours, and finally passed the advanced practical exam you get the designation FCAMPT (Fellow of the Canadian Academy of Manipulative Physiotherapists). This is the classical route to take but there is a newer masters program at the University of Western Ontario that fast tracks this processes by giving you level 3-5 and the FCAMPT designation by doing 1 solid year of study…there are pros and cons to this program as what I’ve been told (many of the cons have to do with the huge loss of income incurred by taking the time away from work to complete the in class sessions in London).

To finish this article off I want to give you a glimpse into what exactly is taught on these courses. I have randomly chosen to give some highlights of my last level 3 upper weekend where we talked about the neck. We reviewed:

Subjective assessment of dizziness, cranial nerve symptoms, cord signs, headache, pain etc

Objective assessment of active mobility tests in the neck (including combined contralateral for CV region and ipsilateral coupling for mid cervical region), passive mobility tests for the OA and AA joints, passive accessory testing for the OA, AA, and mid cervical joints (e.g bilateral and unilateral anterior glide at the OA joint), stability testing of the neck using compression, distraction, anterior, posterior lateral and rotational shear—this tests the passive restraint systems in the neck like the alar and transverse ligaments. We learned how to length tension test the suboccipitals (debatable if you can actually isolate these muscles), SCM, lev scap, and all 3 scalene muscles. We talked about treatment techniques in the form of mobilizations for the neck as well as locking techniques and exercise for the deep neck flexors. We also talked about pathologies like thoracic outlet syndrome, spondylosis, nerve entrapment and so on…

Manuals all ortho div students have seen

Overall I love these courses because they really challenge my clinical reasoning skills and force me to critically reflect on my clinical practice. I sometimes fear I have fallen into a “comfort zone” of treatment and do similar techniques for various conditions. This a common trap for therapists and I refuse to be a one trick pony. These courses help me identify issues with my patients I would have never even thought to have looked at prior to taking the courses. Do I agree with everything that they are teaching me? NO! I could do a whole rant on how I really don’t think we can be as specific to a spinal segment (with palpation or grading of mobs) as they want us to be. But hey, you have to take the good with the bad I guess.

Please let me know if I missed anything in this article or if you want any more detailed info on what was said.

Thanks for reading!

Jesse Awenus, P.T

VERY cool case presentation

Posted: March 9, 2012 in Uncategorized

This is my first case presentation on my blog…so exciting. I had a VERY interesting (and awesome) case at my clinic this week that I had to share with whoever wants to listen. I always feel hesitant to write about clinical cases  because I realize there are many ways to skin a cat and I’m sure another therapist will come along and tear apart my diagnosis and subsequent treatment. This case however, the results were unlike any I have experienced yet as a physiotherapist.

A 43-year-old woman presented to clinic 3 days ago suffering from a 3 year off and on again history of “heaviness in the ears”. This was accompanied by bouts of dizziness and a slight ringing in the ears as well…she has become VERY annoyed with this and stated it was messing up her life. At first my red light caution flag came up, so I did a very thorough history and exam. Her reported mechanism of injury was doing a dive in her pool, twisting her neck. I immediately thought “uh oh, vertebral artery issues”. So I asked her about the 5 D’s and 2 N’s which were all negative. Her BP was 128/85 (not bad). Her HR was 73 BMP. Even though the sensitivity and specificity of the vertebral artery stress test sucks, I did it anyways (why not, right?). It was negative as well. She had no recent trauma to speak of.

Does this look fun?? NO!

