Coaching & Cueing (Part 3 - External Verbal Cues)

The type of cue one chooses should be based on the environment, individual, and task.This article should help you understand when to best choose an external cue.External Cue: focuses on how the body’s output affects the environment (outcomes, objects, etc.) 

Science of External Cueing

External verbal cues (VC) have been the most commonly discussed type of cueing in the past decade. There’s a good reason: the latest research has provided some clear results that can have a major impact on coaching.

• “External focus allows the motor system to “self-organize”; efficiently coordinating and directing forces needed for accurate, maximal and sustained force production.” -David C. Marchant

Research shows:

External VC Are Better Than Internal VC for:

• Performance
• Skill Acquisition
• Complex Motor Tasks
• Multi-Segmental Motion
• Force Generation (summative, accuracy, endurance)

8 Benefits of External Cueing

1. Allows the Motor System to “Self-Organize”
2. Keeps Movement Reflexive and Automatic
3. Frees the Brain From an Extra Task - Constrained Action Hypothesis
4. Decreases Aberrant Muscle Activity = Less EMG Activity = Conservation of Energy
5. Less Co-Contraction
6. Increases Speed
7. Better Retention and Carryover
8. Produce Greater Force, Increased Accuracy of Target Forces, and Increased Duration of Force Production

How to Use External Cues

The most important aspect of external cueing is incorporating part of the existing environment.  Simply chose something that is NOT part of the individual (i.e. don’t reference muscles, kinematics, etc.).  It can be anything from a belt buckle to a location in the room.To achieve a more specific outcome, Nick Winkelman uses a 3-D approach to cueing.  He states that we need to cue Distance (close, far, etc.), Direction (away, towards, etc.), and a Description (push, snap, drive, etc.).Cue selection depends on a variety of factors including: environment, task, desired outcome, biomechanical movement, participants experience, readiness, etc.  Different cues will elicit different results.  “Drive the ground away” will be different than “punch the ground away”.  There are many external cueing choices for each movement. Which one you choose is where the “art” of coaching comes into play.

Analogies

Analogies also fall into the external cueing category.“Analogies allow us to convey technical complexity through the lens of relatable stories/experiences that are easy to understand.”-Nick WinkelmanFor example, during a single leg deadlift you can tell the patient to keep their belt/waistband level like an airplane (then add the visual cue of tilting your hand which way their pelvis needs to move in the transverse plane).

Choking

An interesting finding during my research was that one of the major causes of choking in sports performance comes from self-focused attention.  When the athlete is under a high stress situation, an internally focused point of view leads to decreased performance (choking).This is obvious when Tiger hits it into the rough after focusing on his glutes.  But it is less obvious when your frustrated medicare patient is losing balance while walking after trying too hard and focusing internally.  An external cue would help in both situations.

Deadlift Example

Lets go back to the deadlift example.  If you’re trying to increase the weight or speed of the movement, then you need an external cue - “push the ground away”.  This would allow the motor system to simply focus on providing the optimal output to accomplish the task based on the current variables.Internally cueing someone to contract their glutes would only clog up the brain and make the movement less efficient.  While this internal cue may not be bad during the learning phase for chunking purposes, it could be dangerous when the person is at the limits of his/her capacity (i.e. 1RM or in a fatigued state).

Summary

External cues are far superior to internal cues for various outcome results (performance, complex motor task, skill acquisition, force generation, etc.).  If you’re learning or performing a complex motor task, don’t clog up the processing with internal cues. Instead, use external cues to free the motor system to choose the most efficient and effective motor patterns.And don't overcomplicate things with too many words.

• “Say the most with the absolute least” -Nick Winkelman

Dig Deeper

Most of the research has been led by Gabriele Wulf.  She provides detailed explanations of the concepts associated with external cueing.  However, if you want to skip going through the research yourself, but want a deeper understanding, you should look to Nick Winkelman.  He has done a great amount of work to bring the message of the research on cueing to the Strength & Conditioning field.

Coaching & Cueing

Part I – IntroPart II – The CategoriesPart III – Verbal Cues – ExternalPart IV – Verbal Cues – InternalPart V – VisualPart VI – ProprioceptivePart VI – Summary

References

Marchant, David C. "Attentional Focusing Instructions and Force Production." Frontiers in Psychology. Frontiers Research Foundation, n.d. (2015)Wulf, Gabriele. "Attentional Focus and Motor Learning: A Review of 15 Years." International Review of Sport and Exercise Psychology 6.1 (2013): 77-104Wulf, Gabriele, and Wolfgang Prinz. "Directing Attention to Movement Effects Enhances Learning: A Review." Psychonomic Bulletin & Review8.4 (2001): 648-60.Wulf, Gabriele, Nancy Mcnevin, and Charles H. Shea. "The Automaticity of Complex Motor Skill Learning as a Function of Attentional Focus." The Quarterly Journal of Experimental Psychology A 54.4 (2001)Rochester, Lynn, et al. "The effect of external rhythmic cues (auditory and visual) on walking during a functional task in homes of people with Parkinson’s disease." Archives of physical medicine and rehabilitation 86.5 (2005): 999-1006. [subscribe2]

June Hits (2015)

Clinical

1) Sure, it’s a dynamic system and the nervous system has a huge influence.  But you can’t dissociate the physicality of our world from the human body.  Simple biomechanics can have a profound effect on your patient’s movement.  Here’s an example of how the first class lever works to Increase Glute Med Activity.2) Don’t forget about the frontal plane aspect of the bunion deformity - “the degree of first metatarsal pronation is linearly related to the amount of medial deviation of the first metatarsal”3) Kathy Dooley goes over the Obturator Externus - “When this muscle is locked long, it will contribute to hip compression. Since the muscle travels from the anterior outer pelvis posteriorly to the greater trochanter’s inner fossa, it works as a sling with obturator internus to keep that femur jammed into the acetabulum. “4) “Short-term practice of LNB (left nostril breathing) improves vagal tone, increases HRV, and promotes cardiovascular health of medical students.”5) Here are the first two posts to my Coaching & Cueing Series

Intro

The Categories

6) If you ever treat cervical patients you need to read this.  Erson shares 5 Ways to Modulate Acute Cervical Pain (PNF/Isometrics, Traction, Functional Mobilization, IASTM with Movement, Education).  Great share of useful clinical information.7) Perry Nickelston goes over a hypothetical piriformis syndrome case (assess bilaterally!)8) Tom Myers has a great post on Foam Rollers

“In epithelial and muscle tissues, the water is squeezed out of the tissues, and then is sucked back in when the pressure moves on or is taken away. Like squeezing a sponge over the sink and then letting it fill again while doing the pots and pans, this is generally a good idea.”

“More time won’t help; more accuracy of placement will.”

9) For more on Foam Rollers check out #11, this quick literature review write up, and this layman friendly article on foam rolling tone with Doug Kechijian10) Here’s a very good article on crawling - “The increased “little brain” activity during cross-crawl, on top of the stimulation to the high-order thinking function of the frontal cortex, contributes to better balance and coordination, which becomes particularly important when kiddo starts to walk and develops an interest in sports.”11) One of the things I learned from Qi Gong was the Teacup exercise.  Here’s a unilateral version shared by Erson.  It’s pretty much good for everything from your hand to your spine.12) Eric Cressey shares a nice quick postural assessment story in #4.13) Inside the Mind of Charlie Weingroff - June Edition.  These have a lot of good stuff in them.  Example - “T=R Principle: If you are a good enough coach to train around an injury, then the most important part of human performance is fitness.  Because it’s resiliency to stress (aka fitness) that led to your injury in the first place. The only reason we need rehab is because we didn’t have training.”14) APTA shares some great information on Dry Needling15) Do you know your foot pathomechanics?  Forefoot varus can be a big problem - it can lead to hyperpronation and excessive internal rotation of the kinetic chain.16) I thought our profession was starting to understand the latest research on tissue deformation.  Then I had an eval last week who left her old PT because he left bruises on her back from trying to “break up knots and scar tissue”.  Don’t be that guy.  Read this and remember that it takes a ton of force (literally >2000lbs) to deform tissue 1%.  And share this with your peers!17) 5 things you should ask your patients from Erson18) “Considered another way, from the top down this time, if at the moment of heel contact the gmedius is delayed (as suggested in the study below from achilles pain), the pelvis is likely to drift laterally and this could cause a reactive inversion strategy of the rearfoot, and maybe even forefoot as well, as an instinctive measure to try and draw support beneath the laterally drifting body mass center of gravity. (This in essence sets up the “cross over gait” deployment strategy we have talked about here for years now).”-Gait Guys19) Kinetic Control goes over our 6th sense (proprioception) and why it’s so important for movement.20) I’ve been doing this Bridge Walkout Exercise with one of my proximal hamstring tendinopathy patients.  It offers solid mechanotransduction without compressing the tendon (hip flexion).  If done correctly it also works core stability.21) “low level activity in the rectus abdominis and external oblique throughout the gait cycle, more concentrated activity of the internal oblique at initial contact/loading response (heel strike).”-The Gait Guys22) Learn how to go from Gary Busey to Denzel Washington in Zac Cupples review of PRI Cervical Revolution - "The neck is the top priority because its mobility maximizes cranial sensory activity".23) The Postural Restoration Institute (PRI) approach can be quite confusing.  Especially to those who have not attended a live courses.  There’s a lot of complexity and there isn’t a very thorough explanation easily accessible.  For those that want to dive deeper into the rabbit hole and learn more I would suggests these three sites:

