January Hits (2015)

1) If you are a manual therapist, please understand the current concepts of manual therapy.  One of these concepts is that we cannot cause an immediate and permanent plastic deformation of tissues.  So painfully digging into tissues to "release" them is really just another form of torture.  Here are 3 Pain Free Manual Techniques from Erson - Pec Minor, Psoas, QL.2) “Based on animal studies, it has been proposed that central sensitization associated to nociception (maladaptive plasticity) and plasticity related to the sensorimotor learning (adaptive plasticity) share similar neural mechanisms and compete with each other.”3) Seth Oberst has a great read on hyperinflation and what to do about it (Part 1, Part 2).4) The FIFA 11+ seems like a good program to reduce injuries.5) Here's some advice for getting stronger.  I particularly like the Russian Skill-Strength methodology of the “everyday maximum”.6) We’re lucky Charlie Weingroff does brain unloading like this.  Tons of great stuff.  “Treat tissues compressing an artery if there is pain.  If it works, it was claudication, not mechanical or neuromuscular. - “So if we have a very low lactic threshold by being terribly unfit and more activity or sooner during any given activity throws us to the lactic energy systems, we are more apt to developing to resting muscle tension and if continued chronic TrP. - “Research is history.” - “Passive stretching without developing tension throughout the range is a mistake. - ”Stress can only do 4 things: Change pain, Change mobility, Change Motor Performance, Change Fitness"7) Attrition substitution is a type of availability heuristic that occurs often in this field.  Make sure you're aware of it so that you don't make this common clinical mistake.8) “Ankle sprain is associated with altered global motor strategy as well as localized joint impairment”-Jordana Bieze Foster (@biezefoster)9) Good vibrations - Make your stressed out, over sympathetic patients hum.  Humming stimulates the vagus nerve.10) The environment I create to stop low kettlebell swings.11) “Much like life, movement is a balance of moderation, modulation and modification.” -Michael Mullins has a great post on knee pain12) Another Chubbs study - “Early rapid strength production of the hip extensor muscles may be a sensitive and effective measure for discriminating between elderly females of different fall histories.”13) Anatomy geeks should love this.14) Another great functional anatomy post from Kathy Dooley - The Psoas - “If the hips are tight from a forward pelvic tilt, psoas is not the one to stretch. Imagine putting nerve tension on all those structures passing through psoas!  Stabilize the spine and move through the hip.  Free up the ribcage so the diaphragm can properly move.  Lay off psoas and focus on adjacent anatomy.”15) Once again, medical imaging may be leading us to the wrong conclusions.  “The 95% reference intervals of morphometric measurements of FAI in asymptomatic hips were beyond the abnormal thresholds, which was especially true for cam-type FAI.” 16) Gait Guys always have good stuff.  Here's a good read on why metatarsalgia happens.  Here's a foot waving exercise for metatarsal plantarflexion and intrinsic dissociation (Part 1, Part 2). 17) The Nominalist is on a tear this month.  Here's a bunch of great articles with a solid perspective on clinical intervention.

Don’t forget about the rotational component of ankle dorsiflexion

"Watch for the unilateral side-benders, they’re everywhere.”

The Myth of the Hinging Knee

Eclectic approach to hip mobility

Foot-to-Hip, PRI, Toe Spaces, Avoiding the Forefoot, and CKC Hamstring

”Shoulders are rarely shoulders, and even if they are shoulders, they’re also necks, and rib cages and cores. “

18) “The goal is to optimize the efficiency of the body so that the environment you create causes appropriate adaptation with minimal compensation.” -Gray Cook discusses Russian/Hardstyle/Strongfirst Swing vs. American/Overhead/Crossfit Swing19) Adriaan Louw thinks there are two main questions we should ask patients to understand their beliefs:

1. “What do you think is going on with your _______ (fill in the painful area)?”

2. "What do you think should be done for your _______ (fill in the body part/issue)?"

“Nothing is as powerful as changing someone’s beliefs.”

20) Dean Summerset goes over 5 Mobility tips - 1) Use Breathing 2) Add Stability 3) Get the Feet Right/Bottom-Up Approach 4) Get the Head Right/Top-Down Approach 5) Distal Fascial Lines 21) Erson - 5 Mistakes you might be making22) Research is confirming what many of us already know - Core Stability Training and the ACL .  "Conclusion: Better H/Q strength ratio was seen in core stabilization group. Core stabilization exercises improved postural stability more than classic rehabilitation."23) “High heeled shoe research model suggests increasing height by 13 cm shortens gastroc by 5%, leads to sarcomere loss.”-Jordana Bieze Foster (@biezefoster)24) Charlie Weingroff shares 8 Reasons Why The Knee Buckles (at the bottom of the post)25) A review of Erson’s Eclectic Approach Course26) “Protect before correct” -Gray Cook27) We already know this clinically, but it’s nice to have some research to back it up.  “These findings suggest that alignment of the lower extremity up to the pelvic girdle, can be altered, due to forces acting on the foot.”  28) Zac Cupples makes you think about wisdom teeth and depth perception.  "My wisdom teeth essentially alter pterygoid position and reduce my mandible’s capacity to move."29) Two great things in one post - beer and periodization.  A great read that simplifies the periodization process.

