August Hits (2014)

1) Does your patient suffer from VOMIT?  It is one of the fastest growing pathologies in our society.  Make sure you are aware of this terrible problem and educate your patients.2) I'm not going to stop drinking it, but here's some good information.3) "Our study demonstrated no benefit for intramuscular PRP injections, as compared with placebo injections, in patients with acute hamstring injuries"4) "The creation of gross spinal movement occurs via the summation of small segmental movements across larger spinal sections." - "the deepest tissues across any articulations of the body are the first to be engaged during movement and thus provides the most specific, and up to date feedback information to the CNS regarding the ongoing assessment of movement outcome. These small muscles/muscle fibers thus act to monitor tension in the connective tissue elements encasing the spine." -Andreo Spina on the Functional Anatomy of the Spine5) Top 11 Bodyweight Exercises from GMB - Squat, Frogger, Monkey, Cartwheel, Pull-Up, Bear, Push-Up, Hollow Body Hold, Scales, L-Sit, Handstand - #GetAwkward6) "When did cardio do absolutely nothing except set me back? When I spent a lot of time in the middle zone of 70-90% of max heart rate; it's no man's land! The take-home lesson is that if you want to be strong and powerful, make your low-intensity work "lower" and your high-intensity work "higher." - Eric Cressey shares his 5 biggest mistakes with powerlifting.7) Erson's 5's : 5 Ways to Get to Cervical End-Range, 5 Exercises for TMD & Headaches, 5 Breathing Cues8) More evidence for the importance of proximal stability to reduce distal injuries.9) Increasing the lever arm on the plank exercise results in better abdominal muscle activation compared to traditional or posterior tilt plank.10) What do you do with those hyper-mobile athletes that score high on the beighton laxity scale?  Make them powerlift!  Danny Matta has a nice article on the importance of tension and stability in these athletes.11) Interesting perspective on the PRI experience from a physical therapist that practices PRI - Zac Cupples 1, 2, 3.12) Jesse Awenes shares some of his favorite glute exercises.  I hadn't heard of the Prone Figure 4 Lift.  Makes sense.13) Great 2 minute video from the Gait Guys on Flexor Dominance of the brain (and therefore body).14) Kathy Dooley goes over power breathing.  "Why not open the mouth in inhalation? Depressing the jaw locks the hyoid, preventing its movement to allow for a more patent airway. Also, if you’re tensing the suprahyoid muscles for breathing, then that is tension you could be using elsewhere."15) Erson's thoughts on cortical smudging - "My explanation for why treatments like IASTM or joint mobilizations work is that they are a novel, non-threatening stimulus that helps “redefine” the smudged limb"."16) How to fix our healthcare system and save $2 million (a must read if you're a PT).17) Should we be deep squatting?  And if so, how do you train it?18) Sleep has become very popular in the past few years.  Here are 2 of the better sleep articles I've read lately (1, 2).  "if you get 6 hours of sleep per night for two weeks straight, your mental and physical performance declines to the same level as if you had stayed awake for 48 hours straight"19) This is an interesting read on the overhead shoulder position by Derrick Blanton.  Take home message - maybe Arnold was right...Internally Rotate Up, Externally Rotate Down.20) 2 ways to teach the nervous system how to use new motion.21) Great Neuroscience Nugget on Oxytocin.  "Possible roles of the hormone in dorsal horn processing, as part of the endogenous “pain” control system and also refer to the large literature suggesting that enhanced oxytocin levels may decrease pain via improving mood, decreasing stress, enhancing calmness and lowering cortisol levels."22) Close your mouth (but not all the way).  Seth Oberst goes over Jaw Positioning for optimal performance.  "Clearly there's a relationship between the upper cervical spine and the jaw - some would argue that the axis of rotation at the TMJ is actually at the C1-C2 joint." - "Not having the basics of jaw positioning (including the tongue) just won't cut it and will lead to alterations in the nervous system, spinal control, and power generation. "23) "Endurance offers you a wider time slot to learn your lifts and perfect your technique while managing fatigue." -Gray Cook24) New study on the effect of compression - "The use of a lower limb compression garment improved subjective perceptions of recovery; however, there was neither a significant improvement in muscular strength nor a significant attenuation in markers of exercise-induced muscle damage and inflammation."25) One of the best running articles I've read in a while.  John Foster tactfully breaks down Pose-like running methods with solid research and empirical evidence - "Accentuating early knee drive is the easiest way I have found to achieve early gluteal activation and is fundamental to the inform running method ."26) "Overall, our data suggest that the large size of the GMAX reflects its multifaceted role during rapid and powerful movements rather than as a specific adaptation for a single submaximal task such as endurance running."27) This is how a great clinician treats Frozen Shoulder.  It's great to see someone clearly describe an example of how they treat a specific pathology.28) Interesting anatomy read from David Butler - "The pupil is a part of an integrated defence detection and response system as the organism works out “what is going on”." - "looking into someone’s eyes evokes a healthy oxytocin release for both of you." - "Myodural bridges are connections between the cervical dura mater and the cervical extensor muscles."29) "Currently, coaches are rushing to find various methods of monitoring their athletes within the training environment (IE, GPS, HR, Force Plates, etc); however, one critical aspect that may often get overlooked is the athlete’s life stress." -Patrick Ward30) People You Should Know - Sir Charles Sherrington may be the most influential neurophysiologists of all time.  Seriously, the guy coined the terms proprioception, neuron, and synapse!  His concepts are still widely used today.  But he's not just the reciprocal inhibition guy.  He laid down the foundations for modern human physiology with his theory that the nervous system is the integrative coordinator of various inputs of the body through neural synapses (not just isolated "reflex arcs").  In 1906 he published the Principia of neurology, The Integrative Action of the Nervous System.  In this body of work he described three main sensory organs (exteroceptive, interoceptive, proprioceptive) and their influence on the body.  Movement professionals owe a great deal to this man and his work.31) Top 3 Tweets of the Month

•  Anthony Donskov‏ @Donskovsc - Consistently training to failure is a failure in training.
• Erwan Le Corre ‏@Erwan_Le_Corre - Technique is not the replacement of strength. Technique is the most efficient use of it.
• Seth Oberst‏ @SethOberstDPT - Take pride in being a great generalist before becoming a specialist

32) Why go to Six-Flags Theme Park when you have a gym membership?

