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]

Mark Cheng Prehab-Rehab 101 Workshop Review

On August 2 and 3rd I was lucky enough to part take in Mark Cheng’s Prehab-Rehab 101 workshop at Perfect Stride in NYC.  This was not only a special event because of the instructor and content, but it was the smallest class size I’ve ever been in.  There were only 13 other clinicians in the class.  Having this much of Mark’s attention provided for a great learning experience.Mark Cheng is an awesome instructor.  He is extremely humble, gracious, and open minded.  Mark was very receptive to random clinical questions and let us dictate the flow instead of forcing pre-determined material down our throats at his preferred pace.  His teaching style makes you feel like you’re learning from a friend as opposed to authoritative lecturer.

Kinesthetic Lesson

I had just finished reading Pavel’s Naked Warrior a couple weeks before the class.  This helped tremendously since Mark was trained by Pavel himself and employs many of his concepts.  One of the biggest concepts I learned from Pavel and Mark is the importance of generating TENSION.As movement practitioners, we often spend a good amount of time worrying about the right load, volume, duration, and kinematics.  However, the ability to develop tension is often overlooked.  Throughout the course, Mark had us focus on the ability to generate the right amount of tension, from the right places, at the right time.While this sounds very cumbersome, it wasn’t in practice.  To reduce the mental effort and avoid a million different external cues, Mark simply had us slow down the movement.  And I mean slow.  I used to think I crawled, quadruped rocked, and TGUed at the right pace.  But after performing these exercises at such a slow pace, I quickly understood the importance of tension and where it needs to be.Since taking this course, I’ve found many patients will hide their dysfunctions/compensations with speed and momentum.  Slowing people down will reveal their true movement ability.

Foot Priority

The feet make up 25% of the bones of the body.  The feet take up a huge amount of real estate in the homunculus.  The feet are how the body first communicates with ground.  The feet are where we translate the body’s internal force to create a ground reaction force that moves the body in space.  Needless to say, the feet are very important.Mark thinks the feet are one of the most neglected parts of the body.  He put a big emphasis on the importance of foot health and having the proper mobility/stability in our body’s most inferior joint.

2 Foot Exercises:

 1) Pulling the Toes Up to Create an Arch/Tripod Foot (Stability)2) Ankle Circles (Mobility)

• Maintain forefoot/toe contact and focus on making slow circles with heel (clockwise & counterclockwise)

Ground Work

Since I started using the developmental sequencing a couple years ago my outcomes have improved dramatically.  I was excited to learn more from Mark on this topic and wasn’t disappointed.  Mark refined the fundamental details and added a ton of new progressions.  These have been very helpful in the clinic.

Groundwork Pearls:

 • Breathing - Mark wants the apex of the breath to be low; around the beltline• The true developmental progression is Breathing - Vision - Head Movement• Everything is driven with the eyes; from supine lifting your head up to crawling.• Mark feels vision is very valuable sensory input and is an easy way to progress exercises.  For example, to challenge half-kneeling he would simply have people look left and right, then progress it to an “H” pattern (with head movement).• Since we live in a flexion dominated world, Mark focused on the extension based progressions.• The Sphinx Progression is awesome• The “wall crawl” is great regression for patients that cannot get to the ground

Turkish Get-Up (TGU)

 Mark Cheng is known for being a leading expert on this subject.  So when he was teaching the TGU I was expecting brutal attention to detail, ruthless criticism, and strict kinematics.  However, it was the almost opposite experience.  Mark just wanted to see good movement.  He didn’t worry about exact hand, knee, or foot positioning.  He allowed for movement variability.

Mark's Focus:

1) Avoiding the Hey Girl Posture

• Keeping proper spine alignment and making sure the 4 knots are tied to the true core

2) Going slow and moving with intention

Hip Hinge

Just when I thought there was nothing left to learn with the hip hinge, Mark took my knowledge to another level.  This demonstrated once again, the importance of the details when performing the fundamentals.

2 Things I Learned:

 1) “Hamstrings at the bottom; Glutes at the top.”  Mark had us emphasize pulling down into our hamstrings at the bottom of the position and then creating as much tension with our glutes at the finish position.2) “What you think you are doing is often different from what you are actually doing”.  This was a bummer.  I thought I was pretty solid at keeping a neutral spine throughout.  It wasn’t until Mark showed us the greatest hip hinge tactile cue of all time that I realized I was losing a little neutrality.  Grab your skin at your belt line on your back and hip hinge down.  If you lose that skin, you’ve rounded your back.

Manual / Tui-Na

 Throughout the course Mark would teach us how he manually gets a “reset” to improve mobility.  This was very interesting for me since I have no experience with Chinese manual therapy.  It was great not only to learn Tui-Na techniques, but I was able to have Mark perform them on me so I could experience what they were supposed to feel like.  One of the things that was really surprising to me was how Mark was able to get these huge cavitations with such little force.  It was a very specific, but gentle force.  He uses leverage, breathing, and gravity to create the traction and manipulation.

