The Problem with Smartphones

• "Men have become the tools of their tools." -Henry David Thoreau

Before I proceed and alienate everyone, I first want to clarify that I am not against technology and I don’t think smartphones are inherently bad.  I’m not trying to pull a John Connor and convince you to rage against the machine and destroy your cell phone.  In fact, I think technology is a critical component of our culture’s development.  Smartphones can be extremely helpful.  Not only can they end many arguments with instant fact-checking, but they provide an  endless supply of free information and the ability to connect with almost anyone in a first world country.  This creates many opportunities that wouldn’t exist otherwise.But like my mom always says, “everything is okay...in moderation.”The problem arises when smartphones go from a tool to a behavior.  Soon after this, addiction ensues.  Next thing you know you’re so dependent on your cell phone that you’re looking for outlets in public places.I know what you’re thinking, a cell phone addiction isn’t that bad as far as addictions go.   It’s just a cell phone, right?  I would strongly disagree.  Not only are all addictions/attachments are bad, but cell phone addiction can have some serious side effects.  To make this evident, I’ve created this list to help people understand the dangers of a cell phone addiction.

25 Reasons Why Your Cell Phone is Bad for You

1. It’s an Addiction (like a drug) 2. Promotes Static Posture (text neck, text claw, slump back, decreased novel sensory input, etc.)3. It’s a Distraction4. Exposure to Radio Frequency Electromagnetic Fields5. Increases Stress6. Can Damage Your Hands7. Blue Light8. Damages Vision / Eyes (Myopia)9. Reduces Downtime10. Reduces Situational Awareness11. Endangers Kids12. Makes You A Bad Parent13. Impairs Gait (disturbs the way you walk)14. Increases Sedentary Lifestyle and Risk of Obesity (even the blue light alone alters metabolism)15. Disrupts Sleep (click here to understand why sleep is important for your health)16. Decreases Attention Span and Capacity17. Decreases Quality of Interactions with Those Around You (damages relationships)18. Tends to promote shallow work instead of deep work19. Prevents Creativity and Daydreaming20. Makes You A Dangerous Driver21. Creates Unnecessary “Work”22. Increases Risk of Mental Health Problems (depression, anxiety, narcissism, etc.) - especially social media use23. Harvests More Bacteria Than a Toilet24. Inhibits Interactions With Surrounding Environment/Nature25. Makes You Less Homo Sapien

• “The danger always exists that our technology will serve as a buffer between us and nature, a block between us and the deeper dimensions of our own experience.”-Rollo May

10 Things That Will Help

1. Treat it like an addiction2. Become aware of your phone use (use an app to assess the time you’re on your phone, yes, I do appreciate the irony of this)3. Leave your phone in another room4. Limit the amount of times you check social media per day5. Don't check social media or emails until late morning/early afternoon6. Put your phone out of reach when you’re spending time with others or doing activities that require attention7. Turn off notifications8. Focus on other things (mindfulness, hobbies, books, etc.)9. Shut off all screens at least one hour before bed10. Take a Digital Sabbatical--The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

 [subscribe2]

Coaching & Cueing (Part 5 - Visual Cues)

Since our species is vision dependent ( >50% of cortex dedicated to processing visual information), visual cues can be an easy way to invoke a sensory change that alters movement patterns.  This includes not only the sensory input from our external environment, but also our unique ability to create an internal vision (motor imagery).

Visual Cueing

External Visual Cue

An external visual cue is simply a change in the environment that the person can see.  The lines on a road are a simple example of this.  The visual input of the lines creates  “barriers” that we have to keep our car between.  It creates an external reference point in the environment to assist with choosing the correct motor output (driving in a straight line).Of course, these visual cues must be used in conjunction with an external verbal cue.  Driving would be pretty dangerous if people didn’t understand that external verbal cue of “stay between the lines when driving”.Specifically with movement training, this type of visual cue can quickly change a movement pattern faster and more efficiently than most other types of cuing.There are two main ways to visually change external environments.  

1. Create a Barrier
2. Create a Target

In the deadlift example I often will place a rolling stool in front of the patients knees, give them the simple external cue of “don’t touch the stool”, and watch them hip hinge cleanly.But you can just as easily perform the same movement with a target cue.  Stand up a foam roller behind them and have them try to hit their butt with it (see picture below).  Butt target practice for proper hinging.  Avoiding or reaching for an object usually creates a better movement pattern than an internal cue of “flexing your arm outward” or “push your knee out” (examples: shoulder - knee).  It avoids clogging up the processing system and allows the brain to figure out the most efficient way to accomplish the task.  It prevents the biggest mistake - the user error.

Can't get your hip patients to stop passively leaning into their labrum and hinging at their backs? Try the visual external cue of a half foam roller. #coach #Cueing #hip #constrainedactionhypothesis #movebetter

A video posted by Aaron Swanson (@aswansonpt) on Sep 1, 2015 at 6:00pm PDT

The examples could go on forever.  Since the visual environment is an open system, there is an infinite amount of ways to alter the environment to change movement patterns.  Creativity is the only limiting factor here.

Internal Visual Cue - Motor Imagery

Motor imagery can be defined as:

• “an active cognitive process during which the representation of a specific action is internally reproduced in working memory without any overt motor output ”-Decety & Grezes, 1999

In other words, it’s giving yourself an internal cue without performing the movement.  The simple act of thinking about internal movement activates some of the same neurons that would fire if you actually physically performed the movement.It stimulates the “top-down” part of movement.  And we know that the cortex is an important variable when it comes to strength.  So think of motor imagery as reps for your brain.This may be the most underutilized coaching and cues in the movement field.  Reading some of the research on this makes me wonder why this isn’t a common thing.  We are missing out on a ton of potential benefits.There’s a decent amount of research out on this, however, most of it has been through the lens of neurological rehab or disuse from immobilization.  But why not use this to help everyone move better? The basic study is this:

• They put two groups in restrictive wrist-hand casts to induce atrophy.  One group performed only motor imagery of the involved immobilised muscles.  The other group did nothing.  The outcomes: the motor imagery group had 50% less strength loss.  They essentially strengthened the muscle without using the muscle.

 Strengthening the body without using the body?  Pretty profound stuff.

Vision

Changing someone’s vision can have profound changed on movement.  As a species we are very dependent on our vision and our culture increases this dependency everyday.  The easiest way to affect vision is to have the patient close their eyes or to alter fixation, which will have a significant effect on their sensory information.  Another way is to cue directional eye movements to change muscle activation and/or challenge stability.  The latest vision sensory change trend seems to be with external devices.  This can be as expensive as strobe glasses or as cheap as smearing vaseline on swimming goggles.However, vision can get much more complicated.  Working with a dysfunctional visual system can give poor information to the system and influence movement negatively.  This is where optometry can have a huge effect on the way people move.  This is it’s own deep rabbit hole to jump down.  The people at PRI have done a tremendous job at bringing this to light and are a great resource for more information.

Summary

Vision may be the easiest way to change sensory information to augment movement.  It can be as easy providing a mirror or as complicated as detailed motor imagery.  Which one you choose depends on you and your client’s goals and your patient population.

References in Previous Articles

Coaching & Cueing

Part I – IntroPart II – The CategoriesPart III – Verbal Cues – ExternalPart IV – Verbal Cues – InternalPart V – VisualPart VI – ProprioceptivePart VI – Summary[subscribe2]   --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

Andreo Spina's Functional Range Release

I was lucky enough to be invited to another one of Dan Park’s quality continuing education classes at Perfect Stride.  This time it was for Functional Range Release (Upper Extremity) with Andreo Spina.  I had been reading a lot about Spina’s work and was excited at the chance to learn about the FR/FRC techniques and principles.

Andreo Spina

Andreo Spina is the creator of FR (Functional Range Release) and FRC (Functional Range Conditioning).  He is an intelligent, articulate, and opinionated speaker.  He has a great knowledge base and a fresh perspective on the human body.  I’ve taken many continuing education courses over the years; Dr. Spina definitely set the record for most rants.  However, all of his rants have a point and are very educational.  He uses sound logic, conventional wisdom, literature, and dry humor to discuss current practices and clinical beliefs.I walked away from his course with a new perspective on the human body, knowledge of how to influence tissue at the histological level, and became a much more efficient manual therapist.*This is my interpretation of the class and how I conceptualize the approach.  For a more complete understanding I recommend taking one of Dr. Spina's course.  He provides an extensive amount of information and resources (9 on-line learning modules, quality lectures, lifetime membership, and social media support).

Bringing it Back to Histology

Neuo-based approaches have really boomed over the past decade.  And for a good reason - they improve clinical care.  While I love these neurological approaches and understand their value, I also think we can go off the deep end with it.  Sometimes it’s easy to forget there’s a physical human body with constantly adapting tissues.  Just as the nervous system has an influence on tissues, the tissues have an influence on the nervous system.  Even renowned neuroplasticty lover, Lorimer Moseley, has mentioned that we should be considering the role of Bioplasticity.Andreo Spina has done a tremendous job of expanding on this tissue concept and making histology clinically relevant.  FR/FRC focuses on addressing the human body from controlled and specific inputs to influence the histological processes and subsequently, the entire human body.To understand this concept, it is important to recognize that the body is constantly turning over at a cellular level (watch this - tissue remodeling).  I think the quote from the class was “if you look at a picture of yourself from 10 years ago, there won’t be one cell that is the same”.How these cells turnover and in what manner depends on many variables.  Specific to Spina’s work, one of these variables is force.  The force that these tissues “feel” dictates how they turnover.  Force influences cellular activity (fibroblast).  And direction is one of the most important variables of this force.This is a very detailed and scientific rabbit hole to go down.  It involves the piezoelectric effect, tensegrity, mechanotransduction, solid-state biochemistry, collagen, fibroblast activity, cellular signaling, etc.  While it's beyond the scope of this review to discuss these concepts in detail, I'll try to briefly summarize them since it is essential to understanding the FR/FRC system.The influence of force on cellular activity deals with the connections between collagen and cells.  Force is applied to the body and imparted on collagen.  Collagen connects to a cell via integrins.  Different cells grab onto the same collagen fibers (via integrins).  When collagen gets a directional force input, it transmits this signal to multiple cells (tensegrity).  This force is then transmitted from the cell cytoplasm to the nucleus (DNA/RNA).  FORCE IS THE LANGUAGE OF CELLS.  One example of this is Wolff's Law.To put it in clinical terms, your sedentary 45 year old patient that has been wearing high heels for over 30 years is going to have some adaptive tissue changes.  There’s going to be a histological tissue adaptation.  After years of not using ankle dorsiflexion, her body will remove the cells that foster normal dorsiflexion.  There isn’t a neurological trick you can do to change tissue in one session.  In fact, there isn’t any one input that will change tissue immediately.  To adapt and influence that tissue, you will need frequent, long duration, directional force inputs.