Heather Carr (1, 2, 3, 4, 5)

Integrative Human Performance (1, 2)

Zac Cupples

Pain & Neuroscience

24) “Tone seems to be dictated by our perceptions of threat and the ability to cope with external demands.” -Another great read on the autonomic nervous system and threat/stress perception by Seth Oberst25) Zac Cupples goes over some gems from the BSMPG Conference including stress response, every neuroscience fan’s favorite animal (Zebras), thoraxes, decision making, and the Cynefin Framework.26) Stairs look steeper for patients with ankle pain?  Interesting read on how pain changes the perception of one’s environment.27) Great piece on Spondylolisthesis and other threatening diagnoses.  “The purpose of dethreatening any diagnosis is not to ignore, belittle or dismiss it, but rather to bring it into the light of a modern understanding of pain – under the ever-increasing power of this spotlight, many diagnostic DIMs [Danger In Me] can be dramatically deflated.”28) “researchers at the University of Virginia School of Medicine have determined that the brain is directly connected to the immune system by vessels previously thought not to exist”29) “Some of these brain changes will remain long after the injury, with epigenetic changes in a number of brain areas evident 6 months after peripheral nerve injury (Tajerian et al 2013) and glial cells remaining ‘experienced’ and on alert for years (Banati et al 2001).”30) The Placebo Effect should be used with more of an warm/empathetic style rather than technical (up to 82% better).  But is it really a placebo?  Or is it a change in the brain that we have not yet identified?31) Random Opinion - it seems that all successful pain science clinicians have one thing in common - HUMOR

Training

32) Hip Thrusters are a great and easy exercise that can easily increase glute strength and improve lumbopelvic function.  However, I’ve noticed many people tend to perform this with terrible form.

Here’s Ben Bruno going over neck position

I wrote an article on why it’s good in the rehab setting

And this video displays the correct and incorrect form

Don’t sacrifice form for more weight - you’ll pay for it later

33) I've been doing a lot of this stuff lately.  Top 10 Bodyweight Exercises From GMB - Squat, Frogger, Monkey, Cartwheel, Pull-Up, Bear, Push-Up, Hollow Body Hold, Scales, L-Sit, and Handstand.34) Don’t let the click baiting “butt wink” title fool you, this is some serious stuff.  Dean Somerset writes a great series on hip morphology and how it affects range of motion (Part 1, Part 2, Part 3).

“those with more acetabular anteversion (forward placement on the pelvis) had greater flexion range of motion and less extension, lateral placement of 45-55 degrees gave the best overall mobility, but a lateral angle of less than 45 degrees gave more flexion range of motion and more than 45 degrees gave less rotation capability. He even showed that if the femoral neck was thicken by 2 mm in diameter it significantly reduced the range of motion in all directions, irrespective of placement.”

“The recipe for deep squatting seems to be slight femoral anteversion combined with acetabular anteversion, lateral placement of less than 45 degrees, and a thin femoral neck.”

“If someone has a very high degree of mobility, the likelihood of their having a thin femoral neck and a shallow socket is pretty high. If they have all the mobility of a clam, they likely have a deeper socket and thicker femoral neck. This combination, regardless of orientation of the acetabulum, will limit the overall diameter of the conical range of motion of the hip due to earlier contact with the acetabulum compared to a thinner neck and shallower socket.”

35) Very informative read on blood flow restriction training from James McCarron - “Setting initial pressures of around 50 mm Hg, a target pressure of 150 mm Hg and using loads of 20-30% 1RM would appear to be best practice from the what data is showing us.”36) Eric Cressey goes over ways to increase your training density37) Dan Pope displays some great hanging scapula exercises.38) Dean Somerset has a nice logical article on unstable surface training.  Make sure to read Eric Cressey’s article on this topic as well.  Unstable surface training has a place in training, just make sure you find it and don’t force it.39) Gray Cook discusses the Squat vs. the Deadlift - I like the “coil the spring” concept.  For more information, check out this article.40) I still like Mike Robertson’s easy exercise introduction format:

Name the Exercise

Describe Why They’re Doing It

Demonstrate the Exercise

Coach the Exercise

41) “Potential productivity is a complex process which depends on integration and interaction of different systems and organs on different levels of organization: from biochemical to genetic to social.”  PP is determined by a host of physiological and psychological factors: genetics, gender, body mass, age, the state of health, energy systems’ power, capacity, and efficiency, the state of the neuromuscular apparatus, the psychological state, motivation, the climate, the season, work conditions, etc.’ -Pavel on work capacity42) It’s good that more people are starting to understand the importance of recovery.  Lance Goyke writes a piece with some advice on how to recover the other 23 Hours of the day that you’re not in the gym.43) Regretting winter decisions?  Me too.  Here’s Eric Cressey’s 15 tips for leaning out for the summer - “Avoiding liquid calories is the still, in my opinion, the biggest dietary game-changer most folks in the general population can implement.”44) 12 Ways to Make Better Exercise Choices by Eric Cressey.  #12 is one that is often overlooked and not discussed on social media.

Research

45) Watch this.  Then make your peers watch it.  Great talk on Evidence Based Medicine and why it can be “rubbish” - Trish Greenhalgh #PatientBasedEvidence46) Study on the kinetic chain influence on Serratus Anterior anterior - the best activation involved the anterior spiral line (serratus-external oblique-internal oblique-hip flexors/adductors).  This is pretty much gait.47)Craig Payne shares some gems from ACSM48) “Tendon microcirculation increases after ultrasound and vibration massage intervention concentrated on the Achilles tendon.” [Gasp] ultrasound can be useful?  Hipster PT’s won’t like that.49) Sometimes research is just good to help spread the word - “This study showed that a single bout of isometric training reduced PT pain immediately and for at least 45 minutes following. An insight into the mechanism was provided by the concurrent increase in cortical inhibition.”

For more on Isometrics for Pain Relief look at #1 here.

50) “Previously injured athletes demonstrated significantly reduced biceps femoris muscle activation ratios with respect to ipsilateral gluteus maximus, ipsilateral erector spinae, ipsilateral external oblique, and contralateral rectus femoris in the late swing phase. We also detected sagittal asymmetry in hip flexion, pelvic tilt, and medial rotation of the knee effectively putting the hamstrings in a lengthened position just before heel strike.”51) It’s sad that this may be news for some people in our profession - “Both hip as well as core strength were significantly correlated to frontal plane alignment during the single leg squat, especially hip abductor strength was an important predictor of the frontal plane kinematics.”52) Interesting article on plantar flexion static-stretching (SS)

“Hence the SS-induced impairments prior to 10-20 minutes post-warm-up may not impact competition performance.”

“The effects of prolonged and intense SS on the joint receptors might lead to inhibitory effects on motoneurons, such as autogenic inhibition and Type III (mechanoreceptor) and IV (nociceptor) afferents and Golgi tendon organ discharge, and their greatest effects can remain for 5-10 minutes (Behm and Kibele, 2007).”

‘In conclusion, the SS protocol effectively increased passive ankle ROM of the stretched limb. The increased ROM appears to decrease the muscle peak force and pre-activation; however these finding were only a temporary effect (less than 10 minutes after the SS protocol was applied). The decrease of jump height and impulse for the non-stretched limb suggests a central nervous system inhibitory mechanism from SS.’