23 Random Goods

1) 5 Asymmetries

• Left to Right

• Top to Bottom

• Anterior to Posterior

• Medial to Lateral

• Internal to External (internal strength;breath,emotions to external strength)

2) The Latissimus Dorsi is also a spinal extensor3) Self-Myofascial Release (foam roll, etc.) should be performed slowly on a relaxed muscle.  You may need to cue or “wiggle” the limb loose.4) 3 Internal Harmonies

• Emotion with Intention

• Intention with Breath

• Breath with Movement

5) Breathe deep into stomach - below belt line6) 5 Tensions at the Top of a Hip Hinge

• Foot arch, push through heel

• Knee Extension

• Glutes

• Abs - ribs down

• Open Chest

7) “Context is king”8) Use manual to bring ease to the area - re-map the brain9) 4 Knots

• Don’t want it too loose or too tight

• Tie the knots to the right core

• If you shrug your shoulder, you just “tied” the knot to your neck - now your neck and traps have become your “functional core”

10) Releasing rotator cuff can have great impact on neck11) 4 Biggest High Yield Areas for Release

• Popliteus

• Anterior Thigh (RF, VL)

• Infraspinatus

• Subscapularis

12) Sometimes you need to contract a muscle to teach it to relax.  Sometimes you need to relax a muscle to teach it to contract.13) The hyperextension you often see with a hip hinge, or other movements, comes from the T-L Junction14) 3 Athletic Movements

• Symmetrical Double Stance

• Split Stance

• Single Leg Stance

15) Getting your head in neutral can increase shoulder flexion ROM16) “Spread the Chest”, “Keep Chest Wide”, “Open Chest”

• Cue for proper scapula, t-spine, and neck position

• Avoids improper scapula packing

17) "I’d mobilize shaq on his stomach with someone pulling his ankles"18) 2 Ways the Chinese Keep a Secret

• Tell Nothing

• Tell Everything

19) Night Cramps - check magnesium20) Fearful / Painful Patients

• Make it playful

• You take away the threat by adding in the fun

• Reaction drills are very engaging, fun

21) Have people walk after interventions.  It allows the body to “re-calibrate” the new stimulus22) 4 Pry’s

• Ball of foot

• Knees Out

• Spread Ischial Tubs

• Open Chest

23) Never assume your patient is relaxed

• Always cue them to relax more during soft tissue mobilization

Bottom Line

One of Mark’s goals was to show us new “access points” for movement interventions.  Anyone can make something more difficult, but it takes an expert to make something easier.  This course not only provided a plethora of new access points for my patients, but also enriched my current practice.  I highly recommend this course with Mark Cheng, especially if it is organized in such a small class size like it was at Perfect Stride.  A special thanks to Dan Park for putting this course together.  --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 Deep Squat (Part 1 - The Good, The Bad, & The Not So Ugly)

The deep squat (aka full squat, aka ass to grass/ATG squat) is one of the most debated, talked about exercises/assessment we have in human movement.  Some talk about the deep squat as if it's the cure to cancer, some talk about it like it's going to cause the apocalypse.  I have found that I always get mixed information and many take either a full medical approach, a full evolutionary approach, or a full performance approach.My goal here is to provide a blend of these approaches.  As a PT that loves S&C and evolutionary medicine, I hope I can give some evidence, some reasoning, and some clinical judgement on the deep squat as an exercise.Let me again emphasize this is through the lens of the deep squat as an exercise; the squat as an assessment is a whole different story (PRI, FMS, SFMA, Loaded, ADL, etc.).If you want to stop reading here, please consider the conventional wisdom of great S&C coaches:

• Squatting is not bad for you, the way you squat is bad for you

Disclaimer

I think a big part of the discrepancy with the performance with the deep squat is that there are so many variables associated with this movement pattern.  These variables include local physical impairments, movement history, exercise history, injury history, education, neuroception, structural changes, coaching, motivation, and culture.So if you took 100 people off the street and had them deep squat, you would see a smorgasbord of different movement patterns.This surfeit of human variables leads to a problem when trying to generalize one of the world's most complex exercises, let alone trying to create a study.But this abundance of variables isn't the only problems with the studies.

3 Reasons Why Evidence isn't the Gold Standard for the Deep Squat

1. The populations vary from individuals who are young and have experience with the deep squat, to older individuals with possibly no experience with the deep squat.
2. The studies don't seem to take into consideration any of the physical impairments; someone with an ankle dorsiflexion restriction is going to squat much differently than someone with a ankle motor control problem.
3. The definition of the deep squat is completely different in some papers (some have mentioned parallel femurs as a deep squat).

So you can't expect too much from PubMed due to the inconsistent populations, lack of data on physical inputs, and a poorly defined task. 