2014 In Review (Best of Posts)

• Dead Summerset
• Eric Cressey (Articles, Guest Articles, Baseball, Videos)
• Bret Contreras
• Todd Hargrove
• Zac Cupples
• The Gait Guys Podcast
• Seth Oberst
• Danny Matta
• Erson
• Sports Medicine Research
• The Nominalist
• NOI Jam

 Top 3 Tweets of the Month

1. Michael J Mullin‏ - @mjmatc - If you're not asking "Where do you feel that?" regularly during your day, u should. You might be surprised at what the response is at times
2. Dr. Andreo Spina‏ - @DrAndreoSpina - Chronic internet contrarians rarely, if ever, contribute anything of value to the collective knowledge
3. Jon Herting‏ - @JonHerting - You shouldn't have to choose between breathing and spinal stabilization. #breathstrong #proximalstability #moveeffeciently #painfreefunction

Chasing Pain...

The Best of 2014

One of the best things about the information age is the amount of great content out there.  There are so many smart, generous individuals sharing information that can improve your skills and increase your quality of care.  These blogs are accessible, straight forward, and clinically applicable.  Here is my year end summary of some of my favorite stuff from this past year.I came out of the stone-age and started using Google Analytics, which allowed me to see which of my articles were most popular, and which ones were only read by my girlfriend.  It wasn't what I expected.Keep in mind that these lists are in no particular order.  And also, this is just a small amount of the great articles out there.  It's just the ones I enjoyed the most from a years worth of Hits.  If your favorites weren't listed here, please feel free to leave a comment with your Top Reads.

Top 5 Theoretical Reads

1. Zac Cupples - The End of Pain
2. Placebos - Nicholas Humprhy, Todd Hargrove, DPPT
3. Todd Hargrove - A Systems Perspective on Chronic Pain
4. Andreo Spina - Functional Exercise
5. Our Kids, Our Species - Eric Cressey, Seth Oberst, Angela Hanscom

Top 6 Clinical Reads

1. Morphology - The Gait Guys (1, 2, 3a, 3b, 4), Dean Summerset, Paul Grilley
2. Jaw Position & The Tongue - Seth Oberst, Zac Cupples, Kathy Dooley
3. Erson - Redefining the Smudge
4. Loading Tendons - Michael Kjaer, Jill Cook
5. Gray Cook - Coaching vs. Correcting
6. Bret Contreras - Hip Extension Forces with the Deadlift, Squat, & Hip Hinge

Top 6 Research Reads

1. The millions of articles on the importance of sleep (see references in this article - constantly updated)
2. The importance of muscle mass in mortality
3. Whether the RTC repair is intact or not doesn't matter
4. Ice possibly delays healing
5. See a PT and save $2 Million
6. Erson - Top 5 Articles That Changed His Practice

Top 5 Exercises

1. Bret Contreras's Hip Thruster
2. Mark Cheng's Sphinx Progression
3. Foot Wave
4. FMS/Strongfirst ASLR Kettlebell Correction
5. Crawl Progressions

Top Course

•  PRI Pelvis Restoration with Jen Poulin

I don't know if it's the learning curve, the culmination of the information, chunking, or Jen Poulin.  But this really pulled together the PRI concepts for me.  I was able to use PRI much more efficiently and able to apply the concepts more often in the clinic.I will say that if you are interested in PRI you have to go to a live course.  The home study courses are good, but they don't compare to the live events.

2014 AaronSwansonPT.com

What I Thought Were My Most Important Articles

• Everything is Moving Proximally
• 4 Mistakes People Make with the FMS System
• The Art of Recovery (Part 1 & Part 2)

What Were My Most Popular Articles

• An Open Letter to Crossfit: The 2 Mistakes (Part 1 & Part 2)
• The Deep Squat
• Mark Cheng Prehab-Rehab 101 Review

Self Clinical Review

4 Clinical Mistakes I Learned From

1. Letting the patient off the hook (for not listening, not exercising, not living a healthy lifestyle, not taking responsibility, dogmatic beliefs, not trying)
2. Not following up with discharged patients to ensure 100% recovery
3. Using pain science as an excuse
4. Overloading patients with assessment results and information

9 Clinical Epiphanies

1. Forefoot pathomechanics, assessment, and treatment implications
2. Importance of morphology (osseous structures)
3. One way or another, everything comes back to the core
4. How to build true scapula stability
5. Importance of direct communication and laying it all out on the table for your patients
6. And then LISTENING to what they think about it
7. Neck patients are rarely just mechanical/kinesiological patients
8. I finally understand what Sahrmann and Kinetic Control is really about
9. The Vestibular System might be the best way to progress static stability exercises 

December Hits (2014)