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The Deep Squat (Part 2 - In the Clinic, In the Gym, How to Train it)

Part I went over the benefits and disadvantages of the deep squat.  In Part II, I will describe how I approach the squat in different settings and how I train it.  Contrary to Part I, which was a collection of the current research and physiological facts about the squat, Part II is mostly empirical evidence and professional opinion.

In the Clinic

Is the Deep Squat a Physical Therapy Intervention?

As movement therapists, should we have people deep squatting as an exercise?The answer is that it all depends on your priorities and the patient's limitations.If someone is in physical therapy for pain, they will likely have many other impairments and dysfunctions that need to be corrected first.  The deep squat might be pretty far down the line for them.  Why?The deep squat is a high level, complicated movement.  It has many parts coming together for a complex movement pattern.  Most patients I see are not ready to perform this movement as an exercise.  They need a lot work on the "parts" just to get to be able to perform a clean unloaded deep squat.  As a result, you may need to master more primitive movement patterns before you attempt the deep squat.

Which Patients Should Deep Squat?

Squat On

Don't get me wrong.  I'm not saying that the Deep Squat doesn't belong in rehab.  In fact, I think there are many patients that can benefit from this exercise while in physical therapy.If the deep squat correlates with their injury, impairments, movement deficits, goals, and lifestyle, then the deep squat should be a focus.  For example, if someone comes in with lateral knee pain, weak quads, and needs to squat down to play with their kids, then the deep squat might be a great exercise (eventually).  If someone comes in with weak glutes, valgus moment at the knee, and likes to play squash, then the deep squat might be a great exercise to work on.

Think Twice Before Deep Squatting

More times than not, the patient is so far away from a deep squat that it would take longer than the average bout of physical therapy to get them to where they need to be.  For example, if someone comes in with back pain and can't touch their toes, brace their abdominals, or hip hinge, then the deep squat is not a priority.If someone has a structural pathology that cannot be changed (eg hip OA, bone spurs, meniscus pathology), then the deep squat may never be part of their program.  For example, if someone comes in with chronic knee pain, meniscus pathology, and a hip impingement, then the deep squat is not a good exercise for them.Now I'm not saying that these patients should never squat.  Many of these patients can eventually learn to squat.  But when they walk into the clinic, there are usually many other variables that need to be addressed first.Keep in mind that as physical therapists our goal is to decrease the patient's pain and help them move better; not to force the most complicated movement pattern on them to perfection.

In the Gym

It's not much different in the gym than in the clinic; priorities and limitations are still the name of the game.

Not Everyone Wants to Deep Squat

Some people may not be in the best position to deep squat and would need a lot of work to gain this ability.  Plus, you have to respect the fact that some people have different priorities.  Some people don't want to spend the necessary time to improve their movement patterns.  Some just want to get their heart rate up and sweat.  Forcing the deep squat on someone who won't put in the work to improve their movement quality is dangerous.

Building a Better Athlete

However, if your client is in the gym because they want to get stronger, move better, and improve performance, then the deep squat needs to be a goal and trained consistently.  The abundance of benefits from the deep squat are just too good to pass up.  Simply put, if you're not squatting, you are missing out on some major strength, stability, and mobility gains.Not only does it generate strength and mobility, but many consider the squat as one of the most important strength and conditioning movements (others: push, pull, hinge, loaded carry).  Missing out on one of the most fundamental exercises is a recipe for disaster and will handicap anyone's athletic development.From a movement pattern perspective, the deep squat has a big carry-over to many other movements.  Much like how a solid deadlift sets a great foundation for kettlebells and horizontal force development, the deep squat sets a great foundation for the olympic lifts and vertical force development.Going beyond the weight room, the squat also prepares athletes for what Charlie Weingroff has termed "level changing".  The ability to vertically change your center of mass (COM) in relation to gravity is what the squat is all about.  Athletes are forced to do this over and over in their sports.  The defensive end has to go from low to high and explode off the blocks, the squash player has to go from high to low to get to that drop shot, the basketball player has to from low to high when attempting to block a shot.  If the athlete is inefficient and doesn't have adequate vertical real estate to perform these movements, they'll have to compensate and waste valuable energy.

Prerequisite to Train the Squat

Mobility

There are many prerequisites before someone can begin to work on the deep squat.  The most important prerequisite is to have adequate mobility to achieve the bottom position without compensations.For some, this may take a long time to correct before they can start to deep squat.  Others may only need a few weeks to clean up some restricted areas.  A big part of this is going to depend on their genetics, development, history, and whether it's more of a structural adaptation or a neurological phenomenon.The 4 main areas you need to focus on are

1. Ankle Mobility
2. Knee Mobility (rarely needs work)
3. Hip Mobility
4. Thoracic Mobility

As always, there are many different ways to achieve the same result.  First assess and find the specific local impairment.  Then use whatever you're good at to help the patient achieve the necessary mobility to squat cleanly.

Training the Squat

One of the best things I've learned from Gray Cook is the importance of movement patterns.  It's often not a strength or mobility issue; it's a neurological movement pattern issue.With that in mind, you want to start training the movement patterns in the right level of challenge.  If it's too difficult, they won't be able to adapt to the movement.  If it's too easy, they won't be challenged enough to improve the pattern.As a PT, I sometimes see people that need to start from ground the ground up, literally...from the ground.  Below is a progression I often use with people.  The prerequisite before each exercise is proficiency in the one before it.  However, this isn't set in stone, it's just an example.  The progression should vary per individual, but the concepts should remain the same (unloaded before loaded, assisted before unassisted, etc.)Another important part of training the squat is to make sure you have clean movement before you add a load.  If you load up a compensated pattern, you will be reinforcing that faulty movement pattern.  You will be "saving" the compensation.  And this "saved" movement pattern can come out at a time when it can seriously damage the athlete.  This is one of the reasons why many need to "maintain the squat, train the deadlift" (another Gray Cookism).So if the movement pattern needs work, don't load it up.  But once they've got the movement pattern down, feel free to load it up with the goblet squat, front squat, and/or back squat.