Defining the Deep Squat

I'm going to call the deep squat simply a squat below parallel with a neutral spine.If you can't get below parallel with a neutral spine, you can't do a deep squat as an exercise.Getting below parallel with spine flexion is great if it's unloaded (SFMA, PRI), but in this article I'm focusing on the act of loading the deep squat for strength, performance, & movement enhancement.

We Used to Always Squat

Tired of standing? Squat down.Need to check something out or inspect an object? Squat down.Hanging out, shooting the shit around a camp fire? Squat down.This was the life for our ancestors (and for some of our current species in different cultures).It's Phylogenetics, the evolutionary history of our species.  It's our species' "family tree" from the beginning of time.The way our bodies have evolved over time has resulted in the movement pattern of the deep squat.But it's also Ontogenetics, the developmental history of an individual.  It's how the interaction of genetics, developmental programming, and environment affects the physical form throughout a lifespan.I've mentioned in a previous post that we have culturally evolved at a rate that far surpases our physical evolution.  Meaning, the world we live in is not made for our physical structures (chairs, shoes, school/work, technology, etc.).This mismatch means that the person in front of you trying to squat should be able to squat (phylogenetics), but may not be able to because of the way they have interacted with their environment (ontogenetics).For example, think of how a 4 year old can deep squat with no problem (phylogenetics), but the 50 year old, life-long sedentary, American desk jockey that can't flex his hip past 90 degrees because of structural changes in his femur/acetabulum has no chance at a deep squat (ontogenetics).But before you start analyzing your patient's phenotype, you should first understand the benefits, risks, and drawbacks of the deep squat exercise.

A Visual Approach to Squatting

Before discussing the benefits and potential drawbacks of the deep squat, it's best to understand exactly what is happening at the knee joint through varying degrees of knee flexion.Here's a diagram with the degrees of knee flexion and the associated forces/EMG activity.This is based on several studies, listed below. * Most studies don't mention any activity beyond 135 degrees.  So this is unknown and why there is nothing beyond 135** It seems the force shifts from anterior to posterior between 50-60 degrees.  This is why there is an overlap.  Yes, I know it's impossible to have both anterior and posterior shear forces at the same time.

Why it's Good

It cures cancer!But seriously, the deep squat exercise has a ton of benefits (see chart below).In general, the deeper the squat, the greater the quad and glute activation.Plus, the deep squat spares the knee of shear forces and prevents ligamentous strain (see figure above).  Since most lower extremity injuries involve weakness and aberrant shear forces, the deep squat can provide a great exercise to help reduce injury.From a performance perspective, the deep squat provides a great exercise for increasing strength (legs, thighs, hips, core) and improving vertical (y-axis) movement efficiency.

Why it's Bad

Ontogeny

The bad often comes from ontogeny.  Everyone was able to squat as toddlers, but what they've done since then will influence what they can do now.  In other words, the way someone has chosen to live their life may make the deep squat a bad exercise for them.  Everyone was born to squat, but not everyone has grown to squat.  This is due to the body adapting to life's imposed demands (mechanotransduction, Wolffe's Law, Davis's Law, bioplasticity, etc.).  Think of it as a structural SAID principle.Someone that spends their life in an anterior pelvic tilt, wearing high heels, and sitting for 80 hours a week will have structural changes in their ankles, hips, and lumbo-pelvic area that will prevent them from a deep squat.  This person would need years of specific training in attempt to reverse some of these adaptations to allow them to squat without compensations.

Compressive Forces

Another potential danger is the high compressive forces (tibiofemoral & patellofemoral) with a deep squat.  Since there is an inverse relationship between shear and compression forces, the benefit of less shear is at a cost of more compression.  For most, this isn't a big problem if you apply the SAID principle and progress slowly.  But for some it may be an issue.

Mobility Restrictions

In general, you should avoid prescribing the squat with people who do not have optimal mobility in their ankle, knee, and hip.  Simply stated, if you do not have adequate mobility in these joints you will compensate and cause more harm than good.

Pathologies

Getting more specific and research-based, I would be very careful to squat with people who have: meniscus pathology, PCL pathology, hip impingement pathology (labral tear or bone spur), chondromalacia (depending on location of pathology), or advanced symptomatic osteoarthritis.However, you should always treat the patient, not the script/image/anatomy.

But What About...

Many times in medicine, one of the first studies that come out on a subject becomes the most popular and becomes dogmatic.  This happened with the 1961 research article by Klien.  Klien reported that squatting was dangerous and increased laxity in the knee.  Everyone jumped on the anti-deep squat bandwagon back then, and some are still dogmatically against the deep squat; even though Klien's results have been refuted in many research articles since.Here are some questions that many have about the squat and it's safety.

Isn't it Bad for Ligaments?

"Because the squat generated lower ACL strain compared with walking or jogging, it was concluded that the squat was a low risk exercise in rehabilitation of the ACL". - Henning et al.