I then thought about BPPV (vertigo). I did the dix-hallpike test bilaterally which revealed no nystagmus or dizziness…does anyone like doing this test? I don’t like throwing my clients down to the bed repeatedly and I’m sure they don’t love it either…But I digress

I remembered reading an article  that talked about upper cervical spine restrictions leading to altered proprioceptive input to the brain leading to sensations of dizziness and ringing in the ears. So, I checked the craniovertebral area and BAM…barley any movement was noted at C1-C2 bilaterally into right and left rotation on accessory glide tests…yeah, yeah I know…PIVM testing is garbage and unreliable…but hey, this is what I felt…it just wasn’t moving. Since this was the largest clinical finding I found I made a decision to treat it. I started with mobilizations…I did that for about 3-4 minutes and it really didn’t change her accessory glide testing. Her upper cervical flexion test was also at about 30 degrees bilaterally (should be roughly 45 on both sides) . I asked my patient if she was alright with me manipulating her neck to free up the restrictions. I told her the risks and benefits and made her aware that if she was at all uncomfortable we could do other things. She was happy to let me do the manip. I put her in the pre-manip hold—zero pain noted by the client. I then did a HVLA thrust at C1-C2 on both sides. Cavitation was noted on first attempt…always nice when that happens.

After the manip, I had her stay on the table for a few minutes. She felt fine and proceeded to sit up. She sat on the side of my treatment table and started to smile…then laugh…and then cry. She stated “I have had this issue for ages and it’s gone…all gone”. It was a great feeling to have helped her with her issue. I saw her again the very next day for follow up. She said she was 90% better and very happy. I did myofascial work on her suboccipitals, scalenes, levator scapula, splenius capitus, and upper traps. I sent her home with chin tucks and scapula retractions as a home program. She called me today at the clinic saying she woke up this morning with zero symptoms….SWEET!

Suboccipital release Doesn't it just look great...

Ok, here is the moral of the story: I went on a hunch…did I know with 100% certainty that her issues was neck related…I’d be lying if I said yes. I went with my best guess and it paid off for me in this instance. Taking manual therapy courses and being an avid reader of the literature has afforded me the ability to know the risk-benefit ratio for the techniques I employ. I know the risk of neck manips (it’s minimal) and I cleared her for everything beforehand. I recalled reading a study (now I remember where I found it)… here’s the link  that showed a very high success rate with manipulative therapy to the neck with the symptoms my client presented with. I wouldn’t start maniping everyone with ear problems, but if you can differently diagnose and rule out issues, you’re well on your way to figuring out why your clients have pain. I don’t use neck manipulation very much as I think for many issues there are better treatments to give (muligan mobs, massage, traction, thoracic manip etc). But for the amount of restriction I felt, I just felt it needed to be done…and I’m happy it proved successful!

Hope this little case presentation was interesting. If anyone has any other ideas about treatment or differentials for this presentation I am very happy to learn!

Thanks for reading.

 

Today’s blog post comes at the request of a few of my back pain patients. Over the past few weeks I have been talking with my patients about their back pain. I have come to realize that some of  these patients genuinely believe they injured their back from bending over to tie up their shoe, picking up a pen off the floor, or reaching for that jar at the bottom of the fridge (all real storey’s about “why” they hurt their backs)…and every time I hear a story like this I have to shake my head….

I think patients think their back is like this...

Patients must believe their backs are about as sturdy as a Jenga tower if they think those simple actions caused their backs to go out. I have to always tell my patients that 9 times out of 10, the pain they’re experiencing is due to many weeks, months, or years of misuse. It is only when the body is tired of trying to compensate for faulty movement (or lack of moevemnt) do they experience pain.  When asked about their gym routines (for the ones that actually go!), almost always do they proudly mention that they do sit ups and crunches as part if their core routine. This is a sure fire way to slowly but surely hurt the back.

Without getting into it too much detail, Dr. Stuart McGill out of the University of Waterloo has done the research and we now know that flexion based exercises (like sit ups and curls) are BAD for the back…and in reality, it doesn’t even train the core in a functional manner at all. Here is a quote from Dr. McGill’s book “Low Back Disorders”

“Too many exercises are prescribed for back pain sufferers that exceed the tolerance of their compromised tissue. In fact, I believe that many commonly prescribed flexion exercises result in so much spine compression that it will ensure that the person remains a patient. The traditional sit-up imposes about 730 lbs of compression on the spine at each repetition. The National Institute of Occupational Safety and Health (NIOSH) has set the action limit for low back compression at 730 lbs; repetitive loading at or above this level is linked to higher injury rates in workers, yet this is imposed on the spine with each repetition of a sit up!”