What Are We Really Feeling?

Another main concept of the course was to question our manual assessment/intervention.I think an analogy might help explain this concept.Lets take a single-leg stance assessment.  You notice that there’s a significant compensated trendelenburg.  A decade ago we may have accused a weak glute medius and then just hammered the patient with isolated hip abduction exercises (movement blunder).  But now we know there are so many possible causes of this movement pattern that it is nearly impossible to pin it on one thing.The same thing applies for manual therapy.  All we have is our hand contacting another person’s body.  There’s just a hand to skin interface and we are trying to feel for something.  But can we really say what that is?  Is it a fat pocket, malaligned collagen, a tissue anomaly, a genetic difference, or tone?  By saying it’s scar tissue or a knot are we bringing the movement blunder to manual therapy?Adreo Spina thinks so.

• “It is not logical to think that a practitioner can feel 'scar' tissue or 'adhesions.' At the level of 'micro-scarring' in connective tissue, the target is much too small for human touch. Not to mention the abundance of overlying tissue making it impossible to feel alterations in collagen directionality. Our hands can however feel forces. It is the forces generated by movement, or tension, that we attempt to feel. We can also think of it as feeling resistance to passive movement in a particular direction. We feel for aberrant tension…and we treat aberrant tension.”

By focusing on feeling for aberrant forces with movement, we have a more honest assessment.  It takes out the assumption blunder and reduces confirmation biases.

Assessment / Approach

For me, Dr.Spina’s approach is best understood from the Dynamic Systems Theory and Degrees of Freedom Problem point of view.  The premise is that there is an infinite amount of ways for the human body to move.  This is because there is a collective Degrees of Freedom that incorporates ALL the complex variables/sub-systems (in the continually changing internal & external environment) required to achieve a task.  One of these variables/systems is the state of the body’s peripheral tissues.  More specifically, an important tissue variable is the degrees of freedom of the joints (articular ROM).  If there are adaptive histological tissue changes that prevent normal joint movement, then the collective Degrees of Freedom will decrease.  The brain will have less motor control options.  The body will lose movement variability.  The attractor state will deepen.Losing degrees of freedom at the joint level can have a significant impact in the body's ability to manage movement.For an example, lets look at a simple digit lock.  It is not a complex open loop system (actually the opposite), but it'll hopefully help explain how this concept pertains to FR/FRC.Take a 3-digit-lock.  Each digit requires a specific number to match the right combination to unlock the lock.  With the numbers 0-9 and a 3 digit combination, there are 1,000 possible combinations.  If you add just one more digit and make it a 4-digit-lock, the number of possible combinations goes from 1,000 to 10,000.  Pretty significant, right?  Simply adding just 1 digit has a massive effect on the amount of variable combinations.One variable can significantly affect the whole system.You could look at the body the same way.  Having minimal joint motion may provide for some adequate movement options (3-digit-lock).  But having even just a little more joint motion can have significant impact in the movement options (4-digit-lock).  What if you needed the 1,001 movement combination to safely land from a jump?  If you only have 1,000 options, you'll compensate and risk injury.  This analogy works for the entire spectrum, from your 1-digit-lock medicare patients to your 100-digit-lock gymnast.

• Articular DOF = Nervous System DOF = Movement DOF

This is why Andreo Spina’s assessment approach is to first check every articulation of the body (joint ROM).  His philosophy is that if you don't have the prerequisite articular motion then your movement will suffer.  Why not focus on the other variables?  Because you can't build strength, stability, or motor control in ranges you don't have.  Developing the optimal ROM takes priority over developing strength in an inadequate range.Once he assesses the joint articulations, he will assess the soft tissue with palpation and passive movement.  If the person is in pain, he tries to reproduce it with palpation to determine a specific tissue diagnosis.  If there is no pain, he palpates the local area to asses how well the tissues are moving.* (=) is influence

Don’t Hang Up

Force is the input that tells the fibroblasts how to lay down.  Research has shown that it takes 2 minutes for these fibroblasts to become activated.  If you’re constantly changing direction or moving, then the cells won’t get the right input.So if you’re trying to influence tissue, you need to hold the directional force for 2 minutes.  He had a great analogy of a phone call.  You need to stay on the line long enough to get the message across.  If you keep hanging up (e.g. pin and stretch manual techniques, STM, etc.), then the communication won’t go through to the fibroblasts.Keep patients in the same posture, don’t pump through ranges of motion, hold tension longer, think directionally.

Isometrics

Isometrics are extremely beneficial.  Here's a list of 10 reasons why:

1. Gives directional force input (communication)
2. No joint shearing
3. No inflammatory reaction
4. Teaches body how to develop tension in a muscle (motor unit recruitment)
5. Increases strength
6. Least provocative strengthening modality
7. Patients can do it frequently
8. Backs up / covers manual therapy intervention
9. Resets the muscle spindle
10. Safe mechanotransduction

Spina has created a very user friendly system for applying isometrics to influence tissue and improve range of motion.  These are PAILs and RAILs (Progressive Angular Isometric Loading & Regressive Angular Isomeric Loading).  These are very direction specific interventions.  These techniques are best understood in the context of the class, but I will briefly describe them here.PAILs I (Communication)

Guiding Soft Tissue Remoulding/Healing

Does not intend on expanding range

Low level, frequent contractions

PAILs II (Expand Range of Motion)

2 minute passive, direction specific stretch

Followed by ramped isometric contraction in opposite direction (20-30 seconds)

PAILs III & RAILs (Expand ROM & Training Stimulus)

2 minute passive, direciton specific stretch

Ramped isometric contraction with 100% effort (longer duration)

Followed by RAILs (inner range hold, actively pulling deeper into the stretch)

Followed by another deep, passive stretch (and repeat)

Anatomy Pearls

During the palpation aspect of the course, Dr. Spina revealed this disconnect between what we were taught and what is actually in the body.  Here's some of these revelations.

• Levator Scapula is medial on the neck

• The "Levator Scapula TrP" that everyone has is really just where the rhomboid and erector spinae cross

• That thing you poke on the front of people’s shoulder is not the biceps tendon, it’s usually the anterior deltoid

• Teres major/minor and long head triceps is a commonly gunked up area

• The subscapularis tendon becomes transverse humeral ligament

• The long head of the triceps becomes the inferior labrum

• Deep muscle grow off bones (like chia pets) - Examples - quadriceps, brachialis, subscapularis, flexor digitorum profundus

• The pec minor, upper trapezius, and latissimus dorsi are disappointing muscles - thinner than you would think

Randoms

1) We all come from one cell - every cell has the ability to be every other cell2) Pain is a terrible outcome measure (Touch Induced Analgesia)3) Epimysial Groove is an important area to treat4) Mechanical Tension = specific aberrant force, Neurological Tension = can be felt during static palpation and is felt throughout the whole muscle (video demonstration)5) “We’re trying to palpate the forces that are restricting movements”6) In the fascia superfiscialis there are small pockets of adipose tissue - this might be the grittiness you feel with IASTM7) BioFlow - continuum of tissues - it all blends together - tissue types are just a different expression of connective tissue8) Fibroblasts - undifferentiated connective tissue cell that can become a precursor cell for many different types of connective tissue (tendons, bone, cartilage, muscle, etc.)9) It doesn’t matter which type of tissue, the response to load/signal will be similar10) “Never use a cannon to kill a fly” -Confusious11) Van Der Wal (article, video)12) No passive structures, just structures whose tension is tuned by the muscles (active structures)13) Force to one cell will cause a cascade of signaling throughout many different cells14) For plastic changes you need >2 minutes (induce thrixotropy and piezoelectric)15) Injury = Fibrosis = Friction/Loss Of Relative Tissue Motion16) After injury - the body recalibrates the stretch reflex threshold = faster activation of muscle spindles during movement = reflexive contraction, prematurely17) Don’t bring a mechanical intervention to a neurologic problem18) The more the neural drive, the less the access to the connective tissue for manual treatment19) Without direction, fibroblasts smear collagen all over the place and create fibrosis20) Deep tissues are mostly proprioceptive/afferent structures (when these are dysfunctional, superficial tissues have high tone)21) Adjust for skin slack or everything will feel like tension22) No single input causes permanent changes - “we’re not fixing anything”23) “I can’t rub someone flexible”24) Flexibility is governed by the nervous system.  You have to train it in the gym, not manually fix it with your hands.25) Inputs

• Muscle responds to NS quickly

• Connective Tissue responds to longer force inputs

26) 1st Job of Rehab = Guide the way the tissue is healing - tell the fibroblasts where to lay down collagen27) Rehab in the injured posture to repair/strengthen damaged tissues28) "Any fool can make something complicated. It takes a genius to make it simple." -Woody Guthrie

• Load > Capacity = Injury

• Load < Capacity = Rehab

• Capacity >> Load = Prevention

29) The deeper in the body, the more the connective tissue (pedunculation)30) Muscles can contract in various ways - Different fibers pull in different directions - Attachments don’t dictate all movement31) “Create the joint…THEN control the joint…THEN strengthen the joint - this concept is central to the FR and FRC systems.”32) “If you can control the scapula in space, does it matter if it’s winging?”33) Improving skin slide, especially over bony prominences, makes a big difference34) “You’re not palpating muscles, you’re palpating the connective tissues that makes muscles”35) NS only gives you access to the ROM it knows it can control36) “Adding passive mobility is where people get hurt”37) Osteoarthritic Rant

• Age doesn’t decrease flexibility, lack of movement decreases flexibility

• Joints maintain their health with movement

• If your joints moved everyday, an osteophyte can’t develop

• OA occurs from lack of motion

38) “RTC should be called the compressor cuff”39) The best way to assess joint motion is with axial rotation40) Opening vs. Closing restriction

• Opening is normal, tissues have to adapt

• Closing is not - comes from a decentrated joint, or tight opposite joint

41) The more contact you have with the patient, the better you can assess (close the circuit)42) Cyriax Knowledge - The longer a muscle is at contraction, the more the load goes to the tendon43) “Think of the body as one group of CT and proteins are added where movement needs to occur”44) One of my favorite quotes from the course

• “Changing posture is about habitual cueing”

45) Tensegrity model runs through the entire body, from DNA/RNA nucleus to ECM46) Give the cue “hold strong” (good psychological priming)47) “You don’t do PAILs for a muscle, you do it for a direction”48) Check the hands in elbow patients - It’s like the plantar fascia in achilles patients49) “Articular independence first….articular interdependence second”

Bottom Line

Overall this was one of my favorite courses I've ever taken.  It gave me a new lens on the human body, provided a simple and effective way to influence tissue, reduced my need for manual therapy, and gave me a direct treatment approach to achieve long term goals.  I highly recommend this course (or the FRC) for all movement professionals.One of the greatest things about Dr. Spina's work is that it can easily be incorporated into any approach.  You can still do all the neurological stuff, but after you get them FN/Centrated/Neutral/Whatever, just add in some inputs that will influence the tissues in the new and improved position.  It's important to work with the nervous system after an injury (motor patterns, pain, ANS, neutrality, etc.), but it's also just as important to work on the tissues themselves.  We are lucky to have so many approaches out there that identify the neurological needs of the system.  Now we're lucky to have Dr. Spina's approach to address the histological needs of the system.

