Professionals

November Hits (2015)

Clinical

  • "Knowing how to think empowers you far beyond those who know only what to think." -Neil deGrasse Tyson

1) Great stuff from David Butler.  He goes over tennis elbow and shares several manual and exercise treatments.  A very generous post.2) “Overextension refers to not just a position of one or more joints, but also a state of mind." -Michael Mullin3) Great post by Sian on patella tendinopathy.  This article seems to cover all the current concepts with a clinical perspective.4) The tongue is more important than you think.  “When the teethers restricted movements of the tip of the tongue, the infants were unable to distinguish between the two “d” sounds. But when their tongues were free to move, the babies were able to make the distinction.”5) “The key factors in the onset of tendinopathy appear to be repetitive energy storage and release, and excessive compression. The key word here is compression, not tearing in the collagen.”6) Great article summarizing exercises benefits on the brain "The fact that physical activity benefits both gray and white matter is the primary reason that exercise is the No. 1 way to keep your brain young"  #ExerciseIsMedicine7) Todd Hargrove always puts out good stuff.  Here's his latest tactful article on "tightness" - "So tension is not a threat, but the absence of adequate rest or blood flow is a threat, which could cause metabolic stress and activate chemical nociceptors. So the problem that a feeling of tightness is trying to warn us about is not the existence of tension, but the frequency of tension or the lack of blood flow (especially to nerves, which are very blood thirsty.)"8) It's complex. Erson gives a brief example on the ecosystem of patients. For a more in-depth understanding check out these two articles. #Variables9) “Tall-kneeling hits ‘save’ on the document of thoracic spine mobility and hip extension. Half kneeling hits ‘save’ on the document of the 3-D hip and the ankle. Both add integrity to the lumbar spine. Half kneeling adds integrity to the knee by keeping that knee tracking over the foot and training that in your warm-up so that you don’t have to think about it when you’re doing lunges or split-stance work.”10) A simple and concise post on returning to athletic activities (running) by Chris Johnson.  Take 2 minutes and read this one.11) This is an interesting neurological (Arthorkinetic Reflex) trick from Z-Health: compress a joint to inhibit, distract a joint to facilitate.

Here are some examples (neck, back/pelvis, cervical/thoracic, hip, shoulder, elbow, ankle, weird stuff)

Seems similar to Andreo Spina’s CARs, but with a different intention

As with any neurological change, the questions are: how long does it last? how do you make it last longer?

12) Zac shares some info from the Omegawave course including some training recommendations13) More great stuff from Charlie Weingroff. It's great that he shares his thoughts to make everyone better. "Sleep is when motor skill acquisition goes from adjustment to adaptation. If you can’t control sleep, I don’t know that motor skill acquisition is a great idea that day. Instead getting after a fitness or pain quality passively is better suited to that day."14) Charlie mentioned Bosch exercises.  I had no idea what they were.  Looked it up to find out more (here & here).  Seems like it’s based on dynamic systems theory, specificity of training, stiffness, and adequate muscle isometric to take advantage of elastic properties of tendons (no muscle slack).15) "Almost any amount and type of physical activity may slow aging deep within our cells, a new study finds. And middle age may be a critical time to get the process rolling, at least by one common measure of cell aging." #ExerciseIsMedicine16) Share this easy read on the importance of strength with your patients. "In other words, the greater your muscle mass, the lower your risk of death," concluded Dr. Karlamangla"

Pain & Neuroscience

  • "Everytime we choose safety we reinforce fear"

17) Here’s a great interactive lesson on exposure therapy, pain connections, conditioning, and neuroscience.  It’s presented in a way that can help people understand why they have pain in certain situations.18) "the nervous system subconsciously monitors energy use and continuously re-optimizes movement patterns in a constant quest to move as cheaply as possible"19) "This study is the first to show that mindfulness meditation is mechanistically distinct and produces pain relief above and beyond the analgesic effects seen with either placebo cream or sham meditation"20) "The current study supports a bidirectional temporal association between depression and fibromyalgia such that each disease occurring first may increase the risk of the other subsequently." You mean it's not just myofascial trigger points and peripheral hypersensitivity?  #Variables21) "When you change your beliefs about a situation, your brain changes the emotions you feel."22) A good argument for why healthcare providers should learn a Cognitive Behavioral Therapy - "I think health professionals who see people are probably exerting greater influence over thoughts, beliefs and emotions than many of us acknowledge. And given that’s the case, I think it’s only ethical to learn to craft that influence in ways that are positive rather than inadvertently doing harm because of ignorance."