53) “The bit of the brain that maps muscle change, changes when muscles change, and can be measured by muscle changes.” -Roger Kerry’s one line summary of this article54) Strength wins again!  Here’s a new study showing the importance of shoulder/neck strength in patients with tension headaches.  As Dr. Andreo Spina has says - “you can’t rub someone strong.” #Context55) “The rate of spontaneous regression was found to be 96% for disc sequestration, 70% for disc extrusion, 41% for disc protrusion, and 13% for disc bulging. The rate of complete resolution of disc herniation was 43% for sequestrated discs and 15% for extruded discs.”  This doesn't make sense to me.  Is it along the lines of if it's really bad it can only get better?  Does anyone know the time for disc regression?

Other

56) 23 Alternative Ways to Reduce Pain & Joint Inflammation.  Patients seem to always ask about these things.57) Zebra and Reptile lovers will enjoy this article - “"Traffic noise may influence metabolic and cardiovascular functions through sleep disturbances and chronic stress," lead study author Dr. Andrei Pyko told Australian Associated Press. "Sleep disturbances may affect immune functions, influence the central control of appetite and energy expenditure as well as increase circulating levels of the stress hormone cortisol."58) “The loss of prefrontal function only occurs when we feel out of control.” -Amy Arnsten in Eric Barker’s article on how to control Fear59) Maybe we’re fat because of the artificial light?  “Excess artificial light is a circadian disruptor: same diet & exercise will have a very different impact on someone with circadian misalignment.”60) I’m a big fan of Louie C.K.  I think he’s as smart as he is funny.  He summarizes dysfunctional human communication in this skit.61) Aaron LaBauer shares some great business advice for Cash-Based PT Practices.62) I patient recently introduce me to Mandalas.  It’s a form of art therapy, meditation/mindfulness, and has great psychological implications.

 Top Tweets of the Month

• Robert Butler PT PhD‏@rjbutler_dptphd - There is a stark difference between "doing corrective exercises" and normalizing a movement pattern. The goal is to keep the goal the goal.
• Scott Johnson, PT‏@PTnomad - If you're a PT and only do exercise with pt's, aren't you just an over qualified personal trainer? #manualtherapy
• Sarah Haag‏@SarahHaagPT - We don't assume 'head injury' when we have a headache... Why do we assume 'back pain' = 'back injury'? #Bronnie2015
• Michael J Mullin‏@mjmatc - Don't automatically attach strength principles to rehab. In rehab, less is often more...
• Aaron Swanson‏@ASwansonPT - Mindless exercise will soon become painful exercise. #BePresent #Feel

Gif of the Month

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

Coaching & Cueing (Part 2 - The Categories)

We need to first clarify an important concept before we go into coaching and cueing:

• NOT ALL MOVEMENT REQUIRES COACHING

To Coach or Not to Coach

If someone is performing a movement/exercise correctly, all you have to do is shut your mouth and smile.If someone is performing a movement/exercise incorrectly, you should ask yourself two questions:

1. Do they need a different environment via a sensory change/coaching and cueing?
2. Is this a professional error?  Is this the right exercise for this patient at this time?

So if someone can’t perform the deadlift correctly, they either need some coaching and cueing (a sensory change) or they need a different exercise.

3 Types of Coaching

I break down coaching into 3 different categories:

• 1) Verbal - External & Internal
• 2) Visual - External & Internal
• 3) Proprioceptive

Each of these categories are a change of the inputs from the environment.  Each section has a specific attentional sensory focus.  Below is a brief introduction to each type of cue.  For a more in depth look at specific cueing types, stayed tuned for Parts III-IV in this article series.

1) Verbal

Verbal cues are by far the most common and one of the most researched coaching cues.

External Cue

Focuses on how the body’s output affects the environment (outcomes, objects, etc.)

Internal Cue

Focuses on the body processes and internal systems (muscles, kinematics, pressure, etc.)

2) Visual

Visual cues are rarely discussed in the coaching realm.  However, there are some interesting concepts in this category that can have a huge impact on your clients’ movement.

External

Influences movement through visual input (visual field, objects, orientation, demonstrations, eyewear, etc.)

Internal / Motor Imagery

“Motor Imagery is defined as an internal rehearsal or reenactment of movements from a first person perspective without any overt physical movement. From another perspective, MI, also known as kinesthetic imagery, is an active cognitive process during which the representation of a specific action is internally reproduced in working memory without any overt motor output” -Carl Gabbard and Ashley Fox

3) Proprioceptive

Proprioceptive cues are very common in both rehab and training (whether the practitioner knows it or not).  It’s a common sense type of approach that can have more profound effects than any other sensory change.  These proprioceptive cues can be divided into MANY different sub-categories.

• Postures
• Load
• Speed
• External Stimulation (tactile, tape, surface, footwear, etc.)
• Regressions
• Progressions
• Lateralizations
• Modifications
• Modulations
• [Insert Latest Terminology]

 

Summary

Which type of cue the patient needs depends on many factors.  A greater understanding of each of these types of sensory changes will help one determine which one to use.  Keep the overall goal in mind and match your desired outcome to they type of cueing.And remember, if someone isn’t performing a movement correctly despite your coaching/cueing, you either need a different sensory change or a different exercise.

Coaching & Cueing

Part I - IntroPart II - The CategoriesPart III - Verbal Cues - ExternalPart IV - Verbal Cues - InternalPart V - VisualPart VI - ProprioceptivePart VI - Summary [subscribe2]

Coaching & Cueing (Part 1 - Intro)

My co-worker was on vacation recently and I was seeing one of his chronic pain patients (years of pain).  She was doing very well and was becoming independent in a full exercise routine.  I did a quick evaluation and noticed one thing that she could improve on from a movement perspective.  I didn’t use any dangerous pathoanatomical language.  I just simply pointed out that she could be stronger if she kept her rib cage down when she performed certain exercises.  We went over this cue a bit more with some basic proprioceptive exercises before she started her exercise program.About 20 minutes into her routine, she stopped and approached me.  I was worried she was going to complain of pain or be confused about the “ribs down” cue.  But instead she said with a smile, “you know, it’s nice to think about something other than my pain for once when I exercise”.As a physical therapist who works with people who have pain with simple movements, this was quite profound.I have been hearing from many professionals that external cues are far superior to internal cues.  Some people even go as far as saying you should never use internal cues.  However, this all or none approach doesn’t seem to be the case in the clinic. With this specific client, internal cues were beneficial on a few different levels.  So I wanted to dig in a little deeper and look at cueing from a different perspective.  I did some research and will summarize my findings in this series.

Disclaimer

Keep in mind this is from a physical therapist’s point of view.  The world of sports performance is always a hot topic.  The exciting things people are doing with professional athletes are always interesting and fun to integrate into rehab.  But what works for the NBA’s Lebron doesn’t always work for the AARP’s Betty.  Not everyone lives their life to improve their sports performance.  So keep in mind:

• Performance Training is a Luxury.  Movement Training is a Necessity.

Chronic Pain

Yes, this patient has been educated on pain science thoroughly, she has read books, watched videos, and has seen a psychologist for her chronic pain.  This post series will be focused on coaching and cues used for improving movement.  For more information regarding pain, I highly recommend starting with Adriaan Louw’s work and ISPI.

April Hits (2015)

Clinical

1) Lately, I’ve been interested in the connection between vision and the cervical spine.  Here’s two interesting articles I found this month.

“The direction of eye movements was horizontal when the sternocleidomastoidmuscle on one side of the neck and the splenius on the other side were activated, and downward when both splenii muscles were vibrated.”

"During neck rotation SCM and MF EMG was less when the eyes were maintained with a constant intra-orbit position that was opposite to the direction of rotation compared to trials in which the eyes were maintained in the same direction as the head movement."

I put people in challenging developmental positions and have them use their vision to either increase motion or to dissociate their vision from their cervical spine (changing muscle activation patterns).

2) Still don’t think vision and the cervical spine are related?  Check out this research article on vision, cervical rotation, and pain “When vision overstated the amount of rotation, self reported pain occurred at 7% less rotation than under conditions of accurate visual feedback, and when vision understated rotation, pain occurred at 6% greater rotation than under conditions of accurate visual feedback.”3) The sign of a great educator is someone that takes complex ideas and makes them seem simple.  Here’s the Great Cantrell teaching the importance of hamstring flexibility (must watch video - share with your peers)4) I like Kelly Starrett’s concept of the shoulder shelf.5) Here's best 20 second explanation of the ankle as a torque convertor.6) You’ve never head a physical therapist talk about wisdom teeth like this - “the maxillary (top side) wisdom teeth limit the excursion of my lateral pterygoids for lateral trusive movements” -Zac Cupples7) Erson goes over End-Range Loading and 4 reasons why it works.8) Seth O’Neil shares a great article on the soleus and it’s implications on achilles tendonosis.  Some gems:

“The actual forces it produces are around 8 times body weight.(5) In comparison the Gastrocnemius produces forces around 3 times body weight.”