Dig Deeper

Cellular/Histological/Bioflow

This is a big rabbit hole to go down.  There is plethora of research and articles.  It is difficult to just reference one.  FR/FRC Instructor, Michael Chivers, recommends starting with Helen Langevin and Donald Ingber.

Motor Control/Dynamic Systems

This is similar to researching cellular adaptations and histological changes to input.  There is so much out there that it becomes difficult to reference.  If you are new to these concepts, start by researching the different types of motor control theories.  Then research Bernstein's work and the degrees of freedom problem.  Then dive into the Dynamic Systems Theory.

My favorite article in this field is from Esther Helen and Linda Smith (Thelen, E. and Smith, L. B. 2007. Dynamic Systems Theories. Handbook of Child Psychology. I:6)

Fascia/Tensegrity

This has become a standard in the movement sciences (or at least I hope so).  Most clinicians are familiar with this approach thanks to the work of Tom Myers, Robert Schleip, Jaap Van Der Wal, and Leon Chaitow (among many others).

Andreo Spina - YouTubeSolid-State BiochemistryMechanotransduction (Jaalouk 2009, Khan 2009)Jeff Cubos - Phases of Healing & Spina's Work, Notes & Quotes from Dr. SpinaDewey Nielsen's Instagram Account (great examples of the FRC approach in practice)Jason Ross - Part I, Part IIVeeWong Course ReviewKevin Neeld - Dispelling the Stretching MythsArmstrong InterviewThe Nominalist has a ton of posts with clinical applications of FR & FRC   --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

 [subscribe2]

An Open Letter to Crossfit: The 2 Mistakes (Part II)

Be sure to check out Part I for my thoughts on Crossfit and Mistake #1.

Mistake #2 = Not Training Unilaterally

Our bodies are inherently asymmetrical.  Don’t believe me?  Here are a couple examples of this natural asymmetry: we have a liver on the right, a heart on the left, 3 lung lobes on the left, 2 on the right, the stomach is tilted, one kidney is higher, the right diaphragm has a better zone of apposition, each brain hemisphere is lateralized for different tasks, and our left-otolitic dominance makes our motor system prefer the right side of our bodies.  On top of this, there are many other possible asymmetries and different morphologies due to genetics/ontogenetics.Not only are our bodies asymmetrical, but we live in a very asymmetrical world.  Everyday activities are asymmetrical; you push the car pedals with your right foot, grab your wallet out of the same pocket, open doors with your right hand, use the computer mouse on the same side.  Sporting activities are asymmetrical; you shoot with your right hand, kick with your right leg, swing a golf club to the same direction everytime.  And then there is just plain handedness.These asymmetries are normal and usually not a problem.  However, sometimes these asymmetries become too significant.  The imbalances become too much for the body to handle.This asymmetrical problem is taken to the next level when you add a symmetrical load to the system.  Symmetrically loading an asymmetrical system is the formula for injuries.  And this is one of the biggest mistakes Crossfitters make.While this applies to the entire body, it is critical in shoulders.  There are two reasons why:

1) You have a much more prominent handedness than footedness

2) Your legs benefit from some unilateral weight bearing activities everyday (walking, stairs)

Therefore, your upper extremity asymmetry is accelerated much faster compared to the lower extremity.  In other words, a right handed person can pretty much go all day without using their left arm at all.Fast forward to this person going from not using their non-dominant arm for most of their life (or past few years) and then throw a barbell at them.  It’s not going to go well.  The symmetrical external load (barbell) won’t be met with a symmetrical internal force (muscles).  Bringing a symmetrical exercise to an asymmetry is a recipe for disaster.Look at your car for an analogy.  If you car alignment is off, it’s going to cause some big problems.  Not only is most of the load going to be dumped onto one side, but it will also prevent a smooth straight path.  With the alignment off, the car will naturally want to veer from straight.  But it is being driven in a straight path, so the car has to pull (compensate) to maintain the desired direction.The same thing happens at your shoulders with barbell exercises.  One shoulder will get too much of the load, the other has to compensate to keep it straight, and it becomes an internal tug-of-war to keep the all important straight bar path.  Therefore, if you have a shoulder asymmetry, then the whole time you are cleaning, pressing, or snatching your shoulders will be compensating against each other.As mentioned in Part I, over time compensations lead to decreased performance and injuries.So what do you do about this?  Start brushing your teeth with your non-dominant arm?  Do barbell cleans with one arm?  Walk on your hands?

A Suggestion

The best thing you can do is incorporate some single arm (unilateral) strengthening into your weekly workouts.  This will not only prevent injuries, but it can also be used as an assessment.  If you can strict press 70# with your right arm, but only 50# with your left, then what do you think is happening when you strict press with a barbell?There are many different ways to work on unilateral strengthening, but in my opinion kettlebells are the best equipment to accomplish this.  They allow for the same metabolic burn, similar technique work, multi-joint strengthening, and most importantly - unilateral strengthening.  Pavel said it best "Your body has to adapt to the barbell while the kettlebell works with your body."Here’s a list of some unilateral shoulder exercises that can be done with just a kettlebell and some space:

Armbars, Bear Crawls, Quadruped T's, TGU, Single Arm Push Ups, Half/Tall-Kneeling/Standing KB Strict Press, Farmers Walks (overhead, rack, suitcase), Single Arm KB: Swing, Squat, Clean, Clean & Squat, Clean & Strict Press, Clean & Push Press, Snatch, Unilateral Suitcase Deadlift, Plank KB Pull Through

There are plenty of great coaches that can probably come up with some amazing unilateral upper extremity WODs.  There’s not just one right way to do it.  As long as you are training unilaterally and exposing weakness you will be decreasing your risk of injury and improving performance.For clinicians there is this Clinical Pearl

• If someone comes in with dominant side shoulder pain from bilateral/symmetrical training, the fix may be to strengthen the non-dominant side

Bottom Line

Like anything that becomes popular or trendy, there quickly becomes a group of people that jump on the bandwagon and a group of people that protest against it.  But this isn’t EDM, this isn’t Instagram, this isn’t the new iPhone.  This is simply another opportunity to help people stay active and exercise.  It’s not for everyone, but it’s not for no one.Medical professionals need to focus on ways to reduce injury and improve the activity rather than just pointing out what we don’t like.  Crossfit coaches need to focus on what’s best for the athletes health rather than what will give them the best workout.  And the Crossfit athletes need to be educated on the risk of lifting with poor technique and/or with a significant asymmetry.

References

Strength is a Good Thing1) Preethi Srikanthan, Arun S. Karlamangla. “Muscle Mass Index as a Predictor of Longevity in Older-Adults.” The American Journal of Medicine (2014) 2) Lauersen JB, Bertelsen DM, Andersen LB.  The effectiveness of exercise interventions to prevent sports injuries: a systematic reviewand meta-analysis of randomised controlled trials.  Br J Sports Med. (2014) Jun;48(11):871-7.3) Harridge, Stephen D.r., Ann Kryger, and Anders Stensgaard. "Knee Extensor Strength, Activation, and Size in Very Elderly People following Strength Training." Muscle & Nerve 22.7 (1999): 831-39.4) Suetta, C., S. P. Magnusson, N. Beyer, and M. Kjaer. "Effect of Strength Training on Muscle Function in Elderly Hospitalized Patients."Scandinavian Journal of Medicine & Science in Sports 17.5 (2007)5) Askling, C., J. Karlsson, and A. Thorstensson. "Hamstring Injury Occurrence in Elite Soccer Players after Preseason Strength Training with Eccentric Overload." Scandinavian Journal of Medicine and Science in Sports 13.4 (2003): 244-506) Nadler, Scott F., Gerard A. Malanga, Melissa Deprince, Todd P. Stitik, and Joseph H. Feinberg. "The Relationship Between Lower Extremity Injury, Low Back Pain, and Hip Muscle Strength in Male and Female Collegiate Athletes." Clinical Journal of Sport Medicine 10.2 (2000): 89-97.7) Peate, Wf, Gerry Bates, Karen Lunda, Smitha Francis, and Kristen Bellamy. "Core Strength: A New Model for Injury Prediction and Prevention."Journal of Occupational Medicine and Toxicology 2.1 (2007)8) Orchard, J., J. Marsden, S. Lord, and D. Garlick. "Preseason Hamstring Muscle Weakness Associated with Hamstring Muscle Injury in Australian Footballers." The American Journal of Sports Medicine25.1 (1997): 81-859) Jankowski, C.m. "The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial."Yearbook of Sports Medicine 2012 (2012): 65-66.10) Willson JD, Dougherty CP, Ireland ML, et al. “Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg. (2005) Sep;13(5):316-25.11) Hewett TE, Lindenfeld TN, Riccobene JV, et al. “The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.” Am J Sports Med. (1999) Nov-Dec;27(6):699-706.Movement Based Exercise vs. Isolated Exercise12) Gentil, Paulo, Saulo Rodrigo Sampaio Soares, Maria Claúdia Pereira, et al. "Effect of Adding Single-joint Exercises to a Multi-joint Exercise Resistance-training Program on Strength and Hypertrophy in Untrained Subjects." Applied Physiology, Nutrition, and Metabolism 38.3 (2013): 341-4413) Gottschall, Jinger S., Jackie Mills, and Bryce Hastings. "Integration Core Exercises Elicit Greater Muscle Activation Than Isolation Exercises."Journal of Strength and Conditioning Research 27.3 (2013): 590-96Exercising in Fatigued State14) Cortes, Nelson, Eric Greska, Roger Kollock, Jatin Ambegaonkar, and James A. Onate. "Changes in Lower Extremity Biomechanics Due to a Short-Term Fatigue Protocol." Journal of Athletic Training 48.3 (2013): 306-13.15) Santamaria, Luke J., and Kate E. Webster. "The Effect of Fatigue on Lower-Limb Biomechanics During Single-Limb Landings: A Systematic Review." Journal of Orthopaedic & Sports Physical Therapy 40.8 (2010): 464-73.16) Barnett S Frank, Christine M Gilsdorf, Benjamin M Goerger, et al.  “Neuromuscular fatigue alters postural control and sagittal plane hip biomechanics in active females with anterior cruciate ligament reconstruction.” Sports Health (2014) Jul;6(4):301-817) Quammen D, Cortes N, Van Lunen BL, et al. “Two different fatigue protocols and lower extremity motion patterns during a stop-jump task.” J Athl Train. (2012) Jan-Feb;47(1):32-41.18) Pau M, Ibba G, Attene G. “Fatigue-induced balance impairment in young soccer players.” J Athl Train. (2014) Jul-Aug;49(4):454-61.Imbalances Are Bad19) Knapik, J. J., C. L. Bauman, B. H. Jones, J. Mca. Harris, and L. Vaughan. "Preseason Strength and Flexibility Imbalances Associated with Athletic Injuries in Female Collegiate Athletes." The American Journal of Sports Medicine 19.1 (1991): 76-8120) Baumhauer, J. F., D. M. Alosa, P. A. F. H. Renstrom, S. Trevino, and B. Beynnon. "A Prospective Study of Ankle Injury Risk Factors." The American Journal of Sports Medicine 23.5 (1995): 564-70.21) Common Sense & Conventional Wisdom (>6 million years BC)Motor Learning22) Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.23) Schmidt, Richard A., and Craig A. Wrisberg. Motor Learning and Performance: A Problem-based Learning Approach. Champaign,IL: Human Kinetics, 2004.24) Williams, L. R., McEwan, E. A., Watkins, C. D., Gillespie, L., & Boyd, H. (1979). Motor learning and performance and physical fatigue and the specificity principle. Canadian Journal of Applied Sport Sciences, 4, 302-308.