Attention Focus & Awareness

23) "And that's what we're doing in treatment and training - restoring and reinforcing a robust sense of self thru awareness and behavior modification." -Seth Oberst24) “Attention’s place in this architecture is to help us structure our internal world so that the thoughts, emotions, or motivations that are most relevant to our goals will get preferential processing through the brain”25) "By paying attention to internal sensory information, your brain can map a better homunculus.  This improved representation gives the brain a better reference point from which it can select the optimal motor strategy for a task."26) No one knows how many hours it takes to become an expert. There are way too many variables involved.  But we do know two things that are necessary: attention focus and feedback.

Exercise of the Month

Can you pronate and supinate your hip?  If not, your foot, knee, or back will likely do it instead.I use this exercise to help cortically map the transverse plane in patients that can't perform a single leg deadlift correctly (open chain hip rotates towards ceiling during downward phase).https://www.youtube.com/watch?v=t7NcR2inqN0

Training

27) Chris Johnson shares a great advanced hip exercise for athletes - Barbell Lateral Taps28) Dean Somerset shares some interesting information on lifting with a flexed versus and neutral spine.  I like the study he provided on disc shape.29) There’s also a lot of research out there that shows that torque is the major problem with spine injuries.  And think about this, if you have an asymmetry and you perform a symmetrical lift, then you just created torque.30) "Our goal as a coach is to help them commit to a challenge that emotionally drives them and stretches their abilities."31) GMB share an easy and modifiable body weight circuit that everyone can do.32) I completely agree with this article. Everyone that exercises should understand this concept. "What if, instead, you approached lifting like it was your job and you got paid to not only make the lifts, but to also to look good and be entertaining while you are doing it? How often would you attempt to set a new record lift 1 rep maximum? How ambitious would that attempt be?"33) I owe GMB a ton for improving my movement. Working on their stuff has really cleaned things up and given me much more true, connected, strength. Try their progression on the L-Sit.

Research

  • "Everything that irritates us about others can lead us to an understanding about ourselves." - Carl Jung

34) Many times in rehab, education has the most profound change. Here's one to instantly decrease PFPS stress:

"Step rate significantly affected peak contact force magnitudes. Increased step rate induced a 16.6% lower patellofemoral force. The effects of an increased step rate also changed the medial component of the patellofemoral force. Step rate modification is an attractive option given that is easily trainable via auditory cues and can induce notable changes in loading patterns. An increasing step rate (i.e. shortening step length) can effectively decrease cartilage contact area and the peak and average cartilage contact pressures that arise in mid-stance. It can also reduce knee energy absorbtion, with the latter effect primaraliy due to running with a more extended limb. The vastus medialis strength did not affect pressure magnitudes, but did shift the location of contact pressure medially on the patella."

35) Research that everyone loves: "Research conducted by the University of Alberta in Canada has found that health benefits in resveratrol, a compound found in red wine, are similar to those we get from exercise."36) "Decreased range of internal femoral rotation results in greater ACL strain and may therefore increase the susceptibility to ACL rupture with athletic cutting and pivoting activities."37) Exercise improves sleep which decreases anxiety. #ExerciseIsMedicine38) “To maximize tensor fasciae latae stretching, patients should be positioned with their hip adducted and extended and with more than 90º of knee flexion.”39) Stress & RecoveryStress & Recovery 