“Gastrocnemius functions largely isometrically whilst the Soleus tends to function eccentrically”

“91% of symptomatic tendons have pathology in the medial part of the tendon- the part relating to Soleus.”

“Most runners with AT will need to use body weight + up to an additional 50-75%. Without this they will not be working at a high enough threshold to rehab to an eccentric strength of around 200% body weight (as shown to be the average for healthy runners).”

9) Here's some PRI magic using occlusion for hip flexor flexibility.  I would love to know what the treatment plan is with this guy.10) “One of the best ways to keep people motivated in activity is to find something that gets them into or close to their flow state where they are engaged.” -Gray Cook on his latest checklist and the Skill:Challenge Ratio11) Only Zac Cupples can make you think about where to sit during the evaluation - “Being to someone’s left could build a better emotional connection.”12) Erson goes over 5 More PT Myths.13) Mike Reinold shows you a simple accessory respiratory muscle assessment (inhale in cervical rotation).14) “Here we show that contrary to predictions from optimal control theory, habitual muscle activation patterns are surprisingly robust to changes in limb biomechanics.”15) Perry Nichelston teaches you some baby moves - unilateral crawl16) “Perhaps we need to think of extension as system closure; a system closing problem. Flexion will be the solution to open the system.” -Zac Cupples17) "Peripheral nerves require extraordinary mobility in relation to surrounding tissues, sometimes sliding up to 2 centimetres as we move." -David Butler18) Mike Reinold goes over some overhead shoulder mobility concepts.  I’ve written detailed articles on two of these concepts (scapula upward rotation & lumbopelvic/core).19) Allan Phillips has a great DNS Review -

“3month position is the “starting line.”  Lift legs off table and secure torso w/o deviation.  Starts with position at ribcage and pelvis.  If not optimal, load shifts to extremities”

“Main time to influence joint morphology is in first year of life”

“Deep neck flexors require stability of abdominal wall”

“Breathing is an expression of the nervous system”

“Abdominal wall contraction can prevent diaphragm from descending”

20) Erson collects advice from Mike Reinold, Barton Bishop, Chris Johnson, Chris Nentarz, and Charlie Weingroff.  Some great gems in there including: “In reality there are flaws in all of the different models of physical therapy. Don't get locked into one thought process or you'll spend more time defending your belief than allowing yourself to grow.”-Reinold |:| “You are only as good as your last injury and the extent to which you rehabbed it”-Johnson |:| “Anything can work for anybody, and nothing works for everybody.”-Weingroff21) Michael Mullins teaches you about Dennison Laterality Repatterning (here & here)22) Navin Hettiarachchi introduced me to this interesting toy for improving foot/ankle function - Cobblestone Mats.23) Kathy Dooley is one of my favorite anatomy teachers.  The “subclavius assists the scapular protraction executed by pectoralis minor and serratus anterior”.  It also has a close proximity to the subclavian vein and artery thus making it relevant for all distal structures via circulation/blood supply.24) Hamstrings

Mike Robertson goes over some injury prevention strategies here.

Harold Gibbons keeps it simple and effective here.

25) In PT school, I remember learning how to teach neck patients to stretch their “levator scapulae”.  In the clinic, I remember these patients coming back feeling much worse without resolving any of their dysfunction.  Cranking and pulling on the cervical spine isn’t a good idea.  A few may get a temporary relief, but this does not provide any permanent change in the tissues.  It doesn’t lengthen the "tight" muscles.  It just places a ton of stress on the delicate cervical spine.  Here is an alternative exercise for neck "tightness" that provides relief without excessive stress.

Clinical Question

26) Two of my clinical mentors are asking a good question regarding post-op knees.  Do femoral nerve blocks affect the patients ability to regain their quad strength after surgery?  Should they only be doing saphenous nerve blocks?  What are the risks and rewards?  If it's just for pain, is it really worth the risk?  Anyone that has any answers or opinions please leave a comment at the bottom of this post.

Pain & Neuroscience

27) Emotions control the volume of pain.  Here’s an article you can share with your patients.28) Radiolab Podcast has a great Placebo Episode.  It's an easy place to start for those that want to learn more about placebo effects and the processing component of the human body.29) Erson’s 5 Pain Science Rants30) Zac Cupples says Salient 21 times and discusses pain - “A salient input is necessary for an altered output.”31) I’ve been studying attention focus recently.  It’s pretty fascinating stuff.  Apparently other people think so too.

Here are 5 questions to ask yourself about attention that can have a profound affect on your happiness.

“Improving one's awareness of the blind spots can improve attentional focus and potentially optimize motor output without inducing a maladaptive response - such as pain, anxiety, excess muscular tension. Because the brain has already "been there" and explored the region, the sensory input (whatever the mode) is likely much less threatening to the system. “ -Seth Oberst with a great read on attentional focus

Chronic pain patients have difficulty switching their attention focus off of their painful body part.  Here's a great TED talk on attention and mindfulness from Catherine Kerr.

Training

32) Here’s a nice collection of some higher level foot stability exercises - I like the kettlebell swap idea.33) I like this idea of the Landmine Squat.  I found it helpful to pre-activate the anterior core.  Give it a try and see what you think for yourself.34) Dean Somerset goes over 5 Squatting Concepts 1) Pause Squats are Underrated 2) Most Squat Restrictions Are Not Muscular 3) Valgus Collapse is Less About Technique & More About Reaction 4) Long Torsos Are Better Than Long Femurs 5) Breathing Patterns Change with Load and Fatigue35) Some interesting PRI Golf exercises - I like the sidelying 45 degree leg lifts.36) Pavel’s 5 Ab Training Mistakes 1) Chasing the Burn 2) Not Focusing on the Contraction 3) Not Using Enough Resistance 4) Exclusively Isometric Training 5) Not Making Every Exercise an Abdominal Exercise37) Feel awkward with GMB.  Here’s their thorough tutorial on How to Planche.38) 5 Miguel Aragoncillo Tips 1) Use Discovery Learning 2) Reduce the Amount of Corrective Exercises 3) Know the Difference Between Blocked & Random Practice 4) Oatmeal 5) Band Love (including this great core engaged hip flexor mob)39) Pavel discusses rest intervals (ordinary, stress, stimulation) - “ if you are only practicing incomplete recovery between your sets of strength exercises, you will never achieve your potential”40) Dean Somerset shares a great modification to the side plank for those with shoulder problems.41) Loaded Carries may be the best abdominal exercise you’re not doing.42) Harold Gibbons shares some breathing based core exercises43) We all benefit when Eric Cressey writes articles to promote a product.  Tons of good stuff from him this month:

He take post-activation potential (PAP) and creates a system (Stage System) to improve your lifting performance.

The Split-Stance Anti-Rotational Ball Scoop Toss exercise.

“The lower the motivation of the exercising individual, the greater the need for randomness to keep exercise engaging. This is working out.  The higher the motivation of the exercising individual, the greater the need for repetition to deliver a specific physiological effect. This is training.” -Eric Cressey on Repetition vs Randomness

Build Multi-Directional Strength & Power.  Tons of exercise examples.

Solid Deadlifting advice.