I said earlier that a sit up is functionally a rather stupid exercise. It trains the rectus abdominus to act as a thorax flexor. While the muscle does have the properties to act as a flexor, its real job lies in its ability to be an anti-extensor. The abs functional job in the human body is to control the rate of spinal extension as apposed to producing spinal flexion. For example, try leaning back while sitting on a workout bench. While leaning back, put a hand on your abs…they are firing like crazy! Why? Because they are contracting eccentrically to make sure you don’t fall off the back of the bench. This is their job in life and sport… the obliques, rectus, and transverse abdominus are ANTI-MOVEMENT muscles. They stabilize the spine and prevent spinal buckling or shearing from occurring. With this in mind, training them as flexor muscles is about as useful as training your biceps by only doing curls…sure you’ll make them look nice (nothing wrong with that!) but you’ll be missing out on all that they can do!

My patients always ask me then “Ok Mr.wiseguy physio, if I can’t do sit ups or crunches, how else am I going to work the core?” Here are my favourite (and safe!) core exercises listed in no particular order:

Chops and Lifts: LONG video demo by Gray Cook but I think it’s worth the time. He explains this far better than I ever could

 

McGill big 3 (plus stir the pot): Another great video with Prof. McGill explaining WHY these exercises are good…plus they are backed my tons of high quality research

 

Deadbug: Great exercise because it uses the core to stabilize the extremities while not putting any load through the back

 

In summery,

  • Your back doesn’t “go out” from picking up a pencil, it was already dysfunctional but you just didn’t know it yet
  • Functionally, the core acts as an anti-extensor and anti-rotation unit–not as a upper body flexor
  • A good core exercise is one in which the extremities move against resistance while the core is stationary working to stabilize the back
  • Sit-ups and crunches suck…they do more harm than good
  • The exercises I listed above will not only make your core stronger, but they will in most cases help your back pain

As always, questions are always welcome

Jesse Awenus, PT

Remind you of someone?

Oh, another HUGE reason for back pain is sitting too much at one time (hmm, I should probably get up). Here is a GREAT and simple exercise sheet you or your clients can use to help stay back pain free at work (courtesyof Dr. Craig Liebenson)

Love this picture!

A few months ago I wrote an article on how muscle tightness might be a result of a skeletal imbalance as apposed to simply a shortened muscle. I discussed how an anterior pelvic posture might actually lengthen the hamstrings due to their origin and insertion being forced further away from one another leading to a series of events that causes the hamstrings to group to seem tight. In this case, the hamstrings aren’t tight, thy’re in tone via the sympathetic nervous system telling the muscle group to stay tense as not to allow tearing to occur. Read my previous post HERE to get caught up.

Awesome Diagram

Professor Janda was a revolutionary in the field of muscle imbalances. Through both study and observation he derived what we now call the upper and lower crossed syndromes. In today’s society where we sit almost all the time, the lower crossed syndrome is almost epidemic! Think about it for a second…when you get up in the morning you sit to have your coffee, have breakfast or read the paper. You sit in your car to get to work, and most of us sit almost all day at work! Then we go home and sit down to eat dinner and relax in front of the T.V! That is a lot of sitting. If you don’t think sitting is detrimental to our health, click HERE to find out more.
From a biomechanical perspective, sitting puts the hip flexors in a shortened position for hours on end. This causes the gluteal muscles to “turn off”in what Professor Stu McGill calls Gluteal Amnesia (reciprocal inhibition). When the glutes turn off and the hip flexors become tight, we see the pelvis pulled anteriorly and then (to make matters worse) the lower back paraspinals get placed in a shortened position and the rectus abdominus gets places in a lengthened position. These changes only help to solidify the pelvis is an anterior position. Clinically, you can measure this by simply looking at the angle between the PSIS and ASIS. In her book Muscle Testing and Function, Florence Kendall states that the PSIS should be no more than 5-10 degrees higher than the ASIS.