“The body does not have the capacity to learn movement patterns when highly stressed/fatigued. This factor is not related to the specificity of training principle associated with overload adaptation in energy systems. The specificity principle of physiological adaptation does not apply to motor learning. To learn skilled movement patterns that are to be executed under fatigued conditions, that learning has to occur in non-fatigued states” — Williams 1979

 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

 [subscribe2]

An Open Letter to Crossfit: The 2 Mistakes (Part I)

As many physical therapists have probably noticed, there is an increase in the amount of Crossfit athletes showing up in our clinics.  This isn’t because it injures everyone.  It’s because it’s becoming very popular and people love it.We see the same thing happen during ski season and marathon season.  It’s not necessarily the activity, it’s the increase in participation.However, that’s not to say that it’s only an increase in participation that leads to a higher incidence of injuries.  There are many other variables involved.  Some of which can be improved upon to decrease the risk of injury.I’ve noticed a few trends in my experience with Crossfit athletes.  The crossfitters that tend to get hurt are the ones that seem to make the same 2 Mistakes:

1) Constantly Training to (and Past) Failure

2) Not Training Unilaterally Enough.

I think if Crossfit could improve on these 2 mistakes they would see a lot less people getting injured.

A Disclaimer

I have nothing against crossfit and don’t think it is ruining our species like some of my peers.  In fact, I think Crossfit is great.  Some of you might agree and some of you might be angry just by reading the word crossfit.  But let me explain why I think it’s good.Crossfit changes peoples lives.  This is often an exact quote from many of my crossfit patients.  I’ve had many patients who have lost tons of weight and become motivated to stay active because of Crossfit.  This leads to changes in other parts of their lifestyle and improves their overall quality of life .  Where personal trainers, spin classes, running, and traditional weightlifting have failed, Crossfit has succeeded.  In a time where obesity and sedentary lifestyles are an epidemic, anything that gets people moving should be viewed favorably.  I’d much rather have our population suffer with the occasional sore shoulder rather than die early from heart disease.Crossfit has popularized strength training.  Too many people go on crazy diets, perform too much aerobic activity, or follow DVD fads to lose weight and get a metabolic burn.  Crossfit has helped shift the emphasis to being strong.  And strength is one of the best modalities for improving function, decreasing injuries, reducing morbidity, and decreases mortality (1-11).Crossfit focuses on movements.  Isolated muscle strengthening and machine based workouts are better than nothing, but they are vastly inferior when compared to multi-joint based movements.  Crossfit has brought functional global movement exercises such as power lifts, olympic lifts, and kettlebells back to the mainstream (12-13, 22).One last disclaimer is that I know not all “Boxes” are the same.  Not all coaches are the same.  And not all athletes are the same.  Like every other activity or profession, there is a continuum of competence among crossfit gyms and coaches. I know there are a ton of very knowledgeable and talented Crossfit coaches out there already doing all the right things.  Also, these mistakes are not just made by Crossfit coaches.  There are many trainers, strength & conditioning coaches, physical therapists, and chiro’s making the same mistakes.  The goal of this article is simply to bring awareness and offer solutions for 2 common mistakes that seem to happen often (not to attack crossfit as a whole).

Mistake #1 = Constantly Training to (and Past) Failure

I understand it’s important to test your limits every once in a while.  And I know that when you’re in a competition or going for a PR many of the rules go out the window.  But that doesn’t mean you should train like this every time.As fatigue sets in, good biomechanics, technique, and form start to fail.  Everyone that has worked out to failure knows this and has felt this.  Even if you haven’t experienced a fatigued state, there is more than just empirical evidence to support this hypothesis.  Research has shown that mechanics and proper form go out the window in a fatigued state (14-18).This is not only bad for performance, but more importantly, it is bad for your health.  The more you continue to train in a fatigued state, the greater your risk for injury.  This injury can either be an acute one or a chronic one.Acute injuries are fairly easy to comprehend.  Acute injuries occur instantaneously when the external load is greater than the tissues accepting it.  It’s a cause and effect event.Some examples of the acute injuries:  A tired and sloppy deadlift with a rounded back on the 10th rep could damage your lumbar spine.  A tired and sloppy snatch with forward shoulders and poor T-spine extension could lead to a labral tear.  A tired and sloppy box jump with a knee caved in could lead to an ACL tear.  In other words, it puts you at risk for an accident that occurs in a split second, but takes months to recover from.Chronic injuries are a little more complicated and have to do with compensations and movement patterns.Movement patterns are the stored neurological “program” that resides in the brain.  This “program” is what your nervous system fires out to make the right muscles fire at the right time to achieve the desired result.  Performing exercises with poor form and inefficient muscle activation can teach your brain poor movement patterns.  In other words, it can set in bad habits.A long winded example might help.  Lets take my favorite exercise done to failure - deadlifting.  When you finish out those last 5 deadlifts with a rounded back because you were too tired to use the right muscles, your brain stores a new motor pattern.  Now your brain has a new easier way to deadlift.  Why lift with muscles when you can just lean on passive tissues like ligaments, joint capsules, and lumbar disks?  In other words, your brain decides it’s better to save energy and rely on tissues that don’t require energy to get the job done (passive tissues).  It decides lifting with a rounded back is a good idea.  Stupid brain.  You might be able to lift more weight (temporarily), but it will be at a cost to your spine.  Overtime, this stress to your back accumulates and can lead to a slew of injuries (paraspinal strain, disk herniation, neurodynamic problems, SIJ strain, etc.).So is it really worth it to sacrifice your movement to push it to the limit at every workout?  Do you really need to do over 40 reps of every exercise on each set?  What if you did more sets instead of more reps? Wouldn’t it be better to stop the set once technique starts to waver?  What if you let people “ladder” down throughout the WOD instead of compensating through?  Why not perform AMPRAP (As Many Perfect Reps As Possible) instead of just AMRAP?

A Suggestion

Better programming and an emphasis on improving technique as well as strength is something that many Crossfitters could benefit from.Crossfit coaches can improve in this realm by emphasizing technique over numbers or metabolic expenditure.  Assessing for poor technique and over-fatigue significantly decreases the risk of injury and will improve performance in the long run (you can’t make gains if you keep having to take time off because you’re injured).  Coaches need to help athletes become aware of when their form goes bad and stop them from grooving bad movement patterns with compensatory muscle activity.  And the WODs they develop can be programmed to avoid unnecessary fatigue and sloppy form on complex movements.However, it’s important to understand that assessing for over-fatigue and poor technique is not just the coaches responsibility.  The athletes need to be EDUCATED that when they can’t maintain form they are at a greater risk for injury and they need to stop.  I think this is one of the biggest mistakes most crossfitters make.  Many of them don’t understand this concept; they don’t understand the dangerous effects of not listening to your body and training with poor technique.  Others are simply not aware of their poor form.  Either way, this mistake needs to be addressed to decrease the risk of injury.A warrior mentality often exists with Crossfitters.  However, this mentality should adopt the idiom - live to fight another day.