1) Two great articles on placebos.  The evolutionary history of placebos from Nicholas Humphrey - “when people are cured by placebo medicine, they are in reality curing themselves” - “The placebo effect is a particular kind of priming effect.”  And how placebo helps pain from Todd Hargrove - "In other words, the placebo effect does not involve anything magical. It is one of many ways that our cognition affect our physiology." - "The research of Benedetti and others has identified three different patterns of mental processes that create the placebo effect: (1) expectations of benefit; (2) reduction of anxiety; and (3) learning through association."2) Customised foot orthoses are no more effective than sham foot orthoses for reducing symptoms and improving function in people with mid-portion Achilles tendinopathy undergoing an eccentric calf muscle exercise programme.  And apparently heel lifts for Achilles patients are not very effective according to the latest evidence.3) This Cupples quote helps display the complexity of the PRI system -”The goal is to flex the sphenoid, which closes the foramen magnum and produces appropriate OA extension. This position keeps the brainstem happy.”  And that’s the simple way to say it.4) It might not be the ITB that’s flicking over the lateral femoral condyle…5) This might be the best glute max exercise you are not doing.6) “Both cognitive and somatic relaxation strategies reduce perceived stress and physiological markers of stress.”7) If you have any interest in handstands, you need to read this.  “when it comes to improving your overall strength, body control, and spatial awareness, it’s hard to beat handstand training.”8) Another very thorough and intelligent series from the Gait Guys.  This time they cover the different aspects of stretching.  Links - Why it Feels Good, Thoughts, Reciprocal Inhibition, Autogenic Inhibition, Symmetrical Tonic Neck Reflex, Asymmetrical Tonic Neck Reflex9) The radial nerve is often involved in elbow pain.  A new study finds “A single session of 3 neural mobilization resulted in a decrease of pain in computer users with lateral elbow pain. A long-term randomized trial is necessary to determine the effects sustained over-time.”  This was their prescription in the study - "The radial nerve was mobilized using a series of 8 oscillations and repeated 3 times with a one minute rest in between."10) “If your muscles are tight no matter how much you stretch, you may need strength to support the stretch.”-Kathy Dooley with a great concise post on the 4 knots11) Foam Rolling

"If there’s too much compression it can cause the muscle to contract harder, but enough compression to cause some overload can help stimulate and then fatigue the receptor, which helps to “release” the muscle or sarcomeres affected so there’s less tension."-Dean Summerset

“Roller massage was painful and induced muscle activity, but it increased knee-joint ROM and neuromuscular efficiency during a lunge.”-Duane C. Button

“The possible effects of foam rolling on serum cortisol, combined with other findings regarding its effects on arterial stiffness, arterial function and vascular endothelial function, are intriguing. While the research is not extensive enough for us to make recommendations, it will be fascinating to see whether future work confirms these findings, which indicate that foam rolling may have some sort of modulatory effect on the autonomic nervous system.” -Chris Beardsley

I think it also has a role in cortical mapping to improve body awareness.

12) “They found that the knee OA patients had significantly less coronal plane range of motion at the midfoot and significantly less sagittal plane range of motion at the hallux compared with the controls.”13) Technology is having quite an effect on our species; both physically and mentally.  We need to make sure we educate patients on efficient mechanics, adverse postures, good movement, and healthy lifestyles.  Otherwise this might be our future.  This text-neck article became popular this past month.  It has some great points, just make sure you don’t give your patients any thought viruses when educating on posture/mechanics.14) Andreo Spina shares a common pull-up mistake.15) Why muscle stiffness is important for elastic recoil during running.16) Eric Cressey goes over 3 coaching cues - 1) Follow your hand with your eyes 2) Drive hamstring tension before pulling the bar 3) Let the scapula go where the humerus goes17) Here’s a nice evidence based article on the high plank exercise.18) “Work capacity is the integrity of postures and patterns against fatigue across time. “-Gray Cook19) It’s not the mind that makes a great clinician, it’s the mindset.20) Physical therapy would be so much easier if everyone just listened to everything I said.  Unfortunately, convincing people to move and changing beliefs are a very important part of the job.  Here’s a great article on how to get people to do what you want them to do.21) An interesting read on endogenous analgesia.  “Our nervous system has the capability to reduce pain by activation of specific pathways that exert inhibitory effects on the messages entering the central nervous system during or after threat or damage to the body.”22) Getting bored with early post ops? Not sure what to add in this slow stage?  Zac Cupples gives some great ideas in this article.23) More on placebos, “compared to control, the injected placebo improved 3 km race time by 1.2%.”24) Erson Friday 5’s

5 TMD Tips - 1) The Nod 2) Diet 3) Mandible Protrusion 4) How They Eat 5) Self Masseter Massage

5 Press-Up Advancements - 1) Full UE Extension 2) Make it Passive 3) Cervical Extension 4) Sag 5) Start in Quadruped and Drop In