"In conclusion, basketball players and distance runners experienced a transient increase in anterior and posterior laxity during exercise. Power lifters doing squats did not demonstrate a significant change in laxity." -Steiner et al

Isn't it Bad for the Tissues Around the Knee?

"With increasing flexion, the wrapping effect contributes to an enhanced load distribution and enhanced force transfer with lower retropatellar compressive forces...Contrary to commonly voiced concern, deep squats do not contribute increased risk of injury to passive tissues." -Hartman et al.

Isn't it Bad for the Knee Cap?

This is basic physics (Force = Pressure x Area).  There is increased compression with the deep squat, but there is also increased retro-patellofemoral contact area.  Meaning the direct pressure on the knee cap is dispersed among a greater area, thus less focal retro-patellar forces.  Just keep in mind the location of the retro-patella forces associated with the different degrees of knee flexion.

Isn't it Bad for Knees?

"The squat does not compromise knee stability, and can enhance stability if performed correctly. Finally, the squat can be effective in developing hip, knee, and ankle musculature, because moderate to high quadriceps, hamstrings, and gastrocnemius activity were produced during the squat." -Escamilla RF

"In conclusion, there is scant evidence to show that deep squats are contraindicated in those with healthy knee function." -Schoenfeld BJ

Bottom Line

The squat can be a very valuable exercise for both rehab and performance.The question isn't about whether squatting below parallel is good for people.  We know that squatting below parallel affords many benefits and few risks.The questions has to deal with what the individual's environment and lifestyle has done to them over time (ontogeny).  What are the patient's physical limitations and adapted structures developed to deal with?  Which ones can you change?  Which ones should you change?Understanding the phases of the squat and the associated forces/EMG activity will help one prescribe the exercise more effectively.Part I deals with understanding the deep squat.  Part II will deal with implications for rehab, performance, and how to train it from the ground up.

Dig Deeper

Evolution:Evolution goes much deeper than phylogeny and ontogeny.  Ontogeny is an umbrella term that includes many more detailed concepts (e.g. phenotype plasticity, epigenome, etc.).  Special thanks to the great professors who helped clarify some of these concepts for me: Daniel Liberman, Robert Boyd, Kathleen Smith, Jennifer Brisson, Jean-Jacques Hublin, Squat Stuff:Brad Schoenfeld has some of the best articles on the deep squat.  Best place to start in my opinion.  Scroll down for the articles - The Biomechanics of Squat Depth, Squatting kinematics and kinetics and their application to exercise performance .James Speck - 5 Reasons to Start Full SquattingChris Beardsley - Squat Depth for Glute Activation, Squat DepthBret Contreras - 7 Reasons to Squat Like a ManHuffington Post - Nick EnglishStrongfirst Front SquatDean Somerset - Do You Need to Squat DeeplyKevin Neeld - The Truth About Deep SquattingVincent St. Pierre - Are Deep Squat SafeNick Tumminello - 7 Reasons This is a Ridiculous MythMenno Henselmans - Partial ROM vs. Full ROMBrent Brookbush - A Kinesiological Approach to the Overhead Squat (16 Video Series)

References

HENNING, C. E., M. A. LYNCH, and K. R. GLICK, Jr. An in vivo strain gage study of elongation of the anterior cruciate ligament. Am. J. Sports Med. 13:22-26, 1985.Klein K. The deep squat exercise as utilized in weight training for athletes and its effects on the ligaments of the knee. J Assoc Phys Ment Rehabil 15: 6–11, 1961Escamilla RF. Knee biomechanics of the dynamic squat exercise. Med Sci Sports Exerc 33: 127–141, 2001.Meyers E. Effect of selected exercise variables on ligament stability and flexibility of the knee. Res Q 42: 411–422, 1971.Chandler T, Wilson G, and Stone M. The effect of the squat exercise on knee stability. Med Sci Sports Exerc 21: 299–303, 1989.Bloomquist, K., H. Langberg, S. Karlsen, S. Madsgaard, M. Boesen, and T. Raastad. "Effect of Range of Motion in Heavy Load Squatting on Muscle and Tendon Adaptations." European Journal of Applied Physiology 113.8 (2013): 2133-142.Hartmann, Hagen, Klaus Wirth, and Markus Klusemann. "Analysis of the Load on the Knee Joint and Vertebral Column with Changes in Squatting Depth and Weight Load." Sports Medicine 43.10 (2013): 993-1008.Caterisano A, Moss RF, Pellinger TK, Woodruff K, Lewis VC, Booth W, Khadra T. The effect of back squat depth on the EMG activity of 4 superficial hip and thigh muscles. J Strength Cond Res. 2002 Aug;16(3):428-32.Steiner M, Grana W, Chilag K, and Schelberg-Karnes E. The effect of exercise on anterior-posterior knee laxity. Am J Sports Med 14: 24–29, 1986.Esformes, Joseph I., and Theodoros M. Bampouras. "Effect of Back Squat Depth on Lower-Body Postactivation Potentiation." Journal of Strength and Conditioning Research 27.11 (2013): 2997-3000.Salem, George J. et al.  Patellofemoral joint kinetics during squatting in collegiate women athletes.  Clinical Biomechanics 16:424-430, 2001.Bryanton, Megan A., Michael D. Kennedy, Jason P. Carey, and Loren Z.f. Chiu. "Effect of Squat Depth and Barbell Load on Relative Muscular Effort in Squatting." Journal of Strength and Conditioning Research26.10 (2012): 2820-828.Schoenfeld BJ. Squatting kinematics and kinetics and their application to exercise performance. J Strength Cond Res 24: 3497–3506, 2010Escamilla, RF, Fleisig, GS, Zheng, N, Lander, JE, Barrentine, SW, Andrews, JR, Bergemann, BW, and Moorman, CT. Effects of technique variations on knee biomechanics during the squat and leg press. Med Sci Sports Exerc 33: 1552–1566, 2001a.