Quadruped Rocking

https://www.youtube.com/watch?v=Zd4io3ltqu0Quadruped rocking is a great place to start for 2 reasons.One, it provides a movement that unloads spine, hip, knee, and ankle joint.  It also allows the patient to "grease the groove" of lumbar/hip dissociation.  Thus, it can be a great starting point to train neutral spine.Two, as Stuart McGill has pointed out, this quadruped position can provide an appropriate assessment to determine squat stance.

TRX Deep Squat

https://www.youtube.com/watch?v=LAExqeGDHOoThe TRX deep squat allows patients to use their upper extremities to partially unload the movement.  Plus, it provides the necessary support to prevent compensatory motion.  If someone can't fully resolve their ankle DF or hip flexion, the TRX can allow them to work around this impairment by shifting the COM posteriorly.

Heels Elevated Squat (COM/BOS Modification)

https://www.youtube.com/watch?v=VKFpyqq_0N4This progresses from the TRX by removing the UE support and loading the movement pattern.  However, the elevated heels does not only mean that you have adjusted for ankle mobility deficits.  There's much more biomechanically going on (e.g. joint alignment, anterior chain stability requirements, posterior chain mobility requirements, etc).This exercise provides is a posterior shift of the COM in relation to the base of support (BOS).  Modifying the COM/BOS orientation causes a cascade of changes that alters the global movement pattern, not just the ankles.

Progressive Box Squats

https://www.youtube.com/watch?v=hn2GFBfqldIThe Box Squat is one of the more common squat variations I use to train the squat pattern.  It allows beginners and those with non-optimal mobility to squat without having to control their COM in the difficult transition phase (eccentric to concentric).  It is also a great way to teach the squat from the bottom up.

Goblet Squat

https://www.youtube.com/watch?v=ZnG3Z7ZgpzsThe Goblet Squat is my favorite squat exercise; both for movement pattern work and for loading.  Adding a load into the system helps to create more tension in the body, which can aid in stabilization.  The act of holding the weight anterior of your COM allows for ease with posterior weight shift during the squat.  And the proper Goblet Squat form ensures that there will be no valgus collapse because your elbows will be in the way.

Front Squat

The Front Squat and Back Squat are exercises for intermediate/advanced strength and performance training.  These are highly technical lifts that require a great deal of strength, mobility, and skill.Specifically, the front squat requires a great deal of ankle dorsiflexion to perform without compensations.  But it is a great way to start loading up the squat that doesn't involve too much trunk flexion.

Back Squat

The deep back squat is difficult to perform well.  I see many people hacking this one up at the gym by performing some weird type of box squat romanian deadlift hybrid where they end up lifting most of the weight with their back.  This occurs either because of poor technique, impaired ankle mobility, and/or the inability to get into their hips.  Regardless, if someone's back is sore after they back squat, you may want to consider regressing them to the front squat or goblet squat.For more information on the front and back squat, check the references below.

Bottom Line

In the end, it's just important to realize that everyone is different.  No one will have the exact same squat.  Some will easily be able to drop all the way down, some will only make it to a little below parallel.  Some people may need a lot of mobility work, some may need a lot of stability work.  And everyone will have different kinematic motion.  Therefore, everyone will require a different training progression, different cues, and different "parts" work.For some, it is not a realistic goal or one worth chasing.  For others, it's a great opportunity to improve movement and performance.The key is to respect people's individuality, don't force it, and respect that it may take a long time for the tissues to adapt to the specific demands of a deep squat.

Dig Deeper

Kjaer, M. "Role of Extracellular Matrix in Adaptation of Tendon and Skeletal Muscle to Mechanical Loading." Physiological Reviews 84.2 (2004): 649-98

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, 1961

Escamilla 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, 2010

Escamilla, 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

Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.Eric Cressey - (Here & Here)Mike Robertson's Squat Tutorials (Here and Here)StrongFirst (Here & Here)Dan John (Here)T-Nation - Squat Articles (many great articles here)Westside Barbell - Squat ArticlesDeepSquater ArticlesBret Contreras (Here)Squat vs. Hip Hinge   --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.

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July Hits (2014)

1) Have you heard about using isometrics to decrease pain associated with tendinopathies?  I was unfamiliar with this concept so I thought I'd send out a tweet to one of the leading experts, Jill Cook.  She gave some great advice that you can immediately use in your practice.  Jill's guidelines:

• Joint Angle = Inner Range Holds

• Duration = Long Holds (up to 45 sec)

• Intensity = Heavy as Possible (no perturbation)