Click Here for Part II

References

Strength is a Good Thing1) Preethi Srikanthan, Arun S. Karlamangla. “Muscle Mass Index as a Predictor of Longevity in Older-Adults.” The American Journal of Medicine (2014) 2) Lauersen JB, Bertelsen DM, Andersen LB.  The effectiveness of exercise interventions to prevent sports injuries: a systematic reviewand meta-analysis of randomised controlled trials.  Br J Sports Med. (2014) Jun;48(11):871-7.3) Harridge, Stephen D.r., Ann Kryger, and Anders Stensgaard. "Knee Extensor Strength, Activation, and Size in Very Elderly People following Strength Training." Muscle & Nerve 22.7 (1999): 831-39.4) Suetta, C., S. P. Magnusson, N. Beyer, and M. Kjaer. "Effect of Strength Training on Muscle Function in Elderly Hospitalized Patients."Scandinavian Journal of Medicine & Science in Sports 17.5 (2007)5) Askling, C., J. Karlsson, and A. Thorstensson. "Hamstring Injury Occurrence in Elite Soccer Players after Preseason Strength Training with Eccentric Overload." Scandinavian Journal of Medicine and Science in Sports 13.4 (2003): 244-506) Nadler, Scott F., Gerard A. Malanga, Melissa Deprince, Todd P. Stitik, and Joseph H. Feinberg. "The Relationship Between Lower Extremity Injury, Low Back Pain, and Hip Muscle Strength in Male and Female Collegiate Athletes." Clinical Journal of Sport Medicine 10.2 (2000): 89-97.7) Peate, Wf, Gerry Bates, Karen Lunda, Smitha Francis, and Kristen Bellamy. "Core Strength: A New Model for Injury Prediction and Prevention."Journal of Occupational Medicine and Toxicology 2.1 (2007)8) Orchard, J., J. Marsden, S. Lord, and D. Garlick. "Preseason Hamstring Muscle Weakness Associated with Hamstring Muscle Injury in Australian Footballers." The American Journal of Sports Medicine25.1 (1997): 81-859) Jankowski, C.m. "The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial."Yearbook of Sports Medicine 2012 (2012): 65-66.10) Willson JD, Dougherty CP, Ireland ML, et al. “Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg. (2005) Sep;13(5):316-25.11) Hewett TE, Lindenfeld TN, Riccobene JV, et al. “The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.” Am J Sports Med. (1999) Nov-Dec;27(6):699-706.Movement Based Exercise vs. Isolated Exercise12) Gentil, Paulo, Saulo Rodrigo Sampaio Soares, Maria Claúdia Pereira, et al. "Effect of Adding Single-joint Exercises to a Multi-joint Exercise Resistance-training Program on Strength and Hypertrophy in Untrained Subjects." Applied Physiology, Nutrition, and Metabolism 38.3 (2013): 341-4413) Gottschall, Jinger S., Jackie Mills, and Bryce Hastings. "Integration Core Exercises Elicit Greater Muscle Activation Than Isolation Exercises."Journal of Strength and Conditioning Research 27.3 (2013): 590-96Exercising in Fatigued State14) Cortes, Nelson, Eric Greska, Roger Kollock, Jatin Ambegaonkar, and James A. Onate. "Changes in Lower Extremity Biomechanics Due to a Short-Term Fatigue Protocol." Journal of Athletic Training 48.3 (2013): 306-13.15) Santamaria, Luke J., and Kate E. Webster. "The Effect of Fatigue on Lower-Limb Biomechanics During Single-Limb Landings: A Systematic Review." Journal of Orthopaedic & Sports Physical Therapy 40.8 (2010): 464-73.16) Barnett S Frank, Christine M Gilsdorf, Benjamin M Goerger, et al.  “Neuromuscular fatigue alters postural control and sagittal plane hip biomechanics in active females with anterior cruciate ligament reconstruction.” Sports Health (2014) Jul;6(4):301-817) Quammen D, Cortes N, Van Lunen BL, et al. “Two different fatigue protocols and lower extremity motion patterns during a stop-jump task.” J Athl Train. (2012) Jan-Feb;47(1):32-41.18) Pau M, Ibba G, Attene G. “Fatigue-induced balance impairment in young soccer players.” J Athl Train. (2014) Jul-Aug;49(4):454-61.Imbalances Are Bad19) Knapik, J. J., C. L. Bauman, B. H. Jones, J. Mca. Harris, and L. Vaughan. "Preseason Strength and Flexibility Imbalances Associated with Athletic Injuries in Female Collegiate Athletes." The American Journal of Sports Medicine 19.1 (1991): 76-8120) Baumhauer, J. F., D. M. Alosa, P. A. F. H. Renstrom, S. Trevino, and B. Beynnon. "A Prospective Study of Ankle Injury Risk Factors." The American Journal of Sports Medicine 23.5 (1995): 564-70.21) Common Sense & Conventional Wisdom (>6 million years BC)Motor Learning22) Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.23) Schmidt, Richard A., and Craig A. Wrisberg. Motor Learning and Performance: A Problem-based Learning Approach. Champaign,IL: Human Kinetics, 2004.24) Williams, L. R., McEwan, E. A., Watkins, C. D., Gillespie, L., & Boyd, H. (1979). Motor learning and performance and physical fatigue and the specificity principle. Canadian Journal of Applied Sport Sciences, 4, 302-308.

“The body does not have the capacity to learn movement patterns when highly stressed/fatigued. This factor is not related to the specificity of training principle associated with overload adaptation in energy systems. The specificity principle of physiological adaptation does not apply to motor learning. To learn skilled movement patterns that are to be executed under fatigued conditions, that learning has to occur in non-fatigued states” — Williams 1979

 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

 [subscribe2]

Foundational Strength Course Review

Two of my favorite things to do in my practice are to assess movement patterns and use kettlebells.  So when I heard about the amalgamation of FMS and StrongFirst I was pretty stoked.  Throw on top that Gray Cook and Brett Jones were teaching the course, and it was my most anticipated course of all time.

Gray & Brett

Gray Cook has been the biggest outside influence on my career.  After graduating from PT school and practicing impairment based PT, I started to notice that there was something missing.  Gray Cook and the SFMA/FMS filled the void.  I've watched almost all the DVDs, read the books, and have attended the SFMA courses.  I was excited to finally catch him live in action.  And he didn’t disappoint.  The man is extremely entertaining, engages you with every word, somehow talks in quotes, and delivers complex and deep concepts in a country simple manner.  And if you can catch him during the breaks he’d blow your mind.  Plus, it’s great to see his passion for movement.  He’s not trying to make money, put down other approaches, or spread a dogma; he’s just trying to help humans “move well, move often”.The surprise for me was Brett Jones.  I’ve heard him in a couple podcast interviews and youtube videos, but I didn’t know what to expect in a course.  I was pretty blown away with his expertise and perspective.  He is an extremely knowledgeable, humble, and humorous speaker.  But my favorite part about Jones was the practicality of his knowledge.   Many times I feel like instructors live in the fantasy black and white world where all their patients do everything they say and get 100% better.  The information and clinical pearls from Jones were extremely applicable and realistic.  Listening to and talking to Jones was like talking to the smartest co-worker you’ve ever had.Together, Brett Jones and Gray Cook were outstanding.  After both of them speak on a topic, there aren't many questions left to answer.

The Course

The course had 1 lecture to start on the FMS and a Gray Cook bonus lecture at the end.  The rest of the 3 days were packed with clinical pearls on screening, interpretation, corrective strategies, technique, programming, and kettlebells.  The amount I learned that can immediately go into practice is overwhelming.  I cannot recommend this course enough for anyone that is interested in movement.There’s no way to possibly go over all these clinical pearls in a blog post, but I'll try to highlight some of the great stuff I learned.

46 Things I Learned at Foundational Strength

1) “The best way to get motor control is through compression or distraction” - Gray Cook2) "Motor Control is Alignment, with Integrity, Under Load" - Gray Cook3) Quotes 1 & 2 explain the rationale behind most of the exercises we learned in this course4) I need to redo all of my FMS screens; I was way too lax.

One of the assistants said it best - "A 3 should look oddly graceful"

5) The set-up for the Screen is the most important.  Spend time getting the proper start position and alignment.  Be brutally detailed.6) “If your screen is wrong, your correctives are wrong”-Brett Jones7) 3's are not the goal of the FMS.  Symmetrical 2's are good enough to train without any restrictions.8) Consider the entire screen when choosing where to start with correctives.  For example, someone with 1's on ASLR and a 1 on TSPU likely has a motor control deficit that prevents >2's on the ASLR.9) Mobility First.  Asymmetrical mobility (ASLR & SM) is the priority since it is the area that can make the most impact on all the other functional movements.  For example, if it's a 2/3 asymmetry on the SM and there's a 1 on the deep squat, you should address the SM.10) Need mobility to get alignment, need alignment to get motor control11) Corrective Progression

Screen/ID Corrective Pattern→ Mobility→ Static Control→ Dynamic Control→ Performance/Strength

Mobility (ASLR/SM) → Motor Control (RS/TSPU) → Functional Patterning (IL/HS/DS)

12) The #1 priority of a corrective is to magnify what you saw in the screen, if it doesn't, then you're probably doing the wrong corrective13) “Corrective exercise is shaking the etch-a-sketch” - Brett Jones

Gives a window of opportunity to change movement

14) “Movement needs to be one of the vital signs, or we won't take movement vitally” - Gray Cook15) “Level the pelvis (ASLR), open the t-spine (SM)” - Gray Cook16) Foot position dictates the hips, the hips dictate the core17) Loaded Carry (Farmer's Walk)

Diagnostic = 3/4 of body weight, measure distance

Encourages alignment, increases integrity, improves work capacity, fires stabilizers

Cook Drill - Overhead⇒Rack Position⇒Suitcase⇒Opposite Arm Overhead⇒Rack⇒Suitcase

Cues - Stay Tall, Push Bell Towards Ground, Breathe

Safe exercise for almost everyone

18) Removing negatives (exacerbating behaviors, activities, exercises, etc.) is just as important as adding correctives.  They advocate removing the negative activities for 2 weeks.19) Gray Cook loves the Jump Rope

"1 minute of jump rope = 2 minutes of running"

“Jump rope is more alignment oriented than running”

20) If a corrective is not changing the movement, then move on.  Don't waste time on correctives that don't lead to a positive change in movement patterns.21) I've never seen anyone so violently attack their neck with a Tiger Tail like Gray Cook does.22) Work the beginning and the end of a movement; the brain will figure out the middle23) Let patients feel the wrong position, exaggerate the extremes of the wrong alignment and then have them find the middle24) Core Engagement for Correctives

Needs to be reflexive, not a hard brace before the movement

Using arms - only pull band down to 40 degrees shoulder flexion, not to full neutral

Reset after each rep - if you engage the core and then do a bunch of reps, the brain still thinks it's one rep

25) Half Kneeling

Keep the front foot light, should be able to lift it without requiring a posterior weight shift

Tell patients they should be able to be stepping on grapes without squishing them

Spend more time setting up the pelvis in the correct 3-D position

Front leg should be 90º or more.  If less, the hamstring will try to help out too much

26) Brett Jones tells his clients, “your success depends on your ability to do your homework”27) “Every concussion is a whiplash” - Gray Cook28) Any asymmetry puts you in the “red”.  In other words, if you have asymmetries there are some exercises that will harm you.29) “Vertical tibia is a good intention, but a bad reality” - Brett Jones30) “Deadlift is not a pull, it’s a push.” - Brett Jones31) Single Leg Deadlift - set them up to reach and touch the wall, better sensory environment, patients feel safer32) Brett Jones knows as many movie quotes as he does FMS correctives33) C-Spine is the "fuse box" for the shoulders.  Many shoulder problems are really c-spine problems.34) Turkish Get-Up - don't high bridge from hand, high bridge from elbow and perform a low sweep35) Half Kneeling Windmill Exercise - more of a spiral than a shift36) Rolling

People got a little carried away with this exercise and started applying it to people that don't need it