See the belly on her? You might have a belly and it has NOTHING to do with your weight...

 

If it is higher, you might consider the patient has having an anterior tilt. Other things to look at are as follows:

Size of lumbar spine lordosis: An increased lordosis indicates the hip flexors and lumbar spine erectors are pulling the pelvis forward which creates an extension moment at the lumbar spine. As stated in the picture above, an increased lordosis might make it look like you have a spare tire around your waist…even if you’re skinny!

Positive Thomas Test: If the psoas, iliacus (NOT iliopsoas!) or rec fem are tight it will be evident in this test. Personally I like it because it’s fairly objective and a positive test is easy to identify. I don’t have the studies off hand, but I can only assume inter-rater reliability would be quite good. It’s hard to miss a leg popping off the table during the test!

 Hip bridge test: Have the patient do a bridge and palpate the glutes and hamstrings. Which are they using more? In the bridging position, the hamstrings are in a shortened position and because of this they should be using mainly their butt muscles to extend the hips off the table. If they are using too much hamstring, or they complain of muscle cramps in the hamstring, they have gluteal amnesia (a weak butt).

 So what do I do clinically for clients that have this issue (and MANY do!)?  There are a few different techniques I use depending on subjective complaints but on the whole, this is what I do (and it’s not rocket science).

1) Lengthen the hip flexors (rectus femoris, psoas, iliacus, and even tensor fascia latta if need be. I like to do this as a PNF (contract-relax) stretch in the Thomas test position because I can get all the above muscles at pretty much the same time. I also like this position because it prevents the lumbar spine from being pulled into extension as seen so much in people who try to stretch their hip flexors.

2) I do soft tissue work to the lumbar spine erectors to try and decerase their tone. I will often follow this by manually rotating the pelvis posteriorly to increase the stretch of the paraspinals and to simply help place the pelvis back where it should be. I like doing my posterior pelvic mobilizations in a side lying position.

3) Glute strengthening/activation. You can literally have a whole post dedicated to glute exercises but for simplicity sake I usually start off by having my clients’ squeeze their glutes while they feel the muscle contract while I palpate the hamstrings. I want to teach them how to fire up their butt while not using their hamstrings…often easier said than done! Mike Reinhold has a great modification to the bridge that I give my patients to strengthen their butt. Here is the video:


4) Core strengthening. Again, not getting too detailed here because there are 100’s of ways to do this. For my average sedentary clientele I give McGill curl ups, plank modifications (off a wall, on knees etc) or even crook posterior pelvic tilts to fire the rectus abdominus and push the pelvis posteriorly. For my athletic patients I like to give front/side planks with harder modifications, dead bug, stir the pot using a physioball, or shoulder touches in a pushup position

5) I do a lot of soft tissue release to the hip flexors, hamstrings, lower back thoracolumbar fascia and paraspinals. It makes the client feel better and hey, is that ever a bad thing?

 6) EDUCATION!! I always tell my clients they need to get up every 30-40 minutes to take a walk around the office. No one position for any extended period of time is good for the body…the lotion is in the motion! I have given my clients instructions to use a stop watch or there is even an app one can download on their home screen that will make a buzzing sound every 30 minutes reminding them to get up.

As always, different patients need different things and this is a general overview of what I do. By no means is it exclusive. A cookie cutter approach will yield cookie cutter results.

Thanks for reading,

Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist

 

We'll see about that...