• Frequency = 2-3x/day

• Keep in mind it will vary for each person

2) A great article summarizing how to improve Crossfit training.  It's really just a good article on programming and layering movements (not just for Crossfitters).3) The Schroth Method seems to be gaining some popularity.  I've even had a couple patients ask me about it.  It looks like it has very similar methods to the Postural Restoration Institute (PRI).  #Scoliosis4) Great read on diet and the human microbiome from Eirik Garnas.5) Adriaan Louw is my favorite pain science guy.  Here are 3 articles with some great Adriaanisms: Zac Cupples Course Review, 11 Questions with Louw, Therapeutic Neuroscience Education6) Ever wonder about that focal loss of hair on your patients legs?  Gait Guys explain it here.  "Hair growth is influenced by local blood flow and “tropic” influences from the autonomic nervous system and sensory feedback loops, supplied to the area segmentally (ie. by each spinal level). "7) The hip hinge is one of my favorite exercises for both myself and my patients.  Seth Oberst goes over it nicely in this post.  Great cue - "Giving at the knees, taking at the hips."8) Sleep for improved motor patterns - "Neurons that fired during learning fired again during subsequent slow-wave sleep"9) Isometrics decrease the blood supply to the muscle, thus making it a great anaerobic exercise.  From a neuro perspective, it increases the neural drive.  These two benefits alone make it worthwhile for your training program or your patients rehab.10) In rehab and fitness, the pendulum eventually swings the other way.  Kathy Dooley explains how the popular knees out cue can be the wrong cue for your patient.  Don't sacrifice tripod foot for proximal alignment.11) The unathletic population can sometimes have difficulty performing MDT shoulder resets.  Here are 3 variations to help troubleshoot this problem.12) 3 Factors for Skill Development from GMB: Adaptability, Prioritization and Cycling, Mindful Practice13) "A big grip tells the brain that the position is a stable one and it is safe to generate a lot more force without risk of destabilization and injury."  Great post from Seth on the importance of grip strength and the nervou system.  Here's another article on grip strength I wrote a couple months ago for Physiospot.14) Tom Myers has a great answer to a question on fascial lengthening direction.  "Since what we want to do in a locked-short muscle is break / melt the bonds between these angled fibers to allow the myofascial unit to lengthen, we run along the tissue in the same direction as the muscle fibers, presumably unwinding some of the muscle tension, presumably hitting some trigger points along the way, but absolutely melting the hydrogen bonds that run in that direction and keep the tissue from lengthening."15) I've really enjoyed Sue Falsone's blog so far.  She's got a great perspective.  Here's one on the different approaches she uses - "How do we blend concepts without “drinking the Kool-Aid” of any one philosophy or teaching?"16) Chris Johnson introduced me to the power of expectations and placebo with this article.  It's important to be aware of this aspect of treatment and to know how to use it to improve outcomes.  Here's another article on the placebo effect and how it can be a good thing.17) "It doesn’t matter how much force you can generate with your extremities if your trunk is not strong enough to oppose and transmit it; and it doesn’t matter how rigid you can make your core if the contraction is not timed properly based on the specific movement demand."  Nice article on half-kneeling from Quinn Henoch.18) Foundational Strength Course Review - The first FMS/StrongFirst course taught by Gray Cook & Brett Jones19) "Any time we make a rapid change, that change is neurophysiologic, not mechanical" -Erson Religioso20) I created this image to simplify the forces associated with the deep squat.  It seemed to get a lot of attention on twitter this month.21) "We should recognize that in some cases, one of the quickest and easiest ways to change motor control is to change the structure of the body which we are trying to control." -Todd Hargrove on how structure affects function.  Great example using the stepping behavior during infant development.22) "Hip socket depth, which is an anatomical variant that can’t be stretched, trained, or undone without surgery, is one of the main biomechanical influencers in how low you can go into a squat before you essentially run out of range of motion and have to find it elsewhere"  Great article on hip joint morphology and it's association with the deep squat by Dean Somerset.23) Mike Robertson has the most thorough exercise tutorials.  Here's his new one on the push-up (and variations).24) “Neutrality is not a point on a map. It’s a parasympathetic state of being.”  - James Anderson (via Zac Cupples)25) David Butler has been stirring the pot lately.  He wrote a post on cancer and whiplash here.  Then Alan Taylor wrote a rebuttal.  It's kind of an angry response, but he has some good points.  Overall I think we should spend less time trying to nullify other approaches and more time trying to share positive knowledge to improve our patient care.26) 3 Reasons Why You Should Focus on Breathing27) Why kids fidget, the ADHD problem, the cause, and a solution - a must read for the future of our species.  “In order for children to learn, they need to be able to pay attention. In order to pay attention, we need to let them move.”28) Great interview with the Seahawks PT, Michael Tankovich.  Some gems: "Movement screening is a daily process.", "The basic premise is that throughout the rehabilitation process, the tension levels applied to the injury site must progressively increase until they reach competition level intensity.", "The first step to improving recovery is to develop a culture of knowledge."29) Are broken bones stronger after they heal?  Answer is here.30) Tommy John surgery has been getting a ton of publicity this year.  Chris Butler put together a nice collection of articles to catch up on why.31) People You Should Know - Vladimir Janda is one of the most influential movement specialists of all time.  However, he is much more than simply the guy that founded the Upper & Lower Crossed Syndrome.  "He was one of the first physicians to combine therapy and medicine in a ‘hands-on’ approach, becoming one of the earliest to practice physical medicine and rehabilitation."  In a time where everyone was focused on isolated strengthening and passive joint structures, Janda developed "Sensorimotor Training" and focused on balance and function.32) Top 3 Tweets of the Month

• Pete Friesen‏ @petef08 - If you don't like the output, then change the input.
•  Danny Matta‏ @dannymattapt - The art of #coaching is picking the right cue for the right person. Reps are the only way to improve this. #CrossFit
• Seth Oberst ‏@SethOberstDPT - Position is stability. Position is power. Position is function. Position is everything

33) Canine Sensorimotor Training             [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.

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June Hits (2014)