15 Random Thoughts on S&C Programs

Slowing down the concentric - “taking 3-5 seconds to externally rotate the humerus during cuff work can prevent the deltoid or lat from taking over” -Eric Cressey

Research

44) This is a dead horse that can’t get beat enough.  “Asymptomatic shoulder abnormalities were found in 96% of the subjects”  Medical imaging is NOT the gold standard for movement, health, or function.45) The latest research in fascia “supports the multiple functions of the connective tissue matrix, combining strength and elasticity – biotensegrity – a word that describes ways in which the architecture of connective tissue cells – such as fibroblasts – respond to different degrees and forms of mechanical load leading to rapid modification of chemical behavior and physiological adaptation – including gene expression and inflammatory responses.”46) Found this entertaining.  Now you can tell your RTC tear patients that it happened because they’re fat!  But really, it has to do with hypovascular zones and cardiorespiratory efficiency.47) The Top 6 Recent Tendinopathy Papers (share with your peers - most people in medicine don’t know this stuff)48) “The infraspinatus muscle was found to be composed of three partitions: a superior, middle and inferior part were present in all muscles. In 62.5% of the muscles, full compartmentalization was established (i.e. a separate nerve branch entered all three partitions). It can be speculated that the different neuromuscular partitions correspond to different biomechanical functions of the infraspinatus.”49) Runners need Achilles Viagra #Stiffness50) Cuing for more knee flexion and less impact on single leg landing led to: increased knee flexion, decreased peak vertical ground reaction forces, and decreased co-contraction (quad & HS).  #ACL51) Chris Beardsley provides a thorough evidence-based review52) Chris Beardsley also has an equally thorough evidence-based review of the Glute Max53) “The study found that twelve weeks of sitting Tai Chi training could improve the dynamic sitting balance and handgrip strength, but not QOL, of the SCI survivors.”54) I heard Gray Cook talking about this years ago - if he was a hipster, he’d be saying he did it before it was researched.  “A simple beam-walking task and an easily collected measure of distance traveled detected differences in walking balance proficiency across sensorimotor abilities.”  #ResearchLagsClinicalExcellence55) “Surgical decompression yielded similar effects to a PT regimen among patients with LSS (lumbar spine stenosis) who were surgical candidates.”  Why choose PT?  One of the side effects of surgery could be death or paralyzation.

Other

56) An interesting way to use a Ladder by Kathy Bowman.57) The Obstetrical Dilemma - “The results show that pelvic width does not predict hip abductor mechanics or locomotor cost in either women or men”58) I’ve been learning some Traditional Chinese Medicine from our acupuncturist.  The Meridians can offer an interesting perspective.

 Top Tweets of the Month

• Seth Oberst‏ @SethOberstDPT - The meaning of sensory information to the brain is much more important than the volume of the inputs
• Charlie Weingroff‏ @CWagon75 - Long term health and maximal performance in a strength sport are fairly exclusive. You can't have both.
• FMS‏ @FunctionalMvmt - We want trainers and rehab professionals to approach their work like Pandora does music: listen to the patterns and refine the information.
• Robert Butler PT PhD‏ @rjbutler_dptphd - FMS is not a treatment model. SFMA is proper treatment model that fits w PRI, DNS, astym, etc
• Sam Yang‏ @allouteffort - Health is first and foremost a mental and attitudinal change.
• Zac Cupples‏ @ZCupples - Claiming to ever have similar baseline characteristics among groups or individuals in research is a myth. #everythingmatters #alwaysnof1
• Aaron Swanson‏ @ASwansonPT - If they can't feel it, they can't control it.

 Gif of the Month

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

March Hits (2015)

Clinical

1) There’s a weird campaign by some Hipster PTs who are arguing that posture isn’t important.  Maybe they’re doing it for social media popularity.  Maybe what they’re really trying to say is that we shouldn’t create thought viruses.  Maybe what they’re saying is that we shouldn’t blame all of our patients' problems on a static postural assessment.  Maybe they don’t understand that posture is a biobehavioral pattern.  Regardless of their underlying point, dogmatically saying posture doesn’t matter is like saying physics and physiology doesn’t matter.2) “From a sensory perspective, moving fast has a lot of sensory noise - it's loud…By lowering the magnitude of the sensory stimuli, we can better perceive excessive muscular rigidity and help to regulate it.” - Seth Oberst3) “The 90-90 hip lift says that the pelvis is too far forward, especially on the left and we would like to put it back to a neutral position and we are going to use a couple muscles to keep it there” -The Nominalist4) Here’s a list of some DNS based exercises.5) A Therapeutic Alliance as "a trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect."  |:| “Quite a bit of literature links a trusting therapeutic relationship to superior patient outcomes”6) The squat is a very trendy social media topic.  Which leads to a ton of people discussing it with a black and white approach.  And someone always has the newest way to squat better or the real reason you can’t squat well.  Tom Purvis goes over the gray of squat biomechanics and body proportions.  One of the best explanations out there.  7) Here's some easy to read pain science analogies and the weighted sleeper exercise for shoulder internal rotation by The Nominalist8) “In most cases, the perception of tightness is just that, only a perception.” -Erson9) “Every exercise is an assessment. Each time your clients and athletes move, they're providing you with information. The more you pay attention, the better you'll be able to individualize their programs and coaching cues moving forward.’ -Eric Cressey goes over 10 assessment tips10) Pelvic floor, breath holding, and crossfit.  “Lifting with a belt also increases the IAP by bracing the back, sides and front of the abdomen…but what about the top (diaphragm) and bottom (pelvic floor) of the abdominal canister? What often happens is that the very strong diaphragm can hold its own and so the pressure gets directed downwards into the pelvic floor.”11) Mike Robertson shares his 3 Safe Shoulder Exercises12) Inside the Mind of Charlie Weingroff (Random Thoughts #2)

• "Screening generally with unlearned movements first will allow for a more organic appraisal of joint position, which is all any movement screen should be judged against."

• "Testing with another series of movements very different from your training but requiring the same “bucket” of movement qualities is likely far more indicative of general motor skill acquisition."

• "One of the summary interpretations that I have made is that for balanced joint position with ideal co-contraction to be achieved, we require full non-threatened joint motion in all planes and vectors."

• "Develop motor skills and fitness simultaneously with carry over to terminal athletic goals"

• "Can you have any kind of legitimate grip without a particular centration of the scapula and t-spine?"

13) “The craniocervical region is incredibly mobile for a reason. That reason is to create precision for our sensors: vision, audition, olfaction, respiration, and vestibular sensation. This precision occurs reflexively, whereas other appendages act proprioceptively.  These sensors drive the neck. Losing the ability to sense is what can increase the need for a neck to become stable. And when you can’t move a stable neck, teeth may be one thing you try to use.” -Zac Cupples with a great article on the cervical spine, occlusion, and the girl he wants to marry14) "When a patient cannot move properly without pain, paraesthesia, or perception of stretch, and a manual technique is performed, we are really modulating that perception." -Erson Religioso15) The Foot Core System - a great read on foot function, evolutionary adaptation, and intrinsic foot assessment & treatment.  An important read for anyone that works with people that have feet.16) Erson shares 2 studies on the importance of vision with cervical patients.17) Louis Gifford’s Mature Organism Model really laid down the blueprint for how I view my patients (inputs, processing, outputs).  Zac Cupples shares his interpretation of this model, jokes about your mom, and lays out a way to influence this system.  A great read that everyone can relate to.18) “When we’re going to move, it’s very biologically important to be engaged in our movement.  If we look at the natural environment around us, animals are 100% engaged in the moment and in their current activity.  When we have two electronic devices on our hip just so we can run—one so we can text and the other so we can listen to music—I’m not sure that many of the lessons that running in the environment could teach us are even accessible.” -Gray Cook19) “What’s the point of asking an athlete to commit an hour a day to more efficient movement if you're not going to address the four hours per day they are reinforcing an unhealthy movement?” -Lee Burton on texting posture20) Erson reviews SFMA 2.  “you can ride a bike after not doing it for 10 years, but can you still do calculus?”21) 7 Reasons to Goblet Squat from the Nominalist 1) Comfortable Hips Below Knees 2) Opens Up Areas that Stretching May Not 3) Increases Hip Capsule ROM 4) Exposes Foot/Ankle Weakness 5) Pelvic Floor Alignment 6) Easy to Reproduce Independently 7) Helps to Isolate the Shoulder22) Shameless Self Promotion - I agree with John, it’s a lot easier to put people in positions where they can’t compensate instead of using 17 different verbal cues.  Sometimes I use the same concept for overhead movements - the deep squat locks out the lumbar spine and prevents a compensatory rib flare.23) It’s important to remember that the human body is an adaptation machine.  If you play basketball 3 times a week, it will adapt to handle those loads (assuming graded exposure).  However, if you only play basketball every several months, the body will not be adapted to handle those loads.  Injury risk and pain are potential outcomes.  Brian Reddy discusses this concept in this article - “Soreness is a sign of working your body in a way it’s not used to.”  Educate your patients.24) Another great post from Zac Cupples.  You might have a different view of the Thomas Test after reading this one.25) Ron Hruska describes my NYC patient population.26) I was having some difficulty determining the driving force of the pes cavus foot type.  Specifically I wasn't confident whether it was a plantarflexex forefoot or a rearfoot varus.  Dr. Suzanne Fuchs pointed me towards the Coleman’s test (5 min into this video).27) Loukia Lili is getting treatment from the cueing master, Mike Cantrell.  Here are 4 videos using PRI and some solid coaching to ensure proper muscle activation (1, 2, 3, 4).28) Dennis Treubig shares 5 things he wishes he would have learned in PT school 1) Treatments aren’t very specific 2) A movement assessment system is important 3) Modern Pain Science 4) How to pick CEU courses 5) Medical imaging is clinically irrelevant 29) One thing I wish we would have learned more about in PT school is psychology.  It’s such an important component that was not covered well in school.30) "attempting to achieve sufficient dorsiflexion through the combined ‘foot pronation-ankle dorsiflexion’ mechanism, as opposed to just dorsiflexion from the ankle mortise joint alone, may change the dynamics of the entire limb…. in this case, hip flexion range observation. Is this because when dorsiflexion is cheated via foot pronation, instead of just ankle dorsiflexion, there is more internal tibia/femoral spin than would normally occur from just sagittal ankle hinging which can in turn impair terminal hip flexion range via impingement type action ? I think so. It would be cool to see what would have happened in the study had the pronating clients been shown my foot tripod restoration exercise.”   -Dr. Allen