It has a very narrow application

Most people don't have the appropriate mobility to be rolling

Don't over complicate it - you simply want the half that's moving to cross midline before the "paralyzed" half crosses midline

Use eyes and head for UE patterns

Prone to supine UE pattern - have arm abducted to 90º

Does 2 things: 1) Resets system with eyes, neck, and crossing midline 2) Promotes segmental movement

Jason Kapnick teaches it as a "reaching" exercise

37) Kneeling exercises - want prime movers off.  If you lock in with prime movers, you lose reflexive stabilization.38) “if you get 2 inches at the hip, you get 1 inch at the ankle” - Gray Cook39) Only coach lifts and techniques, don’t tell people how to move.  You want people to feel movement, not hear it.40) Pigeon pose or hip ER stretches - keep knee in line with hip socket41) OTIS & ITIS (Oscillating Technique for Isometric Stabilization & Impulse Technique for Isometric Stabilization)42) Losing mobility = losing inputs = losing information43) There are 31-32 muscles that assist in hip flexion.  Don't assume or guess.  Don't isolate one muscle.44) “When you open your mouth, you blow out too much CO2 at rest.” - Brett Jones45) Balance should be achieved with rotation, not lateral movement.  This is why walking is so graceful.46) Sidelying thoracic mobility exercises (open book) - make sure they are not just "falling" into extension

My Top 5 from Foundational Strength

Top 5 Correctives for Higher Level Patients

1/2 Kneeling Windmill Progression

Plank Variation Dog⇒Hands⇒Elbow

Crooked ArmBar

Cook KB Rotations

Half-Kneeling Rotations & Press

Top 5 Correctives for Lower Level Patients

Half Push-Up

ASLR KB Progression

Loaded Carries

Crocodile Breathing

Halos

Bottom Line

This was one of the best courses I've ever attended.  Part of what made this course so great, was the required level of understanding prior to participating.  Everyone in the course already knew the concepts and theory.  So most of the time was spent on how to apply the right technique to the right patient and layer interventions.  I'm not sure I've ever walked into the clinic on a Monday after a course with so many new tricks to try.As with all interventions, nothing is a better teacher than kinesthetics.  Try some of these exercises on your own, then apply them to the appropriate patient.

Dig Deeper

Gray CookFMSStrongFirst  --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

 [subscribe2]

The Art of Recovery (Part 2 of 2)

Part I went over stress, tissues, the nervous system, and many of the factors that are involved with recovery.Throughout a PT session there are many opportunities to influence the patient's health; both for the immediate and long term effects.  This post will go over the 4 factors of recovery that I often try to discuss with patients before they are discharged from Physical Therapy.

4 Factors of Recovery

Each of these 4 factors could be a book on its own, let alone a blog post.  To save myself some of the mental stress of going over each of them in-depth, I'll just briefly describe the factors and some methods for improvement.Before you start educating patients, it's important to follow the golden rule:

• Don't prescribe anything you haven't tried yourself

This goes not only for exercises, but the lifestyle changes as well.  If you don't sleep well, have never meditated, and eat bad food, then you shouldn't try to influence other people.

Sleep

Sleep is a difficult one.  Going to bed at a descent hour is extremly difficult these days.  Youtube, reddit, twitter, league pass, and Netflix (how can you just watch 1 episode of House of Cards?).  But it's one of the easiest ways to improve recovery.Sleep gives us the lowest level of stress (internal & external) on the body.  This low level of stress allows us to get out of the red and into the black.  It lets us recover.  Both mentally and physically.The science behind sleep (and why we need it) is still not conclusive.  But we do know that sleep plays a huge role in hormone regulation (melatonin, GH, TSH, testosterone, cortisol, etc.), augments immune system function, improves cardiovascular function, increases cognition, and improves neural function (stimulate oligodendricytes, myelin, neural development/repair).  Plus, the supine position puts the lowest load on the body.Sleep expert at NIH, Dr. Michael Twery, sums up these benefits of sleep nicely; "Sleep affects almost every tissue in our body."So even if we don't know all the reasons behind why we sleep, we at least know that it's good for you.Most experts agree that you need at least 7 hours of sleep a night.  Of course it varies from person to person, but if you're getting less sleep than 7 you might have trouble recovering from the day's cumulative stress (especially if you've put extra stress on it; i.e. workout, injury).

Improving Sleep

 

Mental Stress

Today's culture creates quite a problem.We have these bodies that were developed from over 6 million years of evolution.  This slow, progressive, evolution of our physical body has given us the genes we have today.  Even though we've become a different species than our ancestors, we still share many of the same genes.  Thus, we share a similar body type as our ancestors.On the other hand, our cultural evolution has skyrocketed in the last 10,000-50,000 years, leaving our physical bodies way behind.  And this cultural evolution continues to progress at an exponential rate.  The Agricultural and Industrial Revolution were the first big events that changed the way humans live.  Now we have the Information/Telecommunications Revolution. We are spending more time plugged in and less time present with our bodies.  From this cultural evolutionary perspective, we don't share much in common with our ancestors.This creates a mismatch between the environment we live in and our physical bodies.  In other words, our bodies are not made to live in today's cultural environment.The result of this, and the fact that we often treat the symptoms instead of the cause, is what Daniel Liberman refers to as dysevolution.  A product of this dysevolution is the increasing amount of mental stress/disorder and physical dysfunction.Luckily for us, there is a method to help prevent or decrease this mental burden - Meditation.

Meditation

Meditation has been around for possibly 5,000 years.  Needless to say, it has some empirical evidence.I have taken UCLA's on-line meditation course with mindfulness expert, Diana Winston.  While this by no means makes me an authority on the subject, it has educated me on some of the science behind meditation and how to apply it.The benefits of meditation are incredible and the profound effects cannot be overstated.  Many people talk about the life changing effects of this practice.  Even some of the most successful people in our society have credited meditation as a big part of their growth and accomplishments.But even if empirical evidence doesn't convince you, modern research has shown many positive effects.

Research Has Shown That Meditation Can

• Improve Physical Health (e.g. cardiovascular, immune system)
• Improve Mental Health (e.g. anxiety, depression)
• Improve Emotion Regulation
• Decrease Sympathetic Drive
• Improve Attention (e.g. conflict attention, improve flow)
• Improve Brain Function (e.g. neurodevelopment, gyrification)
• Decrease Pain
• Improve Well-Being

Sounds pretty good, right?And did I mention that it's free and easy?  Well...it's free and physically easy.  Developing your meditation practice is a process and requires some motivation and mental effort.  But don't take that as a deterrent, it's not exhausting or mentally fatiguing.  In fact, most people feel energized after meditating.  The most difficult part is getting started and developing the habit of meditating.I think one of the best places to start is with Diana Winston's 5 minute breathing meditation (YouTube).This is a great place to start for 3 reasons:

1) Everyone can perform 5 minutes

2) It goes over the basics and gives you a standard guideline for future meditations

3) The diaphragm is the only voluntary muscle that can directly influence the autonomic nervous system.  Breathing augments the parasympathetic response of meditation.

It's important to note that I don't immediately jump directly from discussing a painful shoulder to giving them a 5 minute meditation recommendation.Before I prescribe meditation to a patient, I first educate them on the autonomic nervous system continuum (sympathetic vs. parasympathetic).  Then I begin to explain some of the benefits of meditation and how it can aide in their recovery.  If they are receptive, I simply write down my meditation recommendation (above), tell them to type it in on google, find a quiet place, and try the 5 minute meditation.One benefit of our accelerated cultural evolution is that there are now plenty of meditation guides, timers, apps, and techno-bio-feedback devices that give people an easy way to stay on top of their meditation practice.

Diet

Bringing up diet is a lot like bringing up politics.  Everyone has an opinion and no one knows what's really going on.Do we eat nothing but bacon?  Is carbohydrate a bad word?  Is there a chocolate diet?However, more science and less propaganda has allowed for a recent paradigm shift in diet.  We're only scratching the surface and the answers will vary per person and per culture.  But it has gotten a lot better than that terrible food pyramid we were taught to believe.Trends will come and go, but I feel that there are 5 facts that would help most people.  Of course there are a lot more to these "facts" than a simple sentence, but hopefully it'll give some direction for nutrition choices.

5 Nutritional Facts

1. Avoid Processed Foods
2. Eat More Vegetables
3. Avoid Simple Carbohydrates
4. Fat is Not Bad for You*
5. Stay Hydrated

I don't think these 5 Facts will change as they seem to be backed up by basic physiology, logic, and evolutionary medicine.  We may learn more about the specifics of each category, but the basic principle shouldn't change.  For example, it is now well known that fats are good for your health, but research is finding out which specific types of fats are healthy and which are detrimental (i.e. trans fats).

Exercise

The benefits of exercise are enormous.  Exercise improves the musculoskeletal system, controls weight, increases life span, reduces diabetes risk, improves mental health, reduces risk of some cancers, improves cardiovascular fitness, and improves sleep.Exercise is also beneficial for recovery both:

• Immediately following a bout of stress

• For the long term ability to adapt to stress.

The immediate beneficial effects of exercise for recovery should be focused on the circulatory system.  The goal is simply to get blood and fluids moving around.  This should include some active dynamic stretching, mobility work, light stabilization, and/or light aerobic exercise.The long term effects of exercise are much more complicated.  This requires specific individualized programming that involves periodization and deloading.  People should have a normal overall fitness and exercise routine to help stress the body for an individualized adaptation.  Because in the long run, the body can only handle what the body is adapted for.There are many great articles regarding the physical aspect of recovery.  Check the references provided below for more detailed information.

Bottom Line

It's often not the over-training, as much as it is the under-recovery.You can have the greatest training program and the best workout session from the best coach in the world.  But unless you are able to recover from it, it won't matter.Bernard Hopkins, record holder for chronologically oldest boxing champion, sums this series it up nicely:

• "Lifestyle is the make or break of any athlete."

I would even go one step further and say that lifestyle is the make or break of anyone's health.

Disclaimer

Now I'm not saying you should go out and give your patients a full nutritional prescription or start discussing their childhood to determine why their boss stresses them out.  Instead, you should just be assessing the factors that influence their recovery and offering some general advice (if you are educated).  Anything more than this would be beyond health promotion and fall out of the scope of your practice.If someone is interested in a more in depth answer, you should refer out.  The patient will benefit from a greater health "team" and the person you refer out to may even start referring in to you.