1) "When an imparted load exceeds the load bearing capacity of the tissue accepting it, damage occurs. Neurological errors in movement execution commonly lead to loads being placed on “unprepared” tissues. It is therefore important to focus on two aspects of training to reduce the likelihood of sustaining injuries: 1. Working on improving neural control via progressively complex movement tasks –  2.Improve the physical, mechanical load bearing capacity of tissues." - Andreo Spina2) Some good PRI exercises in this article by CPG.3) A story about a man amputating his own arm to try to get rid of his pain.  It didn't work.  #PainScience4) Avoid negativity, ignore trolls, stay open minded, and smile more.  "Smiling leads to decrease in the stress-induced hormones that negatively affect your physical and mental health."5) Mike Robertson has a great post on the importance of Force Absorption.  "Lee Taft likes to use the term “load to explode.” If you can't flex, adduct and internally rotate, you can’t effectively load your system."6) This is a great read from Sue Falsone.  We often spend so much time bickering about today's different approaches that we forget about our profession's past.  "There are no truly unique concepts at this point. Everything has its basis in history. What we are doing is refining, repackaging, recreating, and resurrecting concepts that have been around for more than a century, and using our modern knowledge and technological advancements to elevate these concepts to a new level."7) Here's a nice quick article on 9 Things You Should Know About Pain.8) Great post from Erson on Rapid vs. Slow Responders.  Tons of clinical pearls in this one.9) Having trouble with ankle dorsiflexion ROM?  Following a 6 week proprioceptive neuromuscular facilitation stretching program, ankle dorsiflexion was increased and tendon stiffness decreased.10) This is a great read from Cressey on mobility vs stability, squatting, olympic lifting shoes, and training vs. working out.  I couldn't agree more that we over-diagnose ankle restrictions.  Elevating someone's heels during the squat doesn't just take out the ankle mobility problem.  There's much more going on.  Assuming it's an ankle restriction is one of most common blunders in movement therapy.11) Another great way to feel awkward from the GMB guys - Crow Pose.  "Hand balancing is a great, enjoyable way to improve your upper body strength, whole body coordination, and awareness."12) Blood Flow Restriction Training is being used for performance, but should we start using it for rehab too?  Here are two evidence based articles on BFRT (1, 2).13) "If sensitization of the central nervous system is in some part responsible for the persistent chronic pain complaints experienced by these patients, then treatment strategies should perhaps focus on trying to “desensitize” the central nervous system and improving endogenous pain modulation." -  Jessica Van Oosterwijck goes over pain education and it's effect on descending facilitatory pathways (endogenous pain modulation)14) The good, the bad, and the not so ugly Deep Squat - why it's good, who should do it, who shouldn't, and other important considerations.15) Is this a visual representation of what happens with manual therapy?16) Learn about Heart Rate Variability (HRV) - Here, Here, & Here17) PRI has a truly integrative approach.  I learned about this when I was in the Postural Restoration class and Michael Cantrell had me bite a pen on my left side, take a few good breaths, and then my R shoulder IR improved 40+ degrees.  It's the most "magic" I've ever experienced in this field.  Lance Goyke shows you an entry point into the rabbit hole in this article on feet and teeth.18) Crawling seems to be popular these days.  And for good reason, but don't forget about the Turkish Get-Ups.  The benefits of each exercise are described in this article.19) When Gray Cook talks, I listen.  "Strength is the single best way to hit ‘save’ on a good movement document."20) Chris Johnson shows you how to take your single leg work up a notch.  Adding a barbell increases the stability/motor control demands, especially in the frontal plane (think see-saw and the fulcrum is your leg).  Try adding these for advanced patients - Barbell Marching, Barbell Step-Up.21) Stumbled upon the top 5 things Anthony Donskov learned in 2013: more specific adaptation, hypothalamus regulator, fatigue is more than muscles getting tired, best course/books, & pulse.22) Sometimes Short Foot exercises and dissociative foot intrinsic exercises can be too cerebral for some patients.  When this is the case, I go to Vele's Lean.  It's simply placing the foot in a neutral state, then loading it to activate the muscles in the correct position.23) Great TEDtalk - Kelly McGonigal: How to Make Stress Your Friend  -  "We know for certain, is that chasing meaning is better for your health than trying to avoid discomfort."24) Quick Book Review: The Polyvagal Theory by Stephen Porges.

Pro's: Gives you a better understanding of the Autonomic Nervous System and how the body progressively responds to stress; 1) Remove Myelinated Vagal (NA) Break 2) Activate Sympathetic Nervous System 3) Activate Reptilian Unmyelinated Vagal Nerve (DN).

Cons: More educational than clinical; doesn't offer many interventions.  The book is very redundant.  I felt like the book could have been half as long.

25) One of the biggest faults I see with the overhead press is loss of core stability and hyperextension of the spine.  Brandon Hetzler writes a great article on how to avoid this compensation and improve your press.  "Pressing from a standing plank is the ideal press posture, but how does one transfer a plank to a pressing, standing plank? My solution — the Press Plank."26) NOI Neuroscience Nugget - "Your muscles are dry."  A great metaphor to improve patient communication.27) People You Should Know - James Cyriax is considered the father of orthopedic medicine.  He was among the first to realize that imaging wasn't enough for a diagnosis and surgery wasn't always the best intervention.  So he developed an assessment to identify soft tissue lesions using passive and active movements; and he developed non-surgical intervention techniques that resolve the findings from the assessment.28) Top 3 Tweets of the Month

• Robert Butler PT PhD @rjbutler_dptphd - agreeing on standards and language will move us light years forward...
• Jon Herting @JonHerting - #1 thing to think about in performance training & rehab. Position affects function.
• Charlie Weingroff @CWagon75 - The result of your work is the evidence.

29) Another way to score a 3 on the FMS Trunk Stability Push-Up   [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.

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May Hits (2014)

1) Do you know about the anti-icing movement?  Many are advocating against cryotherapy post injury.  Some blindly jump on the bandwagon, some feel threatened and become defensive, and most of us just want to know why.  I've recently come across a couple great articles on the theory and evidence that explains why we should not ice injuries.  Even if you continue to ice, you should at least know what it really does (e.g. numbing effect, descending modulation, body temp regulation, placebo).

• Dr. Minkin, Josh Stone, Kelly Starrett, Jeff Cubos, SportsPhysio, Aaron Hutchins, Poor Rats

• To sum it up "Groceries In, Garbage Out"

• Groceries In - inflammation brings in tissue healing cells, ice prevents the flow of these important cells

• Garbage Out - icing actually constricts the lymphatic vessels, pushing the inflammatory proteins out from the lymphatic vessels and back into the interstitial space - the muscle pump is best for reducing swelling/inflammation