Diet, Nutrition, & the Microbiome

40) My good friend, Jesse Cullen-DuPont, is one of the smartest guys I know.  He has a passion for diet/nutrition and has dug deeper on this subject than anyone I know.  I asked him to send me some of his favorite links, here’s what he gave me:

Dr. John Cryan Podcast

Microbial Endocrinology

Chris Kresser Podcasts (American Gut Project, Leaky Gut, Altered Intestinal Microbial Balance)

41) This is why I always take diet advice with a grain of salt (no pun intended) - “Different diets work for different people, and now new research reveals that it may be possible to predict how people will react to different diets, based on the composition of the microbes in their gut.”  Unless you’re a dietician, please don’t prescribe specific diets to people.  #OutOfYourScope #Microbiome42) This is one of my favorite reads by Andrew Rothschild on the holistic nature of the gut microbiome and how it affects pain.43) “A growing body of data, mostly from animals raised in sterile, germ-free conditions, shows that microbes in the gut influence behaviour and can alter brain physiology and neurochemistry.”   #BellyNeurotransmitters #LessDrugsBetterFood “44) "No Sugar" Foods with Maltodextrin Mess with Your Gut Microbiome - Effects are Significant and Could Explain Rise in IBD, Crohn's, Ulcerative Colitis & Co” #EatLessProcessedFood45) Great article on our nation's diet problems - too much fear of fats, too little understanding of glycemic index/load. "glycemic index influences human physiology, clearly demonstrating its importance to preventing and treating obesity, diabetes and cardiovascular disease"46) Here’s a list of 100 common food’s glycemic index and load.47) “Irregular eating patterns, including not having consistent meal times or eating late into the night, can affect health, metabolism and circadian rhythm.”

Other Good Stuff

  • "You don’t get frustrated because of events, you get frustrated because of your beliefs." -Albert Ellis

48) "The academic disparity between young children in poverty and children from wealthier families is not a result of what their parents can offer. It is a result of the different types of learning experiences they are afforded at school.  In other words, it is not the “word gap” but the opportunity gap that is the problem."49) “Repeating aloud boosts verbal memory, especially when you do it while addressing another person”50) Why we sleep - including a great video.51) A friend that only shakes your hand is no friend at all. "The closer the person in social relationship, the larger the body area this person is allowed to touch."  Hug it out.52) 4 Relaxation Techniques for Decreasing Anxiety

1) Autogenic Training

2) Progressive Relaxation

3) Applied Relaxation

4) Meditation

53) Great advice on walking on how to get more out of it54) “the U.S. is one of only two countries worldwide in which drug companies are allowed to advertise directly to consumers” #SolveHealthcare55) Sleep deprived or darkness deprived?  "Electric light can delay or shut down nighttime physiology, whereas light from a wood fire or flame cannot."

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--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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October Hits (2015)

Clinical

  • "Each time we introduce an assumption, we also introduce a new bias into the final solution" -Serge Gracovetsky

1) "Our neurological wiring has evolved into networks of patterned behavior designed to efficiently complete tasks mandated by the environment. Anatomy provides the frame to carry out these behaviors; the changes to structure are the tangible result of our habits. But once we open up some behavioral options for new habit formation, anatomical abnormalities don't seem quite so concrete and problematic."-Seth Oberst2) Here's the last category of the Coaching & Cueing series - Proprioceptive Cues3) Want another tool for decreasing muscle tone? Try shortening the muscle and use some reciprocal inhibition.

The Gait Guys want you to decrease hypertonic muscles by stretching the antagonist?  Interesting article on reciprocal inhibition and muscle spindles.

Erson wants you to try shortening the muscle for 30-60 seconds before you go aggressive.