Walter, Chip. Last Ape Standing: The Seven-million Year Story of How and Why We Survived. New York: Walker &, 2013

Lieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. New York: Pantheon, 2013. Print

 --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]

23 Things I Learned From McKenzie Part A

I have been following Erson Religioso, a PT and blogger, for quite some time now.  He has repeatedly (no pun intended) discussed the effectiveness of Mechanical Diagnosis & Therapy (The McKenzie Method or MDT).  He's a very knowledgable clinician and runs his social media with integrity.  Over the years he has provided a great deal of clinically applicable information and I have seen results in my practice using some of his methods.I decided I had to check out MDT first hand and learn about their method.  This past July I took McKenzie Part A - The Lumbar Spine with Dave Oliver.

23 Things I Learned

1) Physical Therapy is a mechanical profession.  We should look for mechanical problems.  If it's not a mechanical problem, refer out.2) Pathoanatomy is for surgeons.  It can cause a ton of fear / centralization if we start diagnosing pathoanatomy.3) MDT is not tissue specific.  It is a symptomatic and mechanically driven system.4) Don't give up so easy.  I used to stop people 3 or 4 reps into their repetitive motion if they had pain.  I learned in this class that if it's a derrangement you need to push through to get a true assessment.  Often times the pain doesn't only go away, but it gets better (green light).5) Don't be so afraid of testing flexion.  People flex thousands of times a day.  If you don't test it, they'll test it when they get back into their car after the eval.6) Practice changing quote: "When you put your hands on a patient it empowers YOURSELF.  When you teach a patient an exercise it empowers THEM."7) Chase their mechanical problems using the stop light system.  Red light is only if the pain remains after testing.8) Exhaust the sagittal plane of movement before giving up.  Don't stop at standing repetitive extension.  Push through all the way to extension in lying with overpressure before saying it doesn't work (as long as it's "stop light" appropriate).  See picture below for example of progression.9) If you're going to chase symptoms, it's best to do it through movement (MDT).10) Plus, if you find a derangement you can resolve their symptoms immediately and then start working on their movement dysfunction (SFMA).11) You're looking for 4 things during the evaluation:

Origin (where pain is coming from)

Classification (derangement, dysfunction, postural)

Direction (relation to symptoms)

Force (overpressure, repetitions)

12) Derangements often have variable symptoms (time, severity, flare ups)13) Derangement is when the joint is de-centrated (not in optimal alignment)14) Finding someone with a derangement makes your job ALOT easier.  You can then use repeated motion to clear their pain.  Since using this system the past few months, patients are amazed by how quickly their pain resolves.15) End-range extension in lying is when you lock out the elbows, exhale, and let the lumbar spine/pelvis relax (Lock, Blow, & Sag).16) Resolving a MDT dysfunction will be uncomfortable.  You have to remodel tissue.  It takes time.17) If there is a lateral shift, you need to fix it before going to extension18) Fixing a lateral shift can sometimes be like "pushing a rock up a hill"19) It's NOT an extension-based system!20) It's a end-range, repetitive motion system.21) End-range is extremely important.  Make sure you get there.22) Patient compliance and lifestyle (postures, ADLs) can make or break the outcomes23) Exercises taught to manage pain can also empower the patient during a potential future injury

My Thoughts

Overall it was a great course and I'm glad to have a better handle on the MDT system.I think it is a great system to use for any patients with pain.  People come into the clinic because they're in pain, not because they have a movement dysfunction.  Clearing out their pain is their #1 priority, therefore, it's your #1 priority too.  Plus, preventing acute pain from becoming chronic is one of the most important aspects of physical therapy.The only problem I have with MDT is their lack/disbelief of stability.  An example of this problem was evident during one of the live case studies.  A woman came in with back pain.  She had excessive motion in every direction (and probably a positive beighton laxity test).  Repeatitive motion exercises only made her worse.  Over the 3 days both directions were tried, and both increased her pain.  She was getting worse.  Without a stability approach what would happen with the rest of her plan of care if you were only using the MDT system?That's not to say it didn't work with the other 5 live case studies.  In fact, besides the hypermobile woman, all 5 patients had a significant decreases in pain after 3 days.  And 3 out of 5 of them were flexion based!MDT is an easy system to integrate into your practice.  It's more than just press-ups for disc herniations.  It teaches you how to use mechanics (repetitive motion) to assess and treat your patients symptoms.  There's no downside to testing repetitive motion and the potential upside is that you can resolve your patients pain in a matter of minutes.  Not a bad deal...