25) This is my favorite new foot exercise.  You'll be amazed at how many of your patients can't do it.25) “pain during training had an impact on the retention of motor memories” - “These results suggest that the same motor rehabilitation intervention could be less effective if administered in the presence of pain.” (via @RyanDavisDC)26) Pavel’s input on cervical positioning during the swing - cervical extension drives posterior chain activation.27) Exposure Therapy “is an experiential treatment approach: people must expose themselves to the things they fear so that they learn, in person, that their fear is not founded upon genuine threat.” -Tory Madden28) Eric Cressey goes over some great cues during the landmine press.29) “Presently, the full explanation for development of tendinopathy remains elusive with two suggestions being currently proposed. One theory posits that tendinopathy reflects a misbalance between overloading of the tissue resulting in both a cell reaction towards apoptosis and increased proteolytic activity. An alternate theory suggests a local unloading of tendon cells due to micro-ruptures of collagen fibres as an initial step in pathological changes seen in tendon injuries. In this scenario, it would be the absence of tensile stimuli that would trigger catabolic alterations of tendon tissue.” #LoadTheTendons30) There are no bad exercises, just bad clinicians/trainers.  We need to stop making black and white statements about specific exercises.  It confuses patients and can discredit our profession.  Don’t agree?  Read these two articles: Bret Contreras - Scotty Butcher31) Eric Cressey shares 5 things he’s learned about mobility - 1) Soft Tissue Importance 2) Breathing 3) Don’t Conform to One Approach 4) Don’t Mistake Laxity for Mobility 5) Deposits > Withdrawals32) People You Should Know - Brian Mulligan is a renowned physical therapist from New Zealand.  Our profession owes him a great deal for his contribution to manual therapy.  He discovered and developed the Mobilizations With Movement (MWM) technique.  This manual approach restores function and decreases pain through non-painful, manual joint “repositioning”.  In other words, his techniques provide an external input to centrate joints and improve human movement.  The Mulligan Technique has become a standard in the physical therapy field as a great tool for manually improving movement.  Here’s his story of how he came up with the technique:

“A young patient (in her 20s) came to see me with a painful immobile swollen interphalangeal  joint.  She injured it playing basketball.  I tractioned the joint to no avail, then applied anterior glides to see if I could get it to move.  No success. I then remember applying a medial glide which caused pain. I then applied a lateral glide and the patient said that it did  not hurt.  While sustaining the lateral glide I by chance asked her if she could move it. To my astonishment she flexed the joint with no pain. I  asked her while I maintained the glide to do some repetitions.  The  result? Virtually full range of pain free movement.  She returned two days later, the finger was fine and no further treatment was necessary.

Why was the treatment so successful?  Louis Pasteur said that  in the field of discovery chance only favours a prepared mind.  I sure had a prepared mind. Why had  the regular manual therapy treatment I was teaching failed? What did I do that was different? After much thinking the only explanation I could come up with was that there had to be a minute positional fault which inhibited joint movement and caused the pain.  With this explanation in mind I began experimenting with all painful joint restrictions and Wow It changed my life.”

33) 4 Top Tweets of the MonthFollow John Kiely.  He consistently puts out useful content.

• Perry Nickelston @stopchasingpain - 'The slower you go, the more your brain teaches your body.'-Thomas Hanna
• Dr. Michael Chivers‏ @drmchivers - Joints need full mobility to give the CNS a good "picture" of what is going on. This way appropriate motor synergies can be chosen.
• Charlie Weingroff‏ @CWagon75 - Figuring out how to skip steps without missing anything starts with tediously honoring a systematic approach so you don't miss anything.
• Robert Butler PT PhD‏ @rjbutler_dptphd - Kettlebell swing should be like a series of standing long jumps where the center of mass doesn't go anywhere @Fakedanjohn

34) Happy Holidays               

November Hits (2014)

1) Stress is stress.  And there are many outputs that can occur in response to stress.  Too often we get stuck obsessing over just one of the outputs - PAIN.  As movement professionals we should focus on the output that we’re the most proficient at - MOVEMENT.  If you disagree, Zac Cupples will convince you in this phenomenal article.  “Assessing movement may be the simplest way to assess an individual’s stress status.”2) Decreased hamstring strength increases ACL loading during sidestep cutting.3) “If your tongue is on the roof of your mouth, you are connecting palate, pharynx, hyoid, jaw, and skull.  You are stabilizing your airway, so you can breathe, while anchoring your TMJ so it doesn’t deviate. Now, your body is more balanced and can better ambulate.” -Kathy Dooley4) Your butt can stop you from peeing?5) Aleks Salkin has some great advice on how to pass your SFG Snatch test.6) “Football players who had greater cervical stiffness and an ability to decrease the displacement of their head following perturbation were less likely to sustain a moderate and severe head impacts.“7) Some good advice for cross-training when injured.8) “Sure posture does not matter when studied, but it's the introduction of variability that resets the nervous system, not always something as simple or mechanical as postural correction.” -Erson Religioso9) Regarding exercise regressions and progressions - “a continuum is an environment that we create.” - Gray Cook10) “Rather than friction causing irritation of the ITB, it is now thought that compression of the associated fat layer may be the culprit.”  The best ITB article I've read in a long time, by John Foster.11) When you bash other approaches it not only confirms your insecurity as a clinician, but it also...12) “Acupuncture points have a higher density of micro-vessels and contain a large amount of involuted microvascular structures. The non-acupuncture points did not exhibit these properties.”13) A great 5 minute TED-Ed video to help explain pain to your patients (via @ShinePTyoga)14) Here’s a nice review of sensory processing in the brain.15) Erson’s Friday Fives