 

As some of my readers know, one of my blog posts has started a little bit of an argument over the philosophy some chiropractors abide by in their practice. Instead of responding to the chiropractors posts individually, I will try my best to show literature (no opinions) to explain why I have come to believe that subluxation theory has no place in today’s healthcare marketplace.

Before I start, I want to reiterate that I am a chiropractic supporter! I support any healthcare discipline regardless of the credential that incorporates current best practice evidence when treating their patients. For myself, as a physiotherapists who limits himself to the diagnosis and treatment of neuromusculoskeletal conditions, I feel I have a responsibility to my patients to seek out the best information I can on the most effective way to assesses and treat. I don’t rely on dogma or the thought processes of any one particular guru to guide my

The Guru...

clinical practice. I don’t subscribe to a single theory, or preach one entity as the cause of all (or most) disease. Like I said in my original post, I have many chiropractic friends who I look up to as colleagues and try to learn from. My father is a chiropractor in practice for 31 years and we are always learning from one another. I am not naïve to the profession as some of the chiropractors on my blog have inferred.

 For the rest of this post when I refer to chiropractic care I am referring solely to adjustments for subluxations. I am NOT referring to the other modalities evidenced informed chiropractors employ…so let’s look at the evidence:

There is questionable scientific evidence chiropractic works. Neither of two cochrane reviews support it, nor can the The National Center for Complementary and Alternative Medicine (the Federal Government’s lead agency for scientific research on complementary and alternative medicine) who state:

“Overall, the evidence was seen as weak and less than convincing for the effectiveness of chiropractic for back pain. Specifically, the 1996 systematic review reported that there were major quality problems in the studies analyzed; for example, statistics could not be effectively combined because of missing and poor-quality data. The review concludes that the data “did not provide convincing evidence for the effectiveness of chiropractic.” The 2003 general review states that since the 1996 systematic review, emerging trial data “have not tended to be encouraging…. The effectiveness of chiropractic spinal manipulation for back pain is thus at best uncertain.” The 2003 meta-analysis found spinal manipulation to be more effective than sham therapy but no more or no less effective than other treatments.” from: http://nccam.nih.gov/health/chiropractic/#9a

 The national center for complementary and alternative medicine, who’s purpose is to support CAM can’t in good conscious conclude that manipulation for “subluxations” works….interesting.

This review then necessitates to me that prudent healthcare practitioners use a multimodal treatment approach. No one therapy alone is sufficient! Just manipulating the spine without doing anything else will yield suboptimal results as stated in the literature.

The chiropractors that have commented on my blog have pretty much stated that the foundations for chiropractic are based on some of the most self evident truths of this universe and they fix subluxations because they feel universal intelligence clearly exists.

Now, no one is arguing against the existence of a supreme being. Nor are we suggesting that faith doesn’t play a role in health. What I do take issue with is the role of D.D. Palmer as high priest.

A quote from his 1910 book “The Chiropractor’s Adjuster” –

“I founded Chiropractic on Osteology, Neurology and Functions of bones, nerves and the manifestations of impulses. I originated the art of adjusting vertebrae and the knowledge of every principle which is included in the construction of the science of Chiropractic.”

and

“I am the originator, the Fountain Head of the essential principle that disease is the result of too much or not enough functionating. I created the art of adjusting vertebrae, using the spinous and transverse processes as levers, and named the mental act of accumulating knowledge, the cumulative function, corresponding to the physical vegetative function — growth of intellectual and physical — together, with the science, art and philosophy — Chiropractic. It is now being followed, more or less, by 2,000 Chiropractors, and its use is being attempted by several other methods. It was I who combined the science and art and developed the principles thereof. I have answered the time-worn question — what is life?”

Besides the obvious factual error (Palmer did not “create” SMT, it has existed in some form since before the time of Socrates), he claims to be the “fountainhead” of knowledge and to be able to answer to the question “what is life?”. There are others who have made similar claims over the years, including, but not limited to David Koresh, Rev. Jones, and General Idi Amin Dada…can you see why his god complex persona discredits him?