Pain

31) “when I can’t find something physically stopping you from doing something, I have to help you get back to normal by using graded exposure (CBT techniques) and explaining pain to you” -Antony Lo31) Kento Kamiyama discusses the lion-pain metaphor.  “The adrenaline rush is a normal response and once the lion goes away, everything returns back to normal.   However, when it is prolonged the body starts using cortisol instead of adrenaline.  Cortisol is a more potent and longer lasting chemical to deal with longer lasting threats.“32) What your adrenal glands really looks like.33) Sometimes new terms are created for self-promotional reasons or for the sake of argument.  Many times I find this trivial - we often waste too much time on semantics.  However, when new terms are created for educational purposes it can be powerful.  NOI recently released a new book to help patients understand pain.  They created the terms DIMs & SIMs (Danger In Me & Safety In Me) - “This is a reminder of the power of context.”34) “Social context matters. It can affect our learning processes, and does so also in the context of pain. While we can only speculate about the underlying mechanisms at this point, it seems plausible that a threatening environment (be it social or not) could facilitate the rapid distinction between threat and safety”-Kai Karos

Training

35) Pavel teaches you why and how to build your slow fibers (1, 2, 3, 4)36) Eric Cressey goes over 7 Thoughts on Speed, Agility, & Quickness Training.  “Understanding what "normal" looks like is important, but don't think "abnormal" is necessarily always inappropriate.”37) Mike Reinold shows you how to prep for throwing - Part 1 & Part 238) 4 Reasons Why You Should Bear Crawl 1) Anit-Extension 2) Reaching 3) Breathing 4) Dynamic Exercise39) Bret Contreras lays out specific plan to build stronger glutes and goes over specific approaches for different populations (powerlifters, bodybuilders, crossfit, beginners, etc.).40) Cressey Coaching Cues 1) Create a Gap 2) Don’t Let the Plate Fall 3) Don’t Break the Glass41) Shante Cofield shows you how to instantly improve mobility - Shoulder Flexion, Functional Internal Rotation, Elbow Flexion, Hip Flexion41) Eric Cressey shares some tips on long-term development for young athletes.42) 5 Reasons Why Your Squat is Difficult 1) Too Much Knees 2) Poor Anterior Core 3) Hyperextension 4) Wrong Squat Type 5) Not Taking Advantage of Irradiation

Research

43) Why kinesiotaping works? Neuromodulation.  A fancy term that just means we're changing sensory input in attempt to change the way the brain processes information.44) John Snyder goes over scapula strengthening exercises through a EMG lens (Part 1 & Part 2)45) “hyaluronic acid (HA) – the key lubricant in the sliding function of fascial layers – lies at the heart of the problem” - Leon Chaitow 46) If you breathe bad, you’ll move bad.  A good read on the FMS and breathing.  “These results demonstrate the importance of diaphragmatic breathing on functional movement. Inefficient breathing could result in muscular imbalance, motor control alterations, and physiological adaptations that are capable of modifying movement.”47) There’s a lot of great work being done on tendinopathies.  Please share this study with your peers - too many people in the medical field are only using eccentrics.  “There is little clinical or mechanistic evidence for isolating the eccentric component”48) If you only practice evidence-based medicine, you are almost 2 decades behind!  “Studies have shown that it takes an average of about 17 years for new knowledge generated by randomized trials to be incorporated into practice.”49) If you’re into injury prevention, you should also be into fatigue prevention “Following a fatiguing exercise protocol, participants showed increased anterior tibial translation, compressive force, and knee flexion range of motion during the transition from non-weight-bearing to weight-bearing. This illustrates an inability of the lower extremity muscles to stabilize the knee joint.”50) A sensorimotor approach to Chronic Ankle Instability - “The STARS interventions include ankle joint mobilization, plantar massage, and triceps surae strengthening.”51) A great read on proprioception and body awareness.  Tons of great references throughout.52) You can explain this with basic biomechanics, physiology, breathing, DNS or PRI philosophies, or just common sense - standing with excessive lumbar lordosis isn't the best posture for your back.

Other

53) “When individuals speak slowly and clearly, they tend to sound more credible than those who speak quickly.”54) Phrenology is interesting. 55) Todd Hargrove’s post on what we can learn from robotics.  “A big part of motor intelligence lives in the “design” of the passive elements of the motor control system – the bones, fascia, tendons, connective tissue, etc. When the passive structures are optimally designed (by natural selection) for a certain task, the muscular and neural systems don’t have to work very hard to produce optimal movement patterns.“56) Stress, Homeostasis, Allostasis and the Bank Account analogy by James Cerbie57) Some nice example dialogues to help change patient behavior from Erson58) “Titin, however, seems to be an essential missing link in how muscles actually work.” -Jules Mitchell59) A Solid Read on Tensegrity by Donald E. Ingber

• “There my studies of cell biology and also of sculpture led me to realize that the question of how living things form has less to do with chemical composition than with architecture.  The molecules and cells that form our tissues are continually removed and replaced; it is the maintenance of pattern and architecture, I reasoned, that we call life.”

• “changing cytoskeletal geometry and mechanics could affect biochemical reactions and even alter the genes that are activated and thus the proteins that are made.”

• “At the Johns Hopkins School of Medicine, Donald S. Coffey and Kenneth J. Pienta found that tensegrity structures function as coupled harmonic oscillators. DNA, nuclei, cytoskeletal filaments, membrane ion channels and entire living cells and tissues exhibit characteristic resonant frequencies of vibration. Very simply, transmission of tension through a tensegrity array provides a means to distribute forces to all interconnected elements and, at the same time, to couple, or "tune," the whole system mechanically as one.”

Top 8 Tweets of the Month

• Charlie Weingroff‏ @CWagon75 - To suggest SMCD, TED, and JMD are the same is awful. The CNS put them there, but it will be wildly different approaches to get them removed.
• Doug Kechijian‏ @greenfeetPT - "Tricking" the nervous system is ok provided you exploit that neurological window of opportunity by applying the right stressors afterwards
• What The Foot‏ @AnatomyMotion - If it extends, flex it, and if it flexes, extend it! #WhatTheFoot
• Anthony Donskov‏ @Donskovsc - "The less you know, the more opinionated you are." -Buddy Morris
• Mark Reid, MD‏ @medicalaxioms - A little extra diagnosis or treatment can get you into a lot of trouble.
• Seth Oberst‏ @SethOberstDPT - It’s all about pattern recognition - the human brain is really adept at it provided we’re aware and present in the moment
• Michael J Mullin‏ @mjmatc - Conscious awareness before subconscious competency = You have to learn it before you can own it
• Aaron Swanson ‏@ASwansonPT - The answer to a question should be followed by another question. #ThereIsNoFinalAnswer #DigDeeper

Gif of the Month

               --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]

My Secret Acupuncture Experiment

I ran a secret experiment on our acupuncturist, Mila Mintsis.But before I go into the details, it’s important to know a few things about the human body.