Dig Deeper

Signs & Symptoms of OvertrainingChen, Jui-Lien, Ding-Peng Yeh, Jo-Ping Lee, et al. "Parasympathetic Nervous Activity Mirrors Recovery Status in Weightlifting Performance After Training." Journal of Strength and Conditioning Research25.6 (2011): 1546-552.Porges, Stephen W. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation. New York: W. W. Norton, 2011.Walter, Chip. Last Ape Standing: The Seven-million Year Story of How and Why We Survived. New York: Walker &, 2013Lieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. New York: Pantheon, 2013. PrintNutritionSugar is a Drug - Rejection of Low-Fat Dogma - Kris Gunnars Science - 11 Problems with the Modern Diet - Don't Fear the FatsPrecision Nutrition - Boosting Recovery, All About RecoveryHydration - Len KravitzBulletProof - Diet Infographics -SleepInfoGraphic - NIH - 11 Benefits of Sleep - Neural Repair - Sleep "Hacking" - Supplements (1, 2) - How Athletes Sleep - FatigueScience - Study on Performance - James Clear's Informative Sleep Guide - Farnam Street Shane Parrish's Science Summary - NYTimes Schwartz - Sleep & Pain Correlation - Healing Power of Sleep - NeuroSleep InfoGraphic - 10 Reasons Why Sleep is Good - GMB - Sleep Deprivation = Cell Damage - Fix Circadian Rhythm - 2015 National Sleep Foundation Recommendations (Hours Per Night) - TNP on Sleep & Pain - Non-Obvious Sleep Solutions - Wear Sunglasses at Night (here & here) - Scientific American How to Be A Better Sleeper - Sleeps Role in Obesity & Psychological Disorders - 7 Steps to Better Sleep - Body in Mind's Sleep, Pain, & Recovery - Eric Barker 5 Ways to Sleep Better - Sleep is good for learning and memory - The New Yorker "Why Can't We Fall Asleep" - Relationship Between Sleep and Pain - Understanding Sleep - Sleep Builds Good Hearts - Optimizing Sleep for Memory - Sleep Restriction Therapy - Nick Littlehales 90 minute cycles and Ronaldo - National Institute of Health: Why Sleep is Important - Sleep removes neurotoxic waste from the brain - NYT Sleep. Clean. - NYT Sleep Problems and Type 2 Diabetes - Sleep & Recovery from YLMSportScience - The Sleep Judge on the Health Benefits of SleepReimund, E. "The Free Radical Flux Theory of Sleep." Medical Hypotheses 43.4 (1994): 231-33.

"Removal of excess free radicals during sleep is accomplished by decreased rate of formation of free radicals, and increased efficiency of endogenous antioxidant mechanisms. Thus, sleep functions essentially as an antioxidant for the brain."

MeditationUCLA Mindfulness Awareness Research Center - Mindfulness Research Summary (Flock L, Flaxman G) - Gyrification - 7 Myths of Meditation -23 Ways to Reduce StressUCLA  - Mindful Awareness Practices (MAPs) I for Daily Living (On-Line).  2013.ExerciseCDC - Harvard - Exercise & the Brain -Mike Robertson - 6 Tips for Recovery , Aging AthletesEric Cressey - 3 Tips for Aging AthleteChris Beardsley - RecoveryKevin Neeld - Post-Game Sympathetic Dominance, Overtraining & RecoveryDan John - Recovery TipsPatrick Ward - Rest, Recover, Regenerate Part 1, 2, 3, 4, 5Seth Oberst - RecoveryEric Bach (via Dean Somerset) - Recovery - Deloading 

Blair, S.  Physical inactivity: the biggest public health problem of the 21st century.  BJSM.

Fountain of YouthThe 23 Hour Plan--The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

 [subscribe2]

The Art of Recovery (Part 1 of 2)

One of the most difficult questions to answer in rehab is: "when will I get better?"Coming out of grad school my response was usually mumbling some ridiculous time period with a deer in the headlights look on my face.  I had no idea.  I knew the tissue healing timetable...and that was about it.  I had little experience with specific injuries and didn't yet understand the complex, multi-faceted factors that influence recovery.Now I'm a little better at hiding that deer in the headlights look, I have more clinical experience, and I know more about the art of recovery.

Stress

Before diving into recovery, you have to understand a little more about the stressors that cause recovery and adaptation.There are two types of stress: Internal Physiological Stress and External Environmental Stress.The Internal Stress is an on-going battle to keep our physiological homeostasis.  We have to adapt to these cellular stressors to make sure we can continue to keep all of our systems functioning together.  This type of stress is perpetual as long as you're alive.The External Stress is what happens when we interact with our environment.  It's how we adapt to function and survive in our surrounding habitat.  This can be physical and/or mental stress.

• Physical Stress includes any external force/load that is applied on the body (e.i., getting out of bed, walking, sitting in a chair, carrying groceries, bring a beer to your lips, etc.).  Even gravity counts as a physical stress.  But don't use that as an excuse to skip your next workout.

• Mental Stress includes all the sensory input and complex psychological processing.  This is an extremely complicated system and cannot be overlooked.  Even listening to music elicits a certain amount of mental stress, let alone listening while texting your friend, checking your email, and trying to avoid walking into people on the sidewalk.

Unfortunately, there is no way to completely avoid stress.  Trust me, with Netflix binge watching I have given it a good shot.  Nevertheless, if you are alive, and you live in an environment, you will have to deal with these internal and external stressors.  And this is a good thing (to a certain extent).

• Stress Must Occur for Adaptation to Occur

All of these different types of stressors are compounded on the body.  In other words, it's cummulative.  The external stressors are added to the internal stressors, and it forces your body to adapt (both physically and mentally).  If your body can't adapt, if it can't recover from the stress...bad things will start to happen.

The Art of Recovery

I know, it sounds like a book you'd see in the self-help section of Barnes and Nobles.  But I've come to realize how important recovery is when you look at the big picture.We all want our magical hands, brilliant exercises, and genius programming to cause specific advantageous adaptations that give our patients super-human like powers.  But the sad truth is, even if we put a magic spell on a patient, they will only get better if they can adapt from it.

• Adaptations Occur During Recovery

Simply put, your patient won't be able to adapt to physical stress without a proper recovery.  The gains will be diminished, non-existent, or even reversed.  And if this short term lack of recovery continues over time, it can lead to a very damaging effect.This applies to everyone; from rehab to strength and conditioning.  Whether it's a post-op ACL or a PR deadlift session, recovery drives the adaptation.Stress can either cause an adaptation or push them further down the biological stress path.

Tissues Heal

Tissues will naturally heal.  Our bodies have a great capacity to repair themselves.Tons of people injure themselves everyday and don't need any rehab or exercises to recover.  Their tissues heal with time (providing they don't do anything stupid).  They just ride the natural progression towards recovery.Understanding this simple concept is a big part of recovery.Since the tissues are going to naturally heal themselves, you better make sure you and your patient don't do anything to disrupt this process.  This comes down to educating your patient on the factors that influence their recovery.  If all you do is control these factors of recovery, the patient will physiologically get better (not talking about pain and/or movement patterns).After you have the preventative/augmentative aspect of recovery covered, you can start to try to create the right environment for the patient to heal in.  This comes down to controlling the specific stressors (seed) you apply to the patient (soil) in the clinic.

Factors That Influence Recovery

The Art of Recovery is an individualized process that depends on who your patient is and what injury they have.  Everyone is different and requires a different recovery process.You can't apply a cookie cutter approach to recovery.  It won't work.  There are too many patient variables to consider: coping style, lifestyle, social factors, occupation, expectations, education level, learning styles, previous injuries, expectations, economic status, goals, cultural background, etc.It needs to be tailored for the human being you are working with.So where do you start?Start by understanding all the factors that can influence recovery.  Specifically, the external environmental factors, since these are the ones both you and your patient have the most control over.  And these external environmental factors can be used to influence the internal physiological factors.Our species will respond in a similar manner to all these factors.  Regardless of who you are, a bad diet, lack of sleep, high level of stress, and lack of exercise will adversely affect your recovery.  However, the degree to which everyone is affected by these factors will differ.Once you understand this complex concept and some of the variables involved, you can then start to assess and individualize these factors to the person's specific needs.It's important to realize that many of these factors can either positively or negatively influence recovery.

Assessing the Patient

Recovery can be viewed from the lens of the nervous system (Autonomic NS).  The nervous system oversees and affects all of the other systems, especially when dealing with stress.Everyone will be on a continuum of sympathetic and parasympathetic dominance.  Where they lie on this continuum depends on many components, but global perspective can help to assess how much stress a person has.If there is a lot of stress (internal & external), the body will be in more of a fight or flight mode (sympathetic) trying to recover from this stress.  If your body is adapted and not as stressed, it will be more relaxed (parasympathetic) and closer to homeostasis.You can generally tell what system is more dominant by spending some time with the patient.  You can just globally look at their symptoms, interactions, affect, demeanor, and body language.  Or you can get a little more objective using the cardiovascular system (heart rate variability).Either way, you need to determine where your patient stands.  Are they too far on the parasympathetic side and need some added stress to initiate positive adaptation?  Or are they too far on the sympathetic side and need to reduce some of the cumulative stress to allow for recovery?In general, your body recovers better on the parasympathetic side.  Especially in today's over stimulated world, everyone could probably benefit from getting a little more parasympathetic.  Just realize that some people will need more work to get there.  And the goal is to get to a state of neutral, not to push your patient into a coma for recovery.

Influencing Recovery

How to influence these factors is a whole other animal.  Because of the complexity of patient variables, it is impossible to have a protocol for influencing recovery.  Developing this approach is much like pain education, it really needs to be specific to the patient.There are 2 things you should take into consideration:

1. People respond differently to different methods of recovery
2. People may not be able to change certain factors

Instead of dogmatically forcing certain methods or certain factors, listen to your patient and work with them on what they can do.For example, the new father with a busy work schedule may not be able to get 7 hours of quality sleep every night.  It's just not in the cards.  So instead of beating a dead horse on sleep, you should educate and promote one of the other factors.  He can probably improve his diet/hydration, exercise for 20 minutes, find 5 minute to meditate, or reduce his technology use at home.And this doesn't need to be a 10 minute lecture or a big intervention.  It is just an open discussion with the goal of educating the patient and helping them improve their recovery.How you educate them is up to you, but if they don't know, they can't change it.  And if they can't change it, that perfect exercise won't "grow" to be the adaptation you were hoping for.