The second issue, how does a grocer (Palmer’s career in 1895) instantly become so well versed in “Osteology, Neurology, and the Fuctions of bones, nerves, and the manifestations of impulses” to found anything?

Third, how does Palmer so easily dismiss the thousands of years of evolution in medical knowledge that came before him? Peracles, Hippocrates, Socrates, Virchow, and Lister mean nothing? Palmer was smarter than the thousands of healers who came before him. He alone is the “Fountainhead”. Please.

Lastly, look at Palmer’s motivation (again from his book):

“One question was always uppermost in my mind in my search for the cause of disease. I desired to know why one person was ailing and his associate, eating at the same table, working in the same shop, at the same bench, was not. Why? What difference was there in the two persons that caused one to have pneumonia, catarrh, typhoid or rheumatism, while his partner, similarly situated, escaped? Why? This question had worried thousands for centuries and was answered in September, 1895.”

Actually, we now have the answer to this worrisome question, and it isn’t chiropractic. Our modern understanding of the immune system, down to the protein synthesis level, has specifically determined the answers in a very provable manner.

Very interesting book!

 More on subluxation theory:

Other chiropractors have declared its unproven status as an area that needs reform:

“Some may suggest that chiropractors should promote themselves as the experts in “correcting vertebral subluxation.” However, the scientific literature has failed to demonstrate the very existence of the subluxation. Until and unless sound research published in credible journals demonstrates the existence and reliable identification of vertebral subluxation, and vertebral subluxation is found to be an important public health problem, society at large will not care about its correction. Thus, “subluxation correction” alone is not a viable option for chiropractic’s future.”

(Murphy, et al.Bringing Chiropractic Into the Mainstream in the 21st Century – Part II“, Dynamic Chiropractic, September 1, 2005, Vol. 23, Issue 18)

 A Beth Israel Deaconess Medical Center article describes the mainstream understanding of vertebral subluxationheory:

Since its origin, chiropractic theory has based itself on “subluxations,” or vertebrae that have shifted position in the spine. These subluxations are said to impede nerve outflow and cause disease in various organs. A chiropractic treatment is supposed to “put back in” these “popped out” vertebrae. For this reason, it is called an “adjustment.”

However, no real evidence has ever been presented showing that a given chiropractic treatment alters the position of any vertebrae. In addition, there is as yet no real evidence that impairment of nerve outflow is a major contributor to common illnesses, or that spinal manipulation changes nerve outflow in such a way as to affect organ function.[32]

 (Robin Brett Parnes, MS, MPH, “Chiropractic Treatment: What You Should Know“, Beth Israel Deaconess Medical Center.)

And finally:

In 2009, four scholarly chiropractors (yes, chiropractors did this study!) concluded that epidemiologic evidence does not support chiropractic’s most fundamental theory. Since its inception, chiropractors have postulated that “subluxations” (misalignments) are the cause or underlying cause of ill health and can be corrected with spinal “adjustments.” After searching the scientific literature, the chiropractic authors concluded:

“No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal, this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.”

 (Mirtz TA et al. An epidemiological examination of the subluxation construct using Hill’s criteria of causation.Chiropractic & Osteopathy 2009, 17:13, 2009)

 With this in mind, it is laughable to me that some chiropractors claim that through the removal of subluxations they have prevented heart surgeries, helped with ADHD or colitis…among other conditions. HOW can any rational healthcare practitioner espouse this? I mean, ca’mon! Let’s be real here.

Another great read

Instead of debating the chiropractors on my site point by point I have taken the time to find my sources. It was said that I am an “unarmed man” when it comes to research. I have just posted excerpts of studies showing you WHY I believe your theory for why you say you do what you do just doesn’t hold water. If anyone has any credible sources to prove subluxaions A) Exist and B) cause the problems some have said they create then please share. I am always up for learning and always ready to change my mind if presented with compelling information.