5 Ways to Increase Ankle DF Without the Talocrual Joint - 1) Calcaneus 2) Great Toe 3) Tibial IR 4) Sidegliding in Standing 5) IASTM to Anterior Calcaneus

5 Ways to Ensure Patient Compliance - 1) Use the Edge of Ability 2) Make it Pain Free 3) Simplify the HEP 4) Encourage Communications 5) Connect with Your Patient

5 More Articles That Have Influenced My Practice

16) The squat is a very complex movement.  There are many variables that can affect the movement pattern.  A common mistake is to blame a complex output on a single input.  The butt wink (posterior pelvic tilt/lumbar flexion at the bottom of a squat) has many possible causes.  Some have blamed it on hamstring length, osseous morphology, ankle dorsiflexion limitations, anterior tibialis weakness, hip flexor weakness, eccentric quad strength, decreased anterior core, glute weakness, lumbar extensor weakness, decreased thoracic mobility, limited hip internal rotation, local motor control dysfunction, or a poor global motor program.  Julie Wiebe adds another variable to this list - Pelvic Floor Dysfunction.  “Squeezing one part of the system does not create a balance.”  The more you know, the better you can assess.17) This is my go to exercise for shoulder patients who have progressed past supine KB holds and quadruped progressions.18) “Generally speaking, slow stretch activates the Ia afferent loop which causes a physiological contraction of the muscle (this is one of the reasons you do not want to do slow, steady stretch on a muscle in spasm).” -Gait Guys19) “Our results show that an increase in the amplitude of force produced by one hand corresponded with a decrease in pain perception in the other hand.”20) Here's an article on shoulder flexion/extension muscle patterns.  “During extension subscapularis and latissimus dorsi were activated at higher levels than during flexion; during flexion, supraspinatus, infraspinatus, deltoid, trapezius, and serratus anterior were more highly activated than during extension. In addition, the pattern of activity in each muscle did not vary with load.”21) Here are a ton of great interviews from CinemaSays.22) Dysregulated Supersystems, Cognition, Phase Shifts, Attractors, Feedback Loops, and more.  This is the best article you’ll read on chronic pain from Todd Hargrove.23) Want your patients to cooperate?  Try telling a story - "character-driven stories do consistently cause oxytocin synthesis".  “Oxytocin is produced when we are trusted or shown a kindness, and it motivates cooperation with others. “24) Here's my opinion on Crossfit and the 2 Mistakes that can prevent injuries.25) David Butler shares an example of how to treat “shin splints” with neurodynamics and pain education.26) Patrick Ward tells you what kind of manual therapy you should choose.27) An interesting read on muscle spindles.28) Bret Contreras sums up everything you want to know about EMG studies in this article.29) “Flexion allows for movement variability, which is desirable in the human system. Variable movement reduces threat perception.  However, system flexion leads to increased instability and the risk of falling forward. To combat this risk, impingement may occur by compensatory extension.” -Zac Cupples30) Loss of anterior core control is an epidemic.  We see it in all different patient populations.  Eric Cressey goes over 6 reasons why you need to focus on the anterior core.31) If you’re doing box squats for performance training, make sure you don’t sit on the box.32) “In fact, MRI findings will increase the fear of their condition, which in turn increases their awareness of their pain”33) “What "master" clinicians often have is not necessarily better hands, or psychomotor competence, but recognition of Clinical Practice Patterns.”-Erson34) Get to know the influence of the one, the only, the Great Toe.  “What happens is that toe stays flexed, the first met head collapses, the arch falls and forces the foot into early pronation which locks up dorsiflexion.”35) It’s not just physical movement that determines return to sport.  “Psychological readiness to return to sport and recreation was the factor most strongly associated with returning to the preinjury activity.”36) Here’s another gait assessment rabbit hole from the Gait Guys.37) Manual therapy is really brain therapy.38) Corey Hart was right.  You should wear your sunglasses (blue blocker) at night if you're using blue light devices.  It’ll improve your health via your Circadian cycle.39) People You Should Know - Robin McKenzie was a pioneer who helped change physical therapy from a passive modality directed by MD’s to an autonomous profession that utilizes active assessment and intervention.  The story behind the origin approach, Mechanical Diagnosis and Therapy (MDT), is worth a listen.  He was one of the first physical therapists to abandon the pathoanatomical biased model in preference for a movement based system.  His approach has changed the way medical professionals address back pain.  It provides physical therapists an avenue with which they can empower patients to treat their own pain.40) Top 3 Tweets of the Month

• Tom Myers‏ @myers_info - Genes are the canvas ; environment is the paint
• Scott Belsky ‏@scottbelsky - Thinking: One of the most important things experience gives you is the confidence to make decisions without certainty.
• Nick Winkelman‏ @NickWinkelman - "Ask your clients how many pillows they need to sleep. If it is more than one they have a mobility problem." -Dan John #AZNSCA #Simple

41) Another way to treat your own back               

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

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

Mistake #2 = Not Training Unilaterally

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

1) You have a much more prominent handedness than footedness

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

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

A Suggestion

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

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

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

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

Bottom Line

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

References

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

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

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

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

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

1) Constantly Training to (and Past) Failure

2) Not Training Unilaterally Enough.