4 Facts to Know

1) The nervous system controls the way we move (muscles are just the “puppets”)2) The autonomic nervous system has a huge influence on our movement

• Sympathetic = tightens muscles for fight or flight, can increase pain

• Parasympathetic = relaxes muscles for rest and relax, can decrease pain

3) Sympathetic Activity EXTENDS our body

• Too much sympathetic activity tightens our big muscles (global mobilisers)

• Puts us in a High Threshold Strategy

• This can lead to back pain, tight calfs, hip pain, shoulder pain, neck tightness, etc.

4) A simple an easy test for the nervous system is a toe touch

• If you can’t touch your toes, one of the culprits could be too much sympathetic nervous system activity - thus too much extension and muscle tightness (muscle tone)

My Experiment

I simply assessed the subject's toe touch before and after acupuncture.I didn’t want Mila to know what I was doing.  I wanted her to be “blind” to the experiment.  She could have easily used Acupuncture to loosen specific muscles and increase range of motion.  To get an unbiased result, she couldn’t even know I was doing an experiment.After acupuncture the subject had a dramatic improvement in his toe touch and a significant decrease in his perception of tightness.How did this happen?  Mila didn’t perform acupuncture with the intention of improving his toe touch.  So there is no kinesiological or mechanical explanation.  What it comes down to one of the most beneficial side effects of acupuncture - decreased sympathetic activity and increased parasympathetic activity.  Less stress, more rest (for the brain and body).  Just after one session, the tight extensor muscles were calmed down, the autonomic nervous system was more balance, and his movement significantly improved.

References

Li, Qian-Qian, Guang-Xia Shi, Qian Xu, Jing Wang, Cun-Zhi Liu, and Lin-Peng Wang. "Acupuncture Effect and Central Autonomic Regulation."Evidence-Based Complementary and Alternative Medicine 2013 (2013): 1-6.Andersson, S., and T. Lundeberg. "Acupuncture — from Empiricism to Science: Functional Background to Acupuncture Effects in Pain and Disease Pain and Disease." Medical Hypotheses 45.3 (1995): 271-81Frank C, Kobesova A, Kolar P. “Dynamic Neuromuscular Stabilization & Sports Rehabilitation”. International Journal of Sports Physical Therapy 2013;8(1):62-73.Porges, Stephen W. The Polyvagal Theory: Neurophysiological Foundations of Emotions, Attachment, Communication, and Self-regulation. New York: W. W. Norton, 2011.Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010.Thelen, Esther. "Dynamic Systems Theory and the Complexity of Change."Psychoanalytic Dialogues 15.2 (2005): 255-83.Postural Restoration Institute - video on extension  [subscribe2] 

February Hits (2015)

Clinical

1) I first learned about the relationship between the pelvis and hip ROM from Chris Johnson - you can instantly increase hip IR on the table by having the patient posterior pelvic tilt.  Then upon studying the concepts of SFMA, DNS, and PRI, I began to understand how the pelvis (as well as diaphragm/thorax/spine) influences the hips.  Now I understand that most hip impingement patients are really pelvis patients, not femur patients.  Mike Reinold wrote a concise and simple post on this concept here.2) The Gait Guys go over the objective hallux valgus assessment and ways to treat it.3) Here’s a great 3 minute video that goes over both the cause and treatment of tendinopathies.4) There’s a lot of discussion on the thoracic spine, rib kinematics, breathing, and shoulder function.  The Nominalist goes over one of the more important aspects of this kinetic chain - Posterior Expansion.  It’s an important post for all clinicians (PRI inspired, but discussed in a way that everyone can understand it).5) Another great running post by Tom Goom.  This article includes a great graphic on the Foot Strike Continuum and some advice on changing mechanics - “In a nutshell what I’m saying is if you want to change footstrike, make a small, manageable change by adjusting stride frequency and stride length, rather than switching footstrike altogether. Increasing stride frequency by as little as 5-10% can significantly reduce loading while having minimal negative effects on performance.”6) I’m sure Eric Cressey is having a big “I told you so” moment…”In conclusion, shrug exercises at 90° or 150° of shoulder abduction angle could be advocated to activate scapular upward rotators, decrease SDRI, and increase CTA in individuals with scapular downward rotation impairment.”7) The Kitchen Sink - neuro-modulation techniques, compression wrap, corkscrew, pre-activation, synergistic muscles...Erson’s take on the ASLR Fix.8) The Nominalist dissects shoulder traction exercises (hangs, farmer’s walks) and gives you a ton of ways to use them with your patients.9) Here’s a great post by Dave Tilley on alternative reasons for hip flexor “tightness” (Part 1, Part 2, & Part 3). The List - Guarding for Instability, Breathing Dysfunction, Too Much Sympathetic Drive, Dysfunctional Core, Poor Motor Skills, Lifestyle, The Other Planes of Hip Motion10) Erson has an MDT cervical clinical pearl - retraction and sidebending for a quick assessment.11) Congratulations to Zac Cupples on becoming PRC.  He is one of the best resources for PRI information.  His summary on advanced integration including this gem “When exhalation occurs, exoskeletal stability increases and chamber pressure decreases.”12) A clinical example of using MDT both distally and proximally for a chronic ankle sprain.13) Maybe the thoracic smash isn’t the answer to all T-Spine issues.  “So, maybe the ‘stiffness’ we feel, at least in a proportion of our patients, is not truly articular in nature, but rather, a reflection of the increased resting tone and dominance of the global muscles of the thorax (which also connect to the scapula, humerus, lumbopelvis, and neck) that creates neuromyofascial compression of joints of the thorax.” -Linda-Joy Lee14) 8 Reasons Why You Shouldn’t Release the Psoas15) Lance Goyke has a 4 part PRI Advanced Integration series (Part 1, Part 2, Part 3, Part 4)16) 2 Great Quotes from Gray Cook - “If you think about it, the SAID principle (Specific Adaptation to Imposed Demand) can be divided right down the middle with specific adaptation being the role of the organism and imposed demand being the role of the environment.”  |:|  “If you’re disengaged or detached from the activity you’re doing, you cannot get into a flow state.  Flow is where records are broken and the intrinsic value of movement can be realized.”17) Here's my review and interpretation of Andreo Spina's Functional Range Release.  It includes an argument for histology, mechanotransduction, dynamic systems theory, why isometrics are the best, and many clinical pearls from Spina.18) Don’t let the arms internally rotate and adduct during the wall slide - via Eric Cressey19) Dynamic Valgus probably isn’t an adductor problem.  A long, interesting read that breaks down the adductor kinesiology, goes over valgus culprits (excessive tibial ER), has visual examples of common compensations, and explains why you shouldn’t do the split stance adductor mobilization.20) Why only kill 2 birds with 1 stone when you can kill 5?  One of my favorite all encompassing “shoulder” exercise.21) Good review of 5 Aspects of ITB Syndrome- 1) Direct Attachment 2) Indirect Attachment 3) Movement Culprit 4) Femur Centration 5) Morphology22) Ischial-femoral impingement.  Never heard of it?  Me neither.  Read this post by the Gait Guys to immediately improve your assessment.23) Leon Chaitow reminds us of the adverse effects of respiratory alkalosis.24) Kathy Dooley goes over the functional anatomy of the QL.  “It’s tight because you’ve lost spinal stability in flexion. Stretch the QL without providing stability, and it will backfire by making itself even tighter...The opposite is true in extension intolerance. The QL is primarily a tonic back extensor and often a pain generator in those who tend to extend too much through the lumbar spine.”25) 3 ways to get out of high-threshold system from Seth Oberst: 1) Optimize Breathing 2) Balance the ANS 3) Go Slower26) If you’re unfamiliar with the high-threshold concept, check out an article I wrote a few years ago describing the difference between Low and High Threshold Strategies.27) Kegels vs. Squats “Teaching women to consciously integrate the pelvic floor into the squatting action to a depth that they can control their form and not tuck under, will retrain the optimum length and function of both the pelvic floor and glutes. I like to teach women to open and lengthen their pelvic floor with an inhale as they lower into the squat, and exhale with a pelvic floor lift as they rise. To me this is the blend and the best of both worlds.” - Julie Wiebe28) Dana Santas goes over Yoga for Athletes (it’s not about stretching) - “Incorporate core and pelvic floor work to inhibit back extensors.”29) A simple shoulder dissociation assessment and xiphoid cues from the Nominalist.  “ ...‘move the top of your sternum back and up behind your ears‘. The chin tuck move will quickly fade out of your vocabulary...”30) I wish I would have heard this before my first PRI course “If we are hyperinflated in particular areas (think left chest wall), how can we expect to go to the left side? Left space is already filled with air. Airflow must be transferred to the right side in order for us to maximally close down our left. Maximal left sided closure via a zone of apposition is necessary to create true left stance.”-Zac Cupples with another great PRI post - this time on PRI Integration for Baseball31) Erson's 5's

Erson shares his Top 5 Online Resources.  He also gives a shout out to some other blogs as well (thanks Erson!)