I realize that this post may have offended some and I’m sorry for that. I started my original post praising where chiropractic is going and by the comments of a few, I am sadly reminded that there is still so far for your profession to go. I find it funny how subluxation based chiropractors tell me that other chiros who do more than fix subluxations are “fake chiros”. These are the chiropractors that have taken it upon themselves to constantly learn more and demand the most from their profession. Are they doing exactly what Palmer said they should do? NO! And I commend them for it!

For a much better author on this topic please visit: http://www.sciencebasedmedicine.org/index.php/subluxation-theory-a-belief-system-that-continues-to-define-the-practice-of-chiropractic/

 Thanks for reading,

Jesse Awenus B.A (Hons) Kin, MSc.PT
Registered Physiotherapist

 

 

Great big toe mobility

If one link breaks,what happens to the rest?

 

As many of you know, the times of treating the site of pain are behind us (with exceptions of course). Through a paradigm shift in the rehab/training world we have come to appreciate the body as an integrated unit, where all it’s part never function in isolation but as a unified whole. This means that when a patient presents with knee pain as an example, the knee is very rarely the cause of the pain. The knee pain is simply the consequence of an issue at a joint either above or below the knee. Now that we have that out of the way….on to the topic at hand!

Low back pain (LBP) is an epidemic. We all know the stat that 80% of us will have back pain at some point in our life…I know I have! The problem then becomes an issue of treatment. Let me just say that I am not dead set in my ways and I know there are many ways to skin a cat..i.e many different treatments can fix the same problem…that’s only if the right problems are addressed. In this blog I will explain how a restriction at the big toe can ultimately lead to back pain…just something else to think about.

Hallux Rigidus can occur for many reasons. This condition presents itself as limitations in big toe extension

Heel strike, to 5th toe, to 1st toe

(dorsiflexion). Why does that really matter? Oh…it matters! Every step you take the big toe is working to create power for push off. We start off with heel strike, the subtalor joint moves us into inversion where our weight is placed on our 5th met head and then we have subtalor joint unlocking which allows the midfoot to fall into functional pronation allowing the big toe to come into contact with the ground. At this point, the big toe digs into the ground to create the push off we need to move forwards. In order for the big toe to flex into the ground to create momentum, it must first go into 45-60 degrees of extension to create the proper length tension relationship to allow the push off phase to occur. This is where problems start to set in.

If the big toe can’t dorsiflex, the body is going to compensate for that lack of movement by trying to shift the body weight medially to get that big toe to hit the ground…the body is smart and will always find a way to do things to keep moving. When we don’t get the movement from the big toe, the knee must go into valgus collapse (knock kneed) to try and get as much weight on that big toe as possible for push off. When the knee goes into medial collapse, the hip moves into internal rotation and the lower back compensates by shifting towards the side of hip internal rotation. When the low back shifts, you can get muscle shortening, facet joint impaction, degenerative changes etc…leading to back pain that started from a lack of big toe extension.

So here is the BIG question…WHY can’t the big toe extend? Arthritis is one reason but I won’t discuss that as again, I believe arthritis is just a consequence of a biomechanical imbalance elsewhere. Here is a big reason that I see clinically. If the flexor hallicus longus muscle becomes restricted, the big toe will not have the mobility to extend due to the muscle keeping it in a plantarflexed position. We sleep in a plantarflexed position so this muscle often becomes tight in some people. If the flexor hallicus longus is fine and patient still can’t dorsiflex the first ray with ambulation then I check peronius longus. Why? The peronius longus has the task of transferring weight from the 5th met head to the big toe during the gait cycle..it helps create that functional pronation I was talking about before. It also has a roll to play in plantar flexing the big toe to help with push off. So, if peronius longus is weak or tight it could be a cause of why the big toe can’t fully get the mobility it needs to create adequate push off power.