2) Here's a nice site for reviewing medical examination/screens.3) David Epstein: Are athletes really getting faster, better, stronger?4) GMB shares their 5 Essential Movement Skills.  Some very interesting and useful stuff.  I frequently squat and bear crawl, but I rarely perform the other 3 movement skills.  So I tried them out while no one else was looking.  I found out that I have difficulty rolling backwards, the crab walk takes more effort than it should, and I cannot cartwheel to my left.  I haven't felt this awkward from movement in a while.  Thanks GMB!5) "A Reset is an intervention that will heighten sensory awareness so that the patient moves and feels better (quantity, quality, or both)".6) Dean Somerset has a nice review of Speed Ladder Drills and what they really do.7) Eric Cressey always has the best shoulder advice.8) Many know about the patients that cannot extend their thoracic spine, but what about the ones stuck in thoracic extension.  Quinn Henoch goes over what this postural/movement dysfunction looks like and how to address it.  Some great PRI stuff with a weight lifting lens.9) A nice review of nutrition for exercise.10) Optical illusions are a great way to explain outputs.  We know pain is an output from the brain.  Inputs are processed in the CNS and the result (output) can be pain.  This is hard for patients to understand.  Optical illusions can show patients that the "illusion" is an output from the brain.11) One of the best things I've read this month from Andreo Spina - "It is the principles utilized during the selection of exercises, not the exercises themselves that determines the extent of functionality".  Couldn't agree more, read the full post here.12) "Neural signals are related less to a stimulus per se than to its congruence with internal goals and predictions, calculated on the basis of previous input to the system." -Karsten Rauss13) This is a fun frontal plane stability exercise to play around with.14) "Is the T6 area a place that is perhaps biomechanically more at risk than other parts of the nervous system especially when you consider what humans do with their bodies these days?"15) Molly Galbraith goes over the 5 Biggest Mistakes Women Make with Their Training Programs16) "From a motor learning perspective, our brains are designed to move us through, and interact with, the surrounding environment. Using our body helps us learn more quickly. The more sensory inputs that children experience through free-play, the better they understand this interaction" Seth Oberst goes over why we need to stop sport specialization and promote free-play.17) Eric Cressey has a similar article here.  "Very few American kids are exposed to the rich proprioceptive environments that not only makes them good athletes, but also sets them up for a lifetime of good movement."18) Erson's 5's - 5 Things to Look for in an Evaluation: Symmetry, Motor Control, Breathing, Thoracic Mobility, Directional Preference19) Adam Meakins has a nice post on his 10 Commandments of Physical Therapy.  I agree with all of these.20) Mike Robertson has 2 great posts on Energy System Training (EST).  He goes over what it is, the science behind it, and why it's applicable to our species (performance & recovery).  Check it out here & here.21) "The enteric nervous system (ENS) is one of the main divisions of the autonomic nervous system and consists of a mesh-like system of neurons that governs the function of the gastrointestinal system. It comprises an estimated 500 million neurons and is so complex it has been dubbed the second brain."22) 4 Biggest Mistakes People Make with the Functional Movement Systems (FMS/SFMA)23) Squats vs. Hip Thrusts: What You Need to Know24) Explain Pain 3 (Day 1, Day 2, Day 3, Day 3-Part 2).  Good review of the conference.  Here are some gems.

"explaining and reconceptualising pain is the best approach we have to treating chronic pain.  However one of the barriers to doing this is health literacy."

“we treat processes, not anatomy”

"Conceptual change, while a type of learning, can be differentiated from other types of learning as it requires a fundamental change in the content and organisation of existing knowledge as well as the development of new learning strategies."

"Pain = (credible evidence for danger) – (credible evidence for safety)"

"central sensitisation patients are not heat sensitive (unlike in peripheral sensitisation – think sunburn and a hot shower) but can be cold sensitive."

“pain is always equally real, regardless of any process of peripheral or central sensitisation”

"neurons that fire at a theta rate are inhibitory "

“Pain is a multiple system output constructed by an individual pain neurotag. This signature is activated whenever the human concludes that body tissues are in danger and action is required and pain is allocated an anatomical reference in the virtual body”

"In chronic pain, thoughts alone can be enough to fire a disinhibited neurotag and elicit pain." 

"Increased activity in the SNS can add to the “inflammatory soup” in an unhealthy tissues, can activate Abnormal Impulse Generating Sites (AIGS) and can dribble out adrenaline into the dorsal root ganglion leading to upregulation of adrenoreceptors." 

"in chronic pain, neurotags can become both sensitised – easier to fire off with a wider variety of ignition cues at lower intensities, and disinhibited – imprecise and less refined."

"Explaining pain is not ‘advice to be active’, but rather explaining the benefits of activity.  Explaining pain is not advice that ‘hurt doesn’t equal harm’, but rather explaining why hurt does not equal harm."

Use Hypnotic Language

"The extent to which a person can recall precisely what occurred during the event, even down to the angle of their feet, the extent to which their knees were flexed etc, may provide a clue as to how precise the protective encoding is within their brain."

25) People You Should Know - Shirley Sahrmann created the Movement System Impairment Syndromes - a big influence on many of today's physical therapists (whether they know it or not).  Path of Instantaneous Center of Rotation and Relative Flexibility/Stiffness are some great concepts that can be used with every patient.26) Top 3 Tweets

• Mark Reid, MD ‏@medicalaxioms  - For two large industries in America, a human being is a place to deposit 1) Calories and 2) Pharmaceuticals. Both sold at a profit.
• Neil deGrasse Tyson ‏@neiltyson  - The limits on your enlightenment come not from the age you stopped going to school but from the age you stopped being curious
• Chris Thomas ‏@ChrisThomas7  - Mastering simple skills frees up the mind to perfect complex skills. Gradually bring the mind & body together without conscious thought

27) This is what a 0 on the FMS Hurdle Step Looks Like            [subscribe2]

4 Mistakes People Make with the Functional Movement Systems (FMS/SFMA)

I am a big fan of the FMS (Functional Movement Screen) and SFMA (Selective Functional Movement Assessment).  Together these screens and their associated principles make up the Functional Movement Systems.

I've been using this system for a couple years and have had a lot of success with it.  The more efficient I become at this approach, the more my outcomes improve.

I still have much to learn and am by no means an expert, but I thought I'd share the 4 biggest mistakes I see people make with the Functional Movement Systems.

4 Functional Movement Systems Mistakes

1) It's Not a Kinesiology or Biomechanics Test

The SFMA and FMS are both seven baseline movements that are used to assess how someone moves.  The big point here is that this is not a kinesiological test or a biomechanical test.  It’s not a strength, stability, or a mobility test.  It is not a test for anything in isolation.