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

A Disclaimer

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

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

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

A Suggestion

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

Click Here for Part II

References

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

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

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

 [subscribe2]

October Hits (2014)

1)A good soap box by Roger Kerry - “Calls to abandon a biomedical model is evidence-based moronicy. And downright dangerous.” - “Movement is everything.” - “Movement helps people contribute to society and it keeps the world going.” - “If you are a research funder, PLEASE STOP FUNDING RIDICULOUS RCTs.”2) The Gait Guys take you down a static assessment rabbit hole with the functional anatomy of the lumbricals, flexor digitorum longus, and quadratus plantae.  One of my favorite reads of the month.3) Go Barefoot - “those feet should be straight-up sensory vacuums taking up as much sensory information as possible” -Seth Oberst4) Adding single joint exercises to a multi-joint exercise program had no effect muscle thickness or peak torque production.  #MovementNotMuscles5) "The secret to great communication is to provide a morsel of intriguing information and wait for the person to ask a question." - Phil Plisky6) We're all guilty of some these from time to time - 5 Mistakes Clinicians Often Make7) If you’re a dog lover and a movement therapist, then you’ll love this.  #TheJoyOfMovement8) From Charlie Weingroff -  The Rule of the Artery - “When blood and lymphatics flow freely, the tissues can perform their physiologic functions without impedance. With the occurrence of trauma (physical or emotional), the tissues contract, twist, and compress. The fluid flow becomes obstructed. Micro-climates of underperfusion result, and are considered to be a significant contributor to the onset of disease. “9) Chris Johnson has put together 2 great compilations of exercise videos for shoulders and hips.  Chris has a ton of orthopedic knowledge and a great attention to detail.  He could probably write a couple pages on each of these exercises.  Hopefully someday he will.10) 4 Questions Your Patients Want Answered:

1) What is wrong with me?

2) How long will it take?

3) What can I do for it?

4) What can you do for it?

“The future of healthcare is going to be empowering patients to help themselves. “ -Adriaan Louw

11) Bret Contreras is spot on with his well written article on the 10 worst types of trainers.  The ½ kneeling, bottoms-up KB press, with cervical RNT is pretty hilarious.  And I'll shamelessly plug my soap box article on the 3 types of physical therapists.12) Here are 2 great active ankle dorsiflexion exercises from the Gait Guys.13) Sue Falsone goes over some of today’s controversial topics in her new post.  “Everyone who uses a calculator is not an accountant. Just like everyone who uses a fine filament needle is not an acupuncturist.”-Edo Zylstra14) Sometimes painful interventions work (foam rolling, overly aggressive manual therapy, certain exercises, surgery, etc.). This might be why - “Here we show that when the meaning of the pain experience is changed from negative to positive through verbal suggestions, the opioid and cannabinoid systems are co-activated and these, in turn, increase pain tolerance”15) I’ve always been a fan of the 10% rule for athletes that have been injured.  Here’s some research that backs it up.16) The amount of variables between individuals is immense.  One of the more overlooked variables is the osseous structures.  Everyone has different bony anatomy.  This can be difficult to understand because we literally can’t see it.  Even though it is not visible, it is an important consideration.  It might not be a mobility problem, it might not be a stability problem.  It might be a osseus structural problem.  Simply put, if it’s not working, don’t force it.  #DontPushThroughBone17) McKenzie (MDT) Part B Knowledge Nuggets from Direct Performance - Day 1, Day 2, Day 3.18) Seth Oberst sent me this great article on twitter.  We both agree - the diaphragm is the most proximal core and has the ability to influence everything.19) A great “don’t throw the baby out with the bathwater” article by Chris Beardsley.  According to research, the Leg Press can be a great exercise to “increase walking efficiency, balance, vertical jump height, horizontal jump distance, short-distance sprinting ability, and the maximum number of bodyweight squats you can achieve in 30 seconds.”20) ”The effects of my treatment will quickly be absorbed into the rhythms and patterns of life, but pivotal education is a game changer.”-Gray Cook21) It’s rare to find an unbiased review of barefoot running.  Luckily for us, Christian Barton has taken the time to write a quality article on the subject with a good balance of research and clinical experience.  “So with a lack of evidence in relation to injury, what can we as health professionals do to advise the curious public? Simple, consider the biomechanical effects of barefoot running, how they may relate to injury, and importantly, how they may relate to an individual.”22) Great MDT tips from Erson.  5 Ways to Get to End Range - 1) Slow Down 2) Soft-Tissue Work 3) Breathing 4) Compression 5) Distal Influence.  And how to improve cervical retraction.23) There is compelling evidence that people learn better from words and pictures than from words alone – this is known as the multimedia learning hypothesis (Mayer 2014).24) I think PRI needs to start paying Zac Cupples.  Here’s another great post on their new course - PRI Integration for Yoga.  “During both this pause and inhalation, the tongue ought to be pushed up into the palate. This movement helps balance the stylohyoid and 16 muscles that attach to the sphenoid. Keeping the tongue here is the best way to shut off the neck without orthotics.”25) “The fact is that no biological tissue in the body has ever been shown to permanently alter in structure following single stimuli application. “ -Andreo Spina 26) Low eccentric hamstring strength is a risk factor for hamstring strains.27) Proof of central mechanisms?  Adriaan Louw once said he wanted to create a CPR for ultrasound use.  “The study found ultrasound and LLLT to provide significant improvements in pain and muscle extensibility, which were superior to no therapy but not to placebos…” #UseThePlacebo28) The Isolated Transverse Abdominus Hollowing Exercise