 In short, to treat this I mobilize/manipulate the first MTP using accessory and physiological glides. I do myofascial release of the flexor hallicus longus from the fibular origin to its insertion (probably getting a few other muscles at the same time…but that’s fine!). I stretch the foot into dorsiflexion, I work on peroneal strengthening (good one being heel lifts a with tennis ball squeezed between the ankles), and I of course work of glute strength…because everybody needs it! I also check the pelvis to see if there is an imbalance at the innonimate…that too can be one cause of big toe problems

Simple big toe self stretch:


Peroneal Exercise:

Are there other reasons for back pain? 100% yes without question. This article was just written to help therapists who have clients with nagging back pain to help think outside the box in terms of possible causes. I know I have been stuck with clients in my practice and have neglected to look at other factors…not so much because I didn’t want to, but more because I just didn’t know they could be issues in the first place. I guess the take away point is to be a detective with the body. Never think that a problem you see somewhere other than the site of pain is unrelated…it probably is. I’m the first to admit that I have been caught chasing symptoms to try and make the client happy. But I have found that if I take the time to explain why I’m wiggling their toe for their back pain, I gain credibility…because If I didn’t explain that, I’d be considered a voodoo therapist in their eyes hahaha

 Thanks for reading and happy new years!

 Jesse Awenus B.A (Hons) Kin, MSc.PT
Registered Physiotherapist

Research Review Service

I get asked this one question daily: What is the difference between a chiropractor and a physiotherapist? I often get asked this question after I perform spinal manipulation as most patients usually deem that to be chiropractic territory. My answer to them is never simple as I usually have to explain quite a bit to make my answer make sense. I also do this because I want to give my profession and the chiropractic profession their credit where it is due….and usually by the time I’m done with my answer I’m sure the patient has regretted asking the question in the first place 😉

I usually tell my patients that today’s physio and chiro practice very similar to one another. There are chiropractors that use soft tissue release, ART, acupuncture, modalities, exercise prescription along with spinal manipulation. There are also physiotherapists that do all that as well. I do mention that there are chiro’s that tend to use manipulation as their primary treatment technique and some even use it as their only treatment technique (Yikes!). I get into the philosophical differences between the two professions and how we as physiotherapists have generally been more evidenced based clinicians…but this is changing. However, I ALWAYS say that just as there are quacked out chiropractors, there are also worthless physiotherapists who use ultrasound and heat on anything that walks in their door.

I have many chiropractic friends and for those that don’t know, my own father is a chiropractor who has been in practice for 31 years. I have seen MANY sides of the profession and have done my research. I know the good, the bad, and the ugly of the profession. In all honesty, I am very pleased to see where chiropractic has gone in the past 10 or so years. The CMCC is producing quality, evidenced based neuromusculoskeletal therapists. They have all but done away with subluxation theory and are promoting patient self-care for the management of their pain. I learn a lot from some of the chiropractors I associate myself with and enjoy their take of the rehab profession as they see it. I LOVE how they are rallying against the subluxation based chiropractors in their own profession. They have realized that in order to gain mainstream legitimacy they must be evidenced informed clinicians who do not rely on 110 year old ideas about how the spine and nervous system function.

 

Physiotherapists and Chiropractors who practice using up to date research as their guide probably do things very similar most of the time. Are there differences in our training? Sure there are, but that does not mean one is better than the other…just different. Today, prominent physiotherapists such as Grey Cook and Mike Reinold are working side by side with amazing chiropractors like Craig Liebenson and and Perry Nickelston. Overall, it has become far less about the letters after your name and more about the quality of work you do that determine the kind of therapist you are.

It is essential that ALL rehab and exercise professionals read and stay current. Also, money should not be their soul purpose for doing what they do. These therapists exist and are doing fantastic work. If you ever need a recommendation for a good physio OR chiro let me know and I’ll be happy to assist.

Happy Holidays,

Jesse Awenus B.A Hons (Kin), MSc.PT
Registered Physiotherapist