It’s a complex neuro-based movement assessment.  It incorporates all the peripheral inputs coming into the CNS (mobility, muscle tension, joint ROM, position, tensegrity, vision, vestibular, etc.).  It incorporates how these inputs are analyzed and processed in the CNS (movement history, expectations, motivation, ANS state, etc.).  And then, it incorporates the output of this process - the physical movement we can see.

Essentially, the top tier tests are screening your neuro-tag for a standard 7 movements.  It shows what movement looks like in your brain.  It shows how the inputs are processed into outputs.  And this happens continuously in real-time throughout the entire movement.

This isn't just a theory.  It's how human movement works.

Anytime you loosen up someone's ankle DF (inputs), it needs to be integrated in the CNS (processing) for the specific movement pattern that was dysfunctional (outputs).  Sometimes this will spontaneously happen after creating mobility, other times you need to "show" the brain the new mobility and create the new movement neuro-tag.

2) 7 General Movement Standards

One of the big complaints I hear is that “people do more than just 7 movements”.  While this is a brilliant observation, it doesn’t debunk the system.

We can all understand Bernstein's Problem (Degrees of Freedom Problem).  The amount of freedom of the joints, coupled with the kinetic pulls of all the different muscles/fascia/connective tissue, basically creates an infinite amount of possible ways to move.  Therefore, the nervous system has an infinite amount of motor programs to choose from.

In other words, with the plethora of variables in human movement, there cannot be just one "right" way to move.

And this is a good thing; it allows our species to have more options to choose from when trying to adapt to a specific environment or task.

The problem exists in the practitioners job of assessing the infinite.  How do you go about testing the infinite ways of movement in a 45 minute eval?

This is where the SFMA/FMS comes in.

It is simply the best standard we have for efficiently screening the infinite movement patterns.

It is a funnel to find the dysfunctional movement family.

How does this apply to your patient's specific problem?

Simply look at the variables associated with the movement screen and match it with the patients dysfucntional movement or functional complaint.   You should be able to find something in common with your patients specific movement problem and one of the 7 movements (FMS or SFMA).

An example may help understand this concept.

If a patient fails MSF (Multi-Segmental Flexion), it means that this individual will likely have difficulty with movements that shift their COG behind their BOS, or lengthen a their posterior chain, or involve a hip hinge, or involve lumbar flexion, or require motor control of trunk flexion, etc. (see picture below for everyday common movement patterns).

It doesn't only mean that they can't touch their toes and fail a test.  It doesn't mean they need to move exactly like the MSF screen every time they bend forward in their life.  It just means their MSF movement pattern is dysfunctional and this will likely affect many of the other infinite movements that share the same variables.

In other words, it narrows the infinite and points you towards a family of movement patterns that need work.

3) It’s More Than Screening for Impairments

A common misconception about the SFMA is that it's only used to find local impairments.

Yes, finding the local impaired segment and tissue dysfunction is important.  But what’s more important is how the local impairment affects the global movement pattern.

Impairments cannot exist in a purely isolated fashion.  Impairments only exist in the context of the whole human body.  It’s not until the impairment adversely affects a movement (or posture) that it becomes a problem.

For example, an isolated latissimus dorsi restriction doesn’t mean anything by itself.  There are plenty of people who sit at desks all day, don’t exercise, and never lift their arms overhead.  Therefore, this impairment rarely becomes a problem for them.  But if this same person goes out and tries to hit a tennis serve over the weekend, this becomes a serious impairment that affects their MSE (Multi-Segmental Extension) movement pattern.  Compensations will occur and the risk of injury will increase.

Yes, the lat restriction is important, but it only becomes a dysfunction in the context of movement.

The goal of they system is to determine the local impairment AND the movement patterns that are most significantly affected.

4) It's a Screen & Assessment, the Intervention is Wide Open

This mistake often occurs as a result of the first 3 mistakes.

Most people are able to address the local impairment, but some have difficulty integrating this new input into the movement pattern.

The movement pattern intervention is basically an application of the concepts to the individuals specific assessment.  There is no cookie cutter protocol to follow.  It's open to the practitioner, the client, the environment, and the task/goal.

If you understand that it’s a complex neuro-based movement system, then you can understand there are an infinite amount of options to achieve the same result.  First address the breakouts (inputs), then integrate them back into the global movement pattern (processing), and finally re-assess the movement pattern (output).

Gray Cook has discussed this process in his 3 R's approach: Reset, Reinforce, & Reload.

Again, it helps to first think of it as a family of movements patterns.  Try to create similar sensory inputs that are “relatives” of the top tier movement pattern.  They don’t have to be identical twins, you just have to be able to tell that they’re related.

If the patient fails MSF, address the local impairments, then integrate them back into the movement pattern.  To do this, just pick an exercise that shifts their weight back, or flexes the trunk forward, or eccentrically lengthens the posterior chain, or rounds the lumbar spine, or requires a hip hinge.  Or a combination of those variables.

The same thing goes for the FMS.  If the patient fails the hurdle step, work on something that stabilizes the stance leg in hip extension, or open chain hip/knee/ankle flexion, or the scissored position (hip flexion & extension), or work on something that stabilizes the trunk upright in the dysfunctional scissored position.  Or a combination of those.

What you choose as your intervention should depend on the results of the movement screen, the breakouts, the examination, your patient, and your own treatment style.

If this open territory makes you uncomfortable, the System has a nice 4x4 exercise progression based on the neurodevelopmental perspective.  This may be the closest thing you will find to a "protocol" for movement patterns.

In the end, it doesn't matter what approach you use to address the findings in the screen and assessment.

There are many different ways to achieve the same thing.

As long as it simulates the similar inputs of the movement pattern, you should get a positive change.  If you don’t get a positive change, the screen will tell you.

And this is may be the most valuable aspect of The System.  It allows for you to "check your work".  It gives a clear indication for which interventions work, and which ones don't.

The System allows you to methodically add and subtract interventions until you achieve the desired outcome.