Erson shares his 5 Favorite Anke Resets - repeated ankle plantarflexion, repeated hallux flexion, tibial IR mob, repeated tibiotalor lateral glides, sciatic neurodynamics/posterior chain

5 Easy Screens from Erson: 1) Cervical Retraction & Sidebend 2) Terminal Knee Extension 3) Shoulder Extension 4) ASLR/PSLR 5) ½ Kneeling Dorsiflexion

One of my favorite posts of the month - Erson goes over his thoughts on 5 Common Treatments.  A great breakdown of how things really work.  Well worth the read.

Pain

32) “Perhaps, though, this is exactly what we do when we identify hyperalgesia: we assume that we know how much pain the person should be feeling – a questionable assumption in itself.” |:| “At this point we must ask for clarity on the distinction between central sensitisation and a lowered pain threshold to a given stimulus: what is the difference? To me, it seems clear that a lowered pain threshold is a clinical finding, whereas (in Woolf’s view) central sensitisation is one of two mechanisms that could underlie that finding. Peripheral sensitisation is the other option; if that can be ruled out, then the patient’s lowered pain threshold is probably due to central sensitisation.” -Tory Madden33) Another great read from Todd Hargrove - “Dogs will eventually stop drooling if you ring the bell enough times without bringing dinner. And people can hopefully extinguish their association between pain and a movement by finding a way to move without pain.“34) Greg Lehman shares a Pain Science Workbook for patients and therapists - you can download it or send it to patients.

Training

35) The LATD (Long Term Athletic Development) seems like a well articulated program36) Some solid, simple, coaching cues from Eric Cressey37) “In order to master anything, you must study, practice, experiment, and evaluate.” -Greg Robins38) Mike Robertson shares his in-season training pearls.  1) Don’t Make Them Sore 2) Consolidate Stress 3) Keep Everyone Fit39) GMB goes over some exercises for foot motor control, strength, and mobility.40) If you are into human movement, you must know about Pavel Tsatouline.  Learn more about Pavel in this great Tim Ferris Interview.41) 5 DNS Warm-Up Exercises42) “If you’re looking for smashing heavier weights in something like a deadlift or a squat, using a fast, plyometric type jump activity immediately prior may be beneficial. If you’re looking to sprint or produce maximal velocity contractions, using some relatively heavy loading with a focus on the hardest contractions against the load could be beneficial.”  -Dean Somerset43) Another entry point for squatting - “Consider adding the bottom-up approach one leg at a time.”44) “a single bell forces you to constantly work hard to fight rotation and prove you are stable and in control” -Andrew Read 45) Mike Reinold brings up a good point about progressing core training from isometrics (minimal spinal motion) to concentrics/eccentrics (lots of spinal motion).46) What do you think about the “valgus twitch”?  The valgus twitch is transient knee valgus that occurs in advanced lifters during deep squats (see Crossfit Games for a good example).  Bret Contreras goes over this mechanism in this post.47) The Runners 3x3 by Chris Johnson48) A great quick and easy read on energy systems.49) GMB categorizes different types of Body Weight Movement Approaches50) Here’s a great post on building the braking system.  Tons of great progressions for your lower extremity patients/clients.

Research

51) VMO or Hip Strengthening for PFPS?  Bret Contreras writes a great article to display the importance of focusing on the question instead of trying to find articles that support your stance (confirmation bias).  Everyone should take a look at this one.52) A 2 sentence review of the Polyvagal Theory by Jesse Cullen-DuPont - “Brain detecting threat - yes or no. Remaining outputs follow suit.”53) “Deficits in sensory and motor systems present bilaterally in unilateral tendinopathy. This implies potential central nervous system involvement. This indicates that rehabilitation should consider the contralateral side of patients.”54) I’ve had patients come in and claim that Crossfit cured much of their pain.  Here’s a study that might suggest why - “An LMC (low-load motor control) intervention may result in superior outcomes in activity, movement control, and muscle endurance compared to an HLL (high-load lifting) intervention, but not in pain intensity, strength, or endurance.”55) Post-surgical extremity patients should be exercising the non-involved side.  Here’s why.56) “Take Home Message: There are many clinical special tests geared towards diagnosing labral tears and femoroacetabular impingement.  Unfortunately, these tests are largely not helpful in confirming the presence of the pathology in population that is likely to have either.”57) Strength wins again.  “weaker athletes displayed more asymmetry than stronger athletes”58) An interesting read on DOMS and what really helps (Yoga and Whiskey) - “Lactate and muscle soreness are not related.” -Jules Mitchell59) “Thus, the 4-week 15:15 MVO2 kettlebell protocol, using high intensity kettlebell snatches, significantly improved aerobic capacity in female intercollegiate soccer players and could be used as an alternative mode to maintain or improve cardiovascular conditioning.”60) Research subjects suppress immune responses using physical conditioning.  “You can’t understand immunity without understanding its neural regulation” -Kevin Tracey61) "New research into the way in which we learn new skills finds that a single skill can be learned faster if its follow-through motion is consistent, but multiple skills can be learned simultaneously if the follow-through motion is varied.  “Since we have shown that learning occurs faster with consistent movements, it may therefore be important to consider methods to reduce this variability in order to improve the speed of rehabilitation,” -Dr. Ian Howard

Other

62) “During hopping or jumping muscle fibres contract almost isometrically, while the fascial elements lengthen and shorten like elastic yoyo springs.” -Leon Chaitow63) The ultimate collection of articles, videos, and blogs for Pelvic Floor Anatomy.64) “Epigenetics and deep homology are two sides of the evolutionary coin. Epigenetics helps explain rapid evolutionary changes and highlights the role environments can play in genetic health. Deep homology reminds us of our ancient origins and the glacial pace at which much evolutionary change occurs.” -Zoobiquity65) The Evolution of the Gluteus Maximus by Eirik Garnas.

Top 5 Tweets of the Month

• TheLeakeyFoundation‏ @TheLeakeyFndtn - "Medicine without evolution is like engineering without physics"
• Doug Kechijian‏ @greenfeetPT - Too bad insurance doesn't cover "fitness" training. For some, just getting stronger is the best rehab.
• Neil deGrasse Tyson @neiltyson - Good education is not what fills your head with facts but what stimulates curiosity. You then learn for the rest of your life
• Christopher Johnson‏ @chrisjohnsonPT - The term "RECOVERY RUN" is an oxymoron. It's called WALKING #RunningRules
• Aaron Swanson‏ @ASwansonPT - There are some things you cannot learn from a book, research article, or lecture. There are some things you can only learn from a patient.

Gif of the Month

              --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, 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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Andreo Spina's Functional Range Release

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

Andreo Spina

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

Bringing it Back to Histology

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

What Are We Really Feeling?

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

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

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

Assessment / Approach

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

• Articular DOF = Nervous System DOF = Movement DOF

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

Don’t Hang Up

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

Isometrics

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

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

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

Guiding Soft Tissue Remoulding/Healing

Does not intend on expanding range

Low level, frequent contractions

PAILs II (Expand Range of Motion)

2 minute passive, direction specific stretch

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

PAILs III & RAILs (Expand ROM & Training Stimulus)

2 minute passive, direciton specific stretch

Ramped isometric contraction with 100% effort (longer duration)

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

Followed by another deep, passive stretch (and repeat)

Anatomy Pearls

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

• Levator Scapula is medial on the neck

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

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

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

• The subscapularis tendon becomes transverse humeral ligament

• The long head of the triceps becomes the inferior labrum

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

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

Randoms

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

• Muscle responds to NS quickly

• Connective Tissue responds to longer force inputs

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

• Load > Capacity = Injury

• Load < Capacity = Rehab

• Capacity >> Load = Prevention

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

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

• Joints maintain their health with movement

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

• OA occurs from lack of motion

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

• Opening is normal, tissues have to adapt

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

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

• “Changing posture is about habitual cueing”

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

Bottom Line

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

Dig Deeper

Cellular/Histological/Bioflow

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

Motor Control/Dynamic Systems

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

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

Fascia/Tensegrity

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

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

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