Dig Deeper

Erson's site is really the best place to go for more information on clinical MDT integrationMcKenzie --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]

Course Review - StrongFirst Kettlebell Workshop

On June 1st I had the pleasure of participating in a StrongFirst Kettlebell Workshop with Phil Scarito.  It was a 1-day course that went over the intricacies of the basic kettlebell movements (Deadlift, Swing, TGU, Goblet Squat, Press).  The theory is that it's better to master the fundementals than to be average at a bunch of different lifts.  Plus, it's these basic KB movements that that have the greatest impact on improving one's physical abilities and movement patterns.Phil Scarito was the instructor for the course.  He is extremely knowledgable on many levels and was able to translate his concepts to everyone from physical therapists to personal trainers to your average gym rat.  Phil is able to go into the greatest details of each movement to truly help you understand the movement at a different level.  He has a great YouTube page with tons of detailed instructional videos.Along with some posterior chain soreness, I learned quite a few things.  Here's some things I learned in one day with Phil Scarito and the StrongFirst instructors.

General

1) Your clients/students/patients will do what you do.  Make sure you can execute the move perfectly and they will too.2) Training barefoot is extremely important.  It allows you to maximally "root" your feet into the ground and give you more power.  Shoes deprive you of that important sensory information.3) Lose big toe contact = lose power4) Fast & Loose - keep moving during your training and use active rest5) Tactical Frog is a great mobility warm up6) Fix the deadlift.  When someone is having difficulty with a movement, often times going back and fixing their deadlift will resolve the problem.  "Don't fix the swing, fix the dealift" - Brett Jones7) "Try to make the light weight feel heavy, and make the heavy weight feel light" - Marty Gallagher8) Breathing is extremely important to develop stability.  Coordinate breathing with movements (biomechanical breathing).9) Think about driving your feet into the ground and pushing the earth away.10) Active Negatives are a great way to learn movement.  It also spares the agonist of eccentric load, allows for successive induction, trains the antagonist, and helps to "grease the groove".11) Always keep the wrists in neutral.  Don't let it bend to accommodate the bell.12) All you need for programming is TGU's and Swings.  Do those everyday and you will make tremendous gains.  (paraphrased Pavel advice)

Hip Hinge/Deadlift/Swing

1) The hip hinge is the basis for the deadlift.  The deadlift is the basis for the swing.2) "Rooting" feet into the ground is extremely important for power transfer.3) Reach down and stay tall before you pick up the bell.  This packs the shoulders while maintaining proper posture.4) It's important to start the swing off right.  This helps activate the lats to develop tension, increases power generation, and properly starts the movement with the right momentum.5) If you let the weight go at the bottom of the swing it should fly backwards, not down.6) Avoid the "high hip hinge".  Don't get lazy and start doing partial range swings.7) Timing is extremely important.  There should be a delay going up (KB "float") and a delay going down ("playing chicken with the KB").8) Don't over think quick lifts.9) Don't be so afraid of flexing your trunk forward.  Many people will bend at the knees to try to keep their torso upright instead of hinging at the hips.10) Make sure to "snap" your hips forward.  Finish the lift tall.http://www.youtube.com/watch?v=_z3T1CwP5bg

Turkish Get-Up (TGU)

1) You can take the TGU and turn it into a million different exercises.  Break it up, practice small parts of it, add a few TGU movements into other exercises.2) The TGU takes you through a full neurodevelopmental progression.  No other exercise can do that.3) Starting position will determine the success of the rest of the movement.4) The legs and arms should be parallel in the starting position, much like a starfish (or at 45 degree angles).5) You should be "rolling" to your elbow, not sitting up to it.6) When you get to your hand "think of wedging yourself between the bell and the floor" - Phil Scarito7) The "2 Lines" to look for:

• In Sitting Phase: Hand, Hip, and Oppoite Foot in line

• In First Kneeling Phase: Hand, Knee, and Foot in Line (same side)

8) Most people do the TGU too fast.  Should be a slow movement with at least a couple seconds in between movements.http://www.youtube.com/watch?v=RkVaQMi9wTQ

Goblet Squat

1) After your hips go below your knees it is all on the glutes to get back up.2) Don't get out of the bottom position too fast.  You want to go slow to prevent the hips from shooting up.3) Pull yourself into the bottom position with your hip flexors (active negative).4) Keep your feet pointed straight ahead and the exercise will naturally prevent valgus collapse at the knee.5) Don't sacrifice form for depth (avoid excessive lumbar flexion).6) A common fault is sitting forward into the knees.  Most people will need to focus on sitting back into their hips.http://www.youtube.com/watch?v=ZnG3Z7Zgpzs