It gives you efficiency and effectiveness, while taking nothing from the way you currently treat.

Bottom Line

The Functional Movement Systems is a very useful clinical tool.  There is much more to this approach than simply screening 7 movements.  Understanding the concepts and principles of this approach will help to prevent errors and increase efficiency and outcomes.

Disclaimer

I do not work for or have any affiliation with the FMS/SFMA System.  This post does not represent the System or anyone affiliated with it.  This is simply my interpretation of the system and some thoughts that will hopefully improve people's understanding of it.  --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.

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April Hits (2014)

1) This is a MUST READ for anyone that puts their hands on their patients.  Erson shares 5 profound articles that changed his career.2) StrongFirst Tactical Strength Challenge Program3) "Think of PNF as a way of means of feeding the sensorimotor system specific purposeful information to create a purposeful and functional motor strategy" - Ramez Antoun4) Post-Activation Potentiation - A phenomena by which muscular performance characteristics are acutely enhanced as a result of their contractile history (Brett Contreras).  You can use this to improve movement patterns and performance.5) Bret Contreras goes over some advanced high-threshold core trainings for higher level clients.  Good stuff and a reminder to take it to the next level when you can.6) "Our perceptions are formed through a process of multisensory integration. This means that, for example, sensory information from the eyes can change how something tastes, or that sensory information from the ears can affect how something feels." - Todd Hargrove on the Marble Hand Illusion Study7) "A dissection study by Gibbons and Mottram (2004) found a 3^rd layer situated deep to the previous 2 described with short fibres that cross the sacroiliac joint (SIJ) and have relations with multifidus, the deep hip intrinsics and the pelvic floor."  They call this layer the Deep Sacral Gluteus Maximus.8) "the language of movement is written in feel, not in words or pictures" - Gray Cook goes over when to coach and when to correct9) How many patients do you see that get injured because of the elliptical?  Seth Oberst goes over why this isn't the ideal "exercise" for your patient in this post.  "When we can't feel the ground, we adapt thru maladaptive co-contraction (like walking on ice) in the leg musculature reducing movement efficiency for when it matters most - like doing actual athletic or sport movements, even walking."10) Subjective history may not always be accurate.  "Every time you pull up a memory, say of your first kiss, your mind reinterprets it for the present day, new research suggests. If you're in the middle of an ugly divorce, for example, you might recall it differently than if you're happily married and life is going well."11) Short muscles are a problem.  Not because of adaptive restrictions, but because of the vicious neuromuscular cycle.  Muscles that are in a shortened position often have increased neural drive (neural activation).  This means they often become over facilitated and need to be inhibited...not stretched.12) Bridge Progressions from Chris Johnson.  I particularly like the variation on the 2nd exercise and have started prescribing it in my practice.13) Interesting study on rotator cuff repairs: "Patients who underwent rotator cuff repair have improved function and reduced pain, regardless of the structural integrity of the repair. Patients with an intact repair have greater strength than those with retears."14) It seems like mobility is getting all the credit these days.  And for good reason, tons of mechanoreceptors, allows for fewer compensations, centration, motor control, core pendulum theory, correlated with lower morbidity, etc.  But what about good ol' fashion strength?  Strength is an important physical characteristic that allows your patients to move better and increases their ability to adapt to physical stress.  Think about your older patients.  If they're having trouble going from sit to stand, is an ankle mobilization or lower extremity strengthening program going to help them more?  Recent research is now backing up the importance of strength in regards to mortality.  Don't forget to get people stronger.15) I wish this would have been around back when I took biology.16) "Sleep complaints are present in up to 88% of chronic pain disorders and at least 50% of patients presenting with insomnia also suffer chronic pain."17) Lifestyle has a great influence on recovery.  Here are 4 lifestyle choices that I like to discuss with my patients.18) During my last affiliation of PT school my CI, Marcus Forman, used to always preach that "the devil is in the details".  He was right in more ways than I could have imagined.  Mike Reinold goes over the details of the simple hip flexor stretch.  Don't let your patients hack up this stretch.19) Erson's 5's - 5 Things Your Patient Needs for Successful Outcomes: Education, Mobility, Symmetry, Stability/Motor Control, Homework.  5 Cervical Radiculopathy Treatments - I've recently been amazed at how well kinesiotaping works for symptom relief. - 5 Modern Ways to Look at Manual Therapy20) A review of pain from Move Forward.  A physical therapist's guide to understanding pain.21) I wrote up this article on grip strength and the rotator cuff for Physiospot.22) Eric Cressey gives 5 tips for people performing/teaching boot camp class, crossfit, and/or other metabolic resistance training classes.  This can improve performance and decrease risk of injury for those participating in these types of classes.23) I'm a big fan of Adriaan Louw and his work.  Zac "Review Machine" Cupples wrote this up about his course (including a great Predator reference).  I've always liked the ion explanation: "When someone is extra sensitive, the nerves increase their resting excitement level so action potentials more readily occur. Adding more ion channels to less myelinated areas can further compound this sensitivity.  Fun fact – Ion channels change every 48 hours, and therapy can positively influence the change."24) Nice review of Andreo Spina's course - "The longer the muscle is when it is contracted, the more force through the tendon/connective tissue at the attachment site" - "All connective tissue (muscles, bones, fascia, etc.) are all just different expressions of the same material."25) People You Should Know: Nikolai Bernstein is the one of the Godfathers of motor control and motor learning.  Read about his Degrees of Freedom Problem ("Bernstein Problem").26) Top 3 Tweets of the MonthTim Cocks (@altThinq) live tweeted some great stuff from Explain Pain 3.  Look at #ExplainPain3.

• @medicalaxioms - It takes considerable knowledge just to realize the extent of your own ignorance. –Thomas Sowell
•  @altThinq - Our current understanding is that as the brain learns it develops precision through inhibition of neurons #ExplainPain3
• @graycookPT - Most of us are too verbal in our movement instruction. We should cause a change, not coach a change.

27) This is pretty much what my exercise routine was during March Madness.                   [subscribe2]