If this worked wouldn't the top Powerlifters be performing it for maximal stability/strength?  Wouldn't the best marathoners be hollowing their stomachs to push through the last few miles?  Wouldn't we see athletes sucking in their stomachs in Gatorade training montages?  I don't use it because it never worked in the clinic for my patients.  Here are 5 other reasons not to use it from Mike Reiman (1, 2, 3, 4, 5).  And if those don't persuade you then there are these two words - Stuart McGill.

29) Sciatic Nerve Morphology and Fascicular Anatomy30) This is useful for cross-training and aerobic exercise substitution with injured endurance athletes.  “In moderately active females similar physiological improvements were observed using stair-climber, elliptical trainer and treadmill running when training volume and intensity were equivalent.”31) Shante Cofield wants you to keep your feet pointed straight.  "When we walk with our feet pointed outwards, we take a structure that is supposed to be rigidly supported by the strength of our foot bones and turn it into something that would make the Viagra reps drool."32) People You Should Know - Karel Lewit is one of the founding members of the Prague School and manual medicine.  He started as a neurologist and specialist in manual medicine with an interest in the spinal column.  Later in his career his interests expanded to a global approach to the functional aspects of the motor system and its rehabilitation.  Lewit’s work has had a great influence on most of the approaches used today.  Read some Lewit wisdom here, here, and here.

• “He who treats at the site of pain is lost”
• “If breathing is not normalized, no other movement pattern can be.”

33) Top 3 Tweets of the Month

• Jon Herting @JonHerting · Oct 11 - Everything matters unless it doesn't matter to the patient #sympatheticvsparasympathetic
• Charlie Weingroff @CWagon75 · Oct 5 - Sometimes serious injury is a great thing for an athlete. It provides the chance to rebuild everything they never had in the first place.
• GMB Fitness @gmbfit · Sep 17 - If you think you are the only expert in your field who has the right answer, you aren't an expert.

34) Why you should learn how to do a cartwheel          

September Hits (2014)

1) "Maintaining the short foot position can generate an arch and produce a monstrous feed-forward loop that maintains tension and stability throughout the system reinforcing to the brain that force can be safely produced. When the arch collapses the nervous system quickly downregulates in an attempt to avoid excess force thru the entire lower quarter while in an unstable position, yielding decreased output." -Seth Oberst on foot positioning2) Tendinopathy research goes pretty deep.  There has been a lot of progress over the years, but there is still a ton we don't know.  Here are 2 posts to update your knowledge: 1) Peter Malliaras's tendinopathy research post 2) 10 Clinical Pearls from ISTS 20143) Adriaan Louw and the ISPI just published a great study on pain education and how it can save the healthcare system a ton of money.  Here is a quick flow sheet to understand the process.  He also has a nice post on the important question, is it a tissue problem or a pain problem?  Adriaan's Medbridge course is worth the subscription alone.4) 10 Benefits of Crawling5) According to research, PRP doesn't work in shoulders or achilles.6) What are you really doing with manual therapy?  And how do you explain it to your patients?  Should you remove certain things to streamline your practice?7) Great review of the research on pain and posture by Todd Hargrove.  "The above evidence suggests that it may be a waste of time to try to identify defects in your static posture according to some ideal model, and correct them as a way to treat or prevent pain." -"The way you move is more important than how you look standing or sitting. "8) Be careful with opinions, theories, and approaches.  "Models are approximations of reality. Reality is far too complex to fit neatly into one model."9) Open up your hips the GMB way - some great hip mobility drills.10) I'm a fan of getting my shoulder patients into half/tall kneeling and doing exercises like this.11) Experienced clinicians already know this, but a new study found that people who blame others, catastrophize, and think life is unfair have more pain after knee replacement surgery.12) I had a patient that fell off her bike and hit her head.  Thankfully she was wearing a helmet and she's okay.  But it's important to remember the Canadian C-Spine Rules for X-Ray.13) Strength wins again!  New study shows high-load strengthening is more effective than stretching for plantar fasciitis.14) I love the way Erson teaches MDT.  Here's a clinical pearl on Flexion Rapid Responders.15) Eric Cressey always has great tips that you can apply to your patients the next day.  This is a great one on getting more Serratus Anterior activation during the wall slides.16) I've never even heard of Dynatomes...this current study demonstrates a distinct difference between dynatomal and dermatomal maps.