A Role in Promoting Health

All you can do is educate and try to sell the patient on recovery.  In the end, their recovery is in their own hands.But also consider that you are doing more than just advocating recovery.A side benefit of focusing on factors that influence recovery, is that you are also promoting a healthier lifestyle.  Not only will they recover more efficiently, but their overall health can dramatically improve with small changes.  This could make a big impact on their quality of life.And think about the effect this could have on our healthcare system.Someone that sleeps 4 hours a night, doesn't exercise, eats bad food, is stressed with work, and sits in a chair for 80 hours a week will cost the healthcare system A LOT of money.  If this person could change at least one of those factors they would be in much better health and put less strain on the healthcare system (if 25% of the population were more fit, it would save over $58 Billion per year).

Bottom Line

Many times we become so worried about applying the perfect stress that we forget about the importance of the patient adapting to it.We can get so caught up with movement patterns, mechanics, pain education, and manual techniques that we sometimes overlook some of the easy ways to help a patient recovery quicker.  Educating and attempting to control the factors that influence recovery is not only a part of their current rehabilitation, but it's also a big part of their overall health.So the next time your patient inquires about "when they will get better", take the opportunity to discuss some of the factors that influence their recovery (and their health).

Dig Deeper

References will be provided in Part II.Signs & Symptoms of Overtraining  --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

 [subscribe2]

Everything is Moving Proximally

In the past 10-20 years there has been a trend towards stabilizing the proximal joint.  Everything seems to be going more and more proximally.  And this is a good thing!  It is providing us with better outcomes and quicker pain free rehabilitation.If you look at the knee joint you can see the progress.  We've gone from isolated patella mobs and VMO strengthening to hip strengthening.  And now we are going even further up the chain and looking at lumbo-pelvic complex.The same thing is happening with the shoulder.  We've gone from isolated thera band ER/IR to scapula stabiliztion.  And now we are going even further and looking at the thoracic spine and ribs.And if we go just 1 step further at both joints we end up where it all began in the first place...the core.

The Greats Love Proximal Stability

This is no where close to being a new concept.  Many of our professions greatest clinicians have been emphasizing the influence of proximal stability on the distal extremities for years.Shirly Sahrman always discussed relative flexibility/adjacent stiffness, PRI's focus is achieving a Zone of Apposition (ZOA), PNF (Kabat & Knott) has always advocated Proximal Stability before Distal Mobility, Gray Cook prioritizes Symmetrical Core Stability, Stuart McGill discusses Super Stiffness, DNS (Kolar) starts with a Centrated Spine for a Punctum Fixum, Kelly Starrett talks about Midline Stabilization, and Janda's Upper/Lower Crossed could be argued to be the result of poor core stability.Anyone that uses these approaches knows of the benefits of core stability for extremity function.It's becoming more and more common in clinics, training rooms, and gyms.  But it goes beyond empirical cases; the research on the influence of the core on the extremities seems to be increasing as well.I would bet that in several years, core training and integration for extremity dysfunction will be as common as hip strengthening for dynamic valgus.

The Core

We could sit here for days and argue over semantics on the definition of the core.  We can then spend another couple hours arguing about how it can be separated: inner core, outer core, local muscles, global muscles, anterior, posterior, lateral, etc.This is great and can provide for some interesting discussion, but these semantics don't change how the core works.I try to keep it simple and define the core is the center of the body.  It's your axial skeleton and all the muscles that connect to it.Regardless of your definition, the focus should be on how the core works, how to assess it, and how to train it for each individual patient.

The Developmental Perspective

Looking at movement through the neuro-developmental lens gives us an unbiased perspective of how we ALL started to move.  Every generation has developed motor functions through the same neuro-developmental kinesiology.  It's a pre-written genetic code with more than 6 million years of evolution.  We are all born with full mobility; and then we struggle our way from rolling, to sitting, to crawling, to walking.We develop our first movement patterns with minimal influence of external factors.  It's the purest form of movement that we have in this world.It's before shoes deprive our sensory input and lock up our ankles.  It's before we're forced into chairs and give away all sorts of proximal mobility.  It's before someone tries to coach or teach us how to move.  It's before we can be influenced by a certain model of movement (yoga, pilates, martial arts, powerlifting, sports, etc.).The developmental perspective shows us how humans move before the detrimental influence of their culture.Needless to say, it's a good standard to measure against.

How the Core Works

Developmentally, all movement starts at our core.  We start to control our head, we start to gain sagittal spinal stability, and then we start moving our extremities.  This combination of spinal stability in concert with extremity movement then drives the rest of the movement development.   Once we have this extremity motion integrated, we start rotating and rolling, then we sit up, then we go from creeping to crawling to cruising to walking.This is all basically a core motor control and strengthening progression.  The core stability demands increase with the each progression of the developmental milestones (least=supine/prone, most=standing/walking).  It's the first SAID principle our bodies have to deal with.If the core doesn't fire efficiently, the baby won't be able to perform the task and the baby will fall down.  Without an integrated core, the baby won't be able to use their extremities for manipulation and movement.In this manner, developmental kinesiology prevents humans from progressing to the next milestone without mastering the previous one.  It's natures perfect self-limiting exercise.Babies don't perform planks, do 3 sets of 10 crunches, or isolate their transverse abdominis.  Thats not how the core works.  The core works to create efficient proximal stability for the production, control, and transfer of force.  The core works to create a stable base for goal oriented movement.  It's a complex, integrated system of feed-forward and feed-back strategy.  And it is developed through the use of the extremities.It's important to note that this "efficiency" is not a measure of strength.  It's an assessment of the neuromuscular patterns.Core efficiency involves the complex coordination, timing, and motor control of ALL the muscles involved in the specific task.  From the big toe on the ground to the opposite shoulder, all muscles must be fire in concert with the core.  It's not just "pre-activating" your inner core.So what happens if your core isn't stable?  If you're not able to transfer force and stabilize your center of gravity?  If you're not able to centrate your center?

What Happens When the Core Doesn't Stabilize

What happens is that the next joint down has to do extra work to stabilize.  The next joint down can't transfer (unload) force to the proximal core.  The next joint down ends up taking on a lot more force.  The next joint down overworks to make up for the lack of efficient proximal stability.  The next joint down gets locks down in attempt to "stabilize" and becomes "tight".  The next joint down becomes inefficient.This is an example of how not having proximal stability leads to decreased distal mobility.So that hip might be restricted and feel tight because it can't transfer (unload) forces proximally because of a lack of core stability.  And those ankles might always be locked up because they might be constantly active as a postural balance strategy because of a lack of core stability (unstable center of mass=instability=terminal segment compensation).That's not to say it can't swing the other way.  With a lack of proximal stability, the distal segment will not be as efficient at producing force/torque.So that overhead shoulder might feel weak because it can't receive valuable proximal force production from the core.  And those achilles might be overworked because they're trying to make up for the lack of proximal stability from the hips and core.

Assessment & Intervention

Assessment

I assess the core using a developmental postural stability progression.  This progression is essentially going from lying on the ground to standing.  From a stable base to a narrow base.  From minimal degrees of freedom to maximal degrees of freedom (joints available).

Postural Assessment

Each posture is progressed from wide base of support to a narrow base of support.

• Supine/prone is assessed with either rolling patterns or foam roll marching (depending on client and space).
• Quadruped is assessed with Alternate UE & LE ("bird-dog").
• Tall & Half Kneeling is assessed with half kneeling to ensure that there are no asymmetries.
• Single leg stance is assessed with eyes open and eyes closed.

I usually assess people for 10-20 seconds in each posture.  I look for the movement quality, common pattern dysfunction, and compensatory strategies.  The goal is for the patient to stabilize the closed chain extremities through their core.  I don't get too caught up in the positioning of the open chain extremities.

Intervention

My intervention follows the developmental postural stability progression in a static to dynamic fashion (low threshold to high threshold).After I have their core movement assessed, I use these positions at their "Edge of their Ability" to develop reflexive static stability and core efficiency.  I usually tell my patients to "find the point where they struggle, but don't fail".http://www.youtube.com/watch?v=b06-S2F3qm0Once they can demonstrate the most difficult level of static stability (narrow base), I add either upper extremity or lower extremity dynamic movements in these postures.  From here, the possibilities are limited by your creativity.Some Examples:

• Upper Extremity: Wall Slides in Tall Kneeling, Plank with Reach, Quadruped T's, UE PNF Patterns in Developmental Postures

• Lower Extremity: Side-Plank with Hip Abd/Flex, Bridges with Marching, Plank with Hip Extension

• Both: Chops & Lifts, Single Leg Asymmetrical Deadlift, Resisted Quadruped Alt UE/LE, Turkish Get-Up, Quadruped Rocking, Crawling/BearCrawling

Bottom Line

• "Any purposeful movement first requires spinal stabilization" -Pavel Kolar

I try to add some core integration for all of my patients.  It's easy to do, there are tons of benefits, and the patients usually like it.  Plus, it taps into the hard-wired CNS developmental patterns.You can incorporate this tomorrow.  Just keep doing what you've been doing with your patient, but throw them at the edge of stability in one of the developmental postures.  They'll get more sensory input, and therefore a better motor output.  Their core gets integrated, and you have a new trick up your sleeve.  Everyone wins.Even if you don't buy into this whole proximal stability thing, you should at least consider it when that ankle dorsiflexion hasn't improved in 6 weeks.

Dig Deeper

Gray Cook:

Motor Control, Stability, and Prime Movers

Sequence of Core Firing

Edge of Ability  

Kelly Starrett - Midline Stabilization, Example of Midline Stabilization FaultSeth Oberst - Motor Control Priority Steve Smith - DNSLieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. New York: Pantheon, 2013. PrintWalter, Chip. Last Ape Standing: The Seven-million Year Story of How and Why We Survived. New York: Walker &, 2013. Print.Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.Liebenson, Craig. Rehabilitation of the Spine: A Practitioner's Manual. Philadelphia: Lippincott Williams & Wilkins, 2007. Print.Studies:Moreside JM, et al.  Hip joint range of motion improvements using three different interventions.  J Strength Cond Res. 2012 May;26(5):1265-73.Leetun DT, et al.  Core stability measures as risk factors for lower extremity injury in athletes.  Med Sci Sports Exerc. 2004 Jun;36(6):926-34.Kibler WB, Press J, Sciascia A.  The role of core stability in athletic function.  Sports Med. 2006;36(3):189-98.Wilson JD, et al.  Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg.  2005; Sept13(5):316-325Shinkle J, et al.  Effect of core strength on the measure of power in the extremities.  J Strength Cond Res. 2012 Feb;26(2):373-80Granacher U, et al.  The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: a systematic review.  Sports Med. 2013 Jul;43(7):627-41.Gottschall JS, Mills J, Hastings B.  Integration core exercises elicit greater muscle activation than isolation exercises.  J Strength Cond Res. 2013 Mar;27(3):590-6. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

 [subscribe2]