Strict Press

1) You can't press with a hyper-extended wrist.  There's no power.2) Don't reach up.  Instead, think of pushing the whole body away from the KB.3) The plank and the military press are very similar exercises.4) Don't let the ribs flair and hyperextend the lumbar spine.5) Actively pull the bell back down (active negative).http://www.youtube.com/watch?v=WTmR-Qr32dg

Summary

More and more people are becoming interested in kettlebells.  As a clinician this means we have to have a better baseline level of knowledge so that we can assess, train, or refer out when we have patients that are using this equipment.Remember the rule with all exercises:

• Make sure you are competent with the movements before you prescribe or assess someone else.

The kinesthetic learning of this course cannot be matched by anything other than performing the movements while being coached by professional.  I highly recommend taking one of these workshop courses with StrongFirst if you have any interest in kettlebells.

Dig Deeper

Strong FirstPhil Sacrito - Website - YouTubePaul GormanGray Cook & Brett JonesKettlebell Studies

McGill

Jay K

Jay K et al

 --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]

NOI - Mobilisation of the Nervous System

On November 3rd & 4th I had the pleasure of taking the NeuroOrthopedic Institue course - Mobilisation of the Nervous System.  I was lucky to have Adriaan Louw as the course instructor.  I learned a tremendous amount over the weekend and returned to the clinic on Monday with an additional approach to treat patients with.  The NOI provides a paradigm shift in the way we view the nervous system and pain.  While it is impossible to cram a weekends worth of great information and techniques into a post, I'll try to provide some key points I learned from the course.

NeuroOrthopedic Approach

Their approach is simple...Tissues Heal!!!  If your patient is having pain and it doesn't correlate with the normal tissue healing time then you should consider another mechanism.  Traditional medicine usually assumes that pain is directly correlated with a pathoanatomical structure.  It often ignores the influence of the PNS (neurodynamics) and CNS (central sensitization).  The NeuroOrthopedic Approach allows you to treat the mechanism of pain (input, processing, output), regardless of whether or not you know the exact anatomical structure.

Nerve Principles

The Golden 3

It was highly emphasized throughout the course that nerves need 3 things to function properly.  When they don't get these 3 things is when most problems arise.  And you can usually fix these problems by giving nerves back the 3 things they need.

1. Blood
2. Space
3. Movement

Neuroplasticity

Neuroplasticity refers to the ability of the nervous system to adapt and alter it's synapses in response to new information, sensory stimulation, development, dysfunction, or damage.  This is widely known to most people when discussing the brain and the role of the CNS.  However, the ability of the peripheral nervous system to adapt via the ion channels is often overlooked.There are many different types of ion channels in the PNS.  Our entry-level physiology education only emphasized the electrical ion channels.  What we must consider is that there are many other types of ion channels that play a role in mechanical transport and conduction.  Like the CNS, these ions change almost instantaneously and are highly adaptable.  For example, when you hear on the news that a blizzard is coming, your ion channels immediately start to prepare by changing to handle the decrease in temperature.The clinical pearl to consider with this is that your manual intervention and language can have direct influence on your patients nervous system (neuroplasticity, ion channels).

Neurodynamics & the Continuum

 Neurodynamics is "the study of the mechanics and physiology of the nervous system and how they relate to each other".  It encompasses how the nervous system interacts with the body on a physical, biological, and neurophysiological level.  There are 5 Laws to Neurodynamics: Container Concept, Joint Relationship to Pressure & Load, Pinch & Elongate, Continuum, and Sequence & Order.  While each law is equally important, the law of the Nervous System as a Continuum is a concept that many people overlook.The nervous system is a closed-chain continuum, much like the tensegrity properties of fascia.  Nerves do not move independently of each other.  When you perform an SLR the whole nervous system moves, not just the sciatic nerve on the moving leg.   Movement in one part of the nervous system will always result in movement in the rest of the system.Clinically this becomes very useful when treating an acute or post-surgical patient.  Mobilizing their adjacent nervous system will result in a low load mobilization of the affected area.  This is something that can easily be implemented into your treatments tomorrow.  The apprehensive neck patient, the post-op shoulder, the tender ankle sprain...these could all benefit from mobilizing the nervous system away from the site of injury.  Dr. Louw discussed how effective this is with his acute whiplash patients.  He places them in a brace and mobilizes the rest of the nervous system and has them perform light aerobic exercise on a treadmill.  And they get better, faster.