Dermatomes are the distribution of the sensory skin loss from a spinal nerve root.  The Dynatomes are the distribution of symptoms from a spinal nerve root.  But keep in mind that there are many structures that can refer peripherally, not just the disc and nerve roots.

17) "89% of the clinically recovered hamstring injuries showed intramuscular increased signal intensity on fluid-sensitive sequences on MRI."18) "Aerobic exercise at approximately 70% of maximal aerobic capacity moderately reduces pain sensitivity and attenuates pain, even after a single session"19) I attended Mark Cheng's Prehab-Rehab 101 Workshop in NYC.  Learned tons of stuff, you can too by reading this.20) I found this article on how fish evolved out of the water fascinating. #GeneticAssimilation #DevelopmentalPlasticity21) "Sports-related concussion increases the risk of subsequent injury by about 50% in elite male football players."22) The movement world would be a better place if more of the top professionals shared like Charlie Weingroff.  You'll like something in this post.  A couple gems: "Part of implicating exposure can be the general nature of twitch of the athlete." - "some things are so non-linear and multi-variant, that they will look like quite foolish within traditional parametric or non-parametric procedures." - "Anything can be anything.  Indeed anatomy often lies." - "Strength can solve a lot of things."23) Dan Pope goes over 9 reasons to use tempo lifts: Technique, Tendinopathy, Decrease Ego, Decrease Stretch Reflex, Control, Less Pain, Hypertrophy, Variability to Training, & Improving Flexibility24) "Early ROM exercise accelerated recovery from postoperative stiffness for patients after arthroscopic rotator cuff repair but was likely to result in improper tendon healing in shoulders with large-sized tears (>3cm)."25) "Neck instability not only leads to a weakened Deltoid but a weakened rotator cuff" -Kathy Dooley26) The PRI and DNS people gotta love this study on sagittal spinal position.  Running with increased spinal extension causes an increase in patellofemoral joint stress.  Running with spinal flexion decreases the amount of patellofemoral joint stress.  Proximal Influences.  Get a Zone, Keep a Cylinder.27) The timeline of human evolution summed up in a Andreas Vesalius infographic.28) The American Heart Association came out and said “Manipulating the neck has been associated with cervical dissection, a type of arterial tear that can lead to stroke. Although a direct cause-and-effect link has not been established between neck manipulation and the risk of stroke, healthcare providers should inform patients of the association before they undergo neck manipulation.”  The IFOMPT responded by saying that this causes unnecessary fear for the public and that we should realize that “Anti-inflammatory drugs, injections, and surgery for the treatment of neck pain or headaches have much greater risks than cervical manipulation.”29) Breathing is extremely important.  Here's a study showing it's effect on muscle activity and cervical ROM.30) I was discussing chronic pain with a psychologist at NYU and he introduced me to this approach.31) Here is a nice article on Pull-Up Progressions: Trunk Stability, Horizontal Pulls, Flexed ISO Hangs, Negatives/Eccentrics, Assisted Pull-Ups, Pull-Ups, Weighted Pull-Ups32) 2 Things I know: 1) You can't fix stupid 2) You can't coach through mobility impairments.  Gray Cook has a great article on why coaching through mobility deficits is a bad idea.  He also goes over his 3 progressive coaching methods: Coaching the Pattern without Load, Assisting the Pattern, and Loading the Pattern and Observing.  And remember "They're learning from the movement, not from your cues."33) The Gait Guys put out some of the highest level of information in the social media world.  It's truly amazing stuff that has great implications on how we practice.  An example is their unbelievably detailed analysis of tibia torsions.  Check out the goods - part 1, part 2, part 3a, part 3b, part4, here, here, and here.  Thank you Gait Guys!34) I think Zac Cupples would be a great person to get a bunch of beers with and talk shop.  Here's his enjoyable post on the Hruska Clinic and other PRI randoms.  He also has a solid post on Jen Poulin's Myokinematics.  “The diaphragm is the core of your core. If you’re not using it, you’re missing the boat.”35) I'm one of the contributors of the Manual Therapy Daily Flipboard Magazine.  This magazine has hourly updates on new articles relating to physical therapy, strength and conditioning, pain, fitness, movement, and health.36) People You Should Know - Elizabeth “Sister” Kenny (1880-1952) was an Australian nurse who helped lay the foundation for musculoskeletal rehab and physical therapy.  Sister Kenny’s controversial approach of treating poliomyelitis patients with movement rather than immobilization changed the course of the disease and improved the lives of the millions affected.  She courageously went against the normal medical model and created an innovative approach that has changed the way we treat the human body.37) 3 Top Tweets of the Month

• Nick Winkelman‏ @NickWinkelman - Coach Tip: The motor system self-organizes to achieve a movement outcome. Cueing the body (ex. Squeeze Glute) interrupts this process.
• John Hawks‏ @johnhawks - The lone scientist is a myth. Great problems today are tackled by teams of scientists with different expertise, working together.
• Ram Dass‏ @BabaRamDass - Information is just bits of data. Knowledge is putting them together. Wisdom is transcending them.

38) A new device to assess lumbopelvic dissociation     [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.

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