Structural Differentiation

Structural Differentiation is to the nervous system what kinesiology is to ART or what the concave/convex rule is to joint mobs.  It is using the continuum to examine, assess, and treat the nervous system.  To fully understand this concept one must have knowledge of the peripheral nervous system the associated movements that tension and slacken the nerves.  I have created a Neurodynamic Chart as a reference.The concept of Structural Differentiation is simply manipulating the nervous system to either add or subtract tension to evoke a response.  This will strengthen your neurogenic hypothesis during the examination and is the basis for treatment.  For example, if you're trying to differentiate a hamstring strain from a sciatic neurodynamic dysfucntion you would put the patient in the slump test position.  If it is a neurodynamic dysfunction the patient will get relief from slackening the nervous system (either neck extension, lumbar extension, or ankle plantarflexion).  If it is solely a hamstring strain the patient will have no relief with neck extension.

The 5 Base Tests (and further differentiation)

We were taught 8 "base tests" in the course.  These base tests provide a starting point for assessing the peripheral nervous system.  Using the Strucutral Differentiation concept you can adapt these tests to make them functional for your specific patient.

• Straight Leg Raise (Tibial, Common Peroneal, & Sural)
• Sidelying Slump Femoral (Obturator, Lateral Femoral Cutaneous)
• Slump (in sitting and in long sitting)
• Saphenous
• Upper Limb Tension Test (Median, Median 2, Radial, Ulnar)

Intervention

Treating the nervous system consists of applying the principles above to the individual.  You want to bring blood, space, and movement to the system.  Use the continuum and structural differentiation.  Treat the containers (manual to surrounding tissues).  Sliders and Tensioners.  And explain pain (which is a whole 'nother animal).Of course this is an oversimplification, but the course wasn't taught with a strict "in the box" intervention.  Instead we were taught the principles, systems, and methods and encouraged to be creative when applying them to the specific patient.  Since we are dealing with a highly adaptive individualized system, I think this process works best.

Bottom Line

There are many approaches for treating the musculoskeletal system, but very few approaches exist for the nervous system.  The NOI group provides a great approach for this system and creates a great opportunity for clinicians to grow and add to their "tool box".  They're not trying to get you to change the way you practice or trying to convince you to join a cult (like some of the other approaches out there).  It's not just a trendy method or technique.  Instead, it's a new way to view and treat your patients.  It offers another "lens" to look through during assessments.  It gives you more options for treatment.  It allows you to confidently and systematically work with the the nervous system.For further information on NOI Group and future courses click here. --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]

Don't Be "That Guy"

I've been in over 25 clinics and worked with over 75 physical therapist.  While this helped me gain knowledge and experience in the field, it has also shown me the different "types" of physical therapist out there.  Most PT's are great clinicians and want to help people to the best of their knowledge.  However, there are some PT's out there that become "that guy".  If you've worked in a couple different practices or if you think back to PT school you have probably met one of these "guys".  There are 3 types of "that guy" in the PT world: the hipster PT, the research snob PT, and the ancient PT.  It's fun to humorously classify these types of PTs, but it's also important to make sure you don't become one of them.

Hipster PT

 This is the hippocritical PT that hates any idea that isn't his own.  He likes to think he's extremely innovative and ahead of the curve.  He thinks disagreeing and saying no makes him better and smarter than you.  No one else's ideas are as good as his and if there's any other way, it's wrong.  His strong beliefs in his own accepted theories prevent him from learning anything new or expanding his skills.  He practices his physical therapy approach like it's a religion.  These are the PT's that subscribe soley to one method and look down at any other method.There are many different approaches out there (SFMA, DNS, PRI, NOI, Paris, Mulligan, Maitland, McKenzie, Feldenkris, etc.).  Thus, there are many ways to accomplish the same thing in the rehab world.  Instead of utlizing all of these great methods into a blend that will best serve the patient, the Hipster PT sticks with the one he decided was cool before everyone else thought it was cool.

Research Snob PT

 This is the guy that spends way too much time pretentiously quoting exact authors and articles to everything he does.  He says "the latest research shows..." in almost every sentence.  He thinks that just having a reference makes him right.  He almost robotically applies EBP and there's no creativity or art to his treatments.  The biggest problem with this is that research always lags behind clinical advancements.  Instead of giving the patient what they need, he forces the best evidence approach for the pathology they have.

Ancient PT

 This is the guy that goes by the motto "if it ain't broken, don't fix it".  They're still spending over 20 visits using only VMO strengthening for their patellafemoral patients while shunning dynamic valgus as a trend that will come and go.  They are either too lazy or too narcicistic to adapt new techniques and new evidence into their practice.  Sure there are some things that will always be applicable, but if you're not up to date with the latest stuff then you're already behind.

Bottom Line

It's important for physical therapists to work together and support one another to better our profession.  Clinical advancements and professional autonomy will only be hindered with a closed-minded approach.We will all be better off if we focus on what we are trying accomplish instead of arguing about what we do differently.  Principles always outlast methods.

• Help People Feel Better
• Help People Move Better

Hopefully this post provided you some humor and possibly some sympathy.  If this post offended you, than you might be "that guy". --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]