4) 5 Thoracic Mobility Drills to Improve Overhead Movements5) Great advice from Erson on improving the effectiveness of your interventions “make sure the patient understands the indications and what the treatments do”.  I wish someone would have told me that when I first got out of PT school.  #Expectations6) Dan Pope "Bridges the Gap" with this must watch jump/plyometric progression series

Double Leg Jump Progression

Single Leg Jump Progressions

Advanced Double Leg Jumps

Advanced Single Leg Jumps

7) A new study shows that back pain is correlated with a positive thomas test.  Here’s a basic stretch and how to coach it correctly.  Sometimes coaching this stretch can reduce the positive thomas test.  Other times it requires more advanced techniques.8) Nothing good about prolonged static postures.  Get them to move.  If they can’t get out of the chair, advise them FIDGET.9) Do your patients have control of their long extensors?  The Gait Guys teach you how to test it.10) Pain alters motor control. "This is why you should probably mitigate threat; in doing so, reduce or abolish pain prior to performing ANY movement based treatment." Erson elaborates on the complexity of the mobility/stability debate.11) "Choice is control and in the presence or history of pain we begin lose choices. People in pain have their movement options reduced, losing variability in their task achievement until there may be only one way left to move. Restoring these choices and rebuilding an agile movement system can be done and the research emerging from the field of neuroscience is assistive in showing just how. Changing the brain’s perception of the movement system resides central to this pursuit."

Stress

Stress is one of the most important variables we have to manage everyday - for both ourselves and our patients.  Understanding stress is just as important as understanding biomechanics and pain science.  Sometimes the keystone variable is something to do with stress.  Being able to identify it and make recommendations can make or break the patient's recovery.12) Books

Polyvagal Theory is a great, complex read on the subject.  It goes over the evolutionary physiology of how we react to stress and why.  It gets quite redundant, but overall is worth the time investment.

Nerve is a much easier, enjoyable read that deals with the neuroscience and psychology of fear, stress, and anxiety.  It's filled with useful anecdotes and gives some solid general advice that you can share with your patients.

Why Zebras Don't Get Ulcers has been recommended by many as well.  I haven't read it yet, but it's on my list.

13) It's important to understand that stress is stress.  It's cumulative and it all matters.14) Then it's important to have a couple different recommendations to help alleviate this stress that is within your scope of practice.15) This is a must read - a new study shows that students are more likely to get injured during periods of high academic stress.  Just being able to paraphrase this study to your patients should help them understand their pain better and decrease the threat.16) Psychoneuroimmunology for Physiotherapists - Stress decreases tissue healing.17) Think about your commuter patients - “Physical activity can mitigate commuting-related stress if workers can include it in their daily routines, but the obvious constraint is time scarcity. Longer commutes mean less time for other activities, which leads to lower life satisfaction.”18) I love living in NYC.  I feed off the buzz and the stimulus drives me further.  But after a couple years of living in the concrete jungle it can start to break you down.  One solution to the high stress environment is practicing meditation.  I took a UCLA course, did some studying, and came to this conclusion for both myself and my patients.19) Living in NYC makes me appreciate getting outside the city much more.  Getting outside into nature isn't just refreshing, but it's healing.  This might be why half of NYC has weekend homes outside of the grind.

Six all-natural (yet scientific) strategies for improving your mind and body.

"This study revealed that forest environments are advantageous with respect to acute emotions, especially among those experiencing chronic stress. Accordingly, shinrin-yoku may be employed as a stress reduction method, and forest environments can be viewed as therapeutic landscapes. Therefore, customary shinrin-yoku may help to decrease the risk of psychosocial stress-related diseases, and evaluation of the long-term effects of shinrin-yoku is warranted."

20) You should subscribe to Psychology Today's email list.  They provide a tone of great articles.  We're not psychotherapist, but we build relationships from the premise of trying to help people get better.  Sometimes this leads to our patients opening up to us and telling us some serious things.  It can help to identify certain patterns and recommend some basic stress reduction techniques, but it's more important to recognize when someone needs some help and to have someone to refer them out to.https://www.youtube.com/watch?v=v-t1Z5-oPtU

Exercise of the Month

This is my go to lateral stability exercise.  Most people perform it too fast and need specific cues for pivoting from the outside of the bottom knee.https://www.youtube.com/watch?v=lG1BjEplYsQ 

Pain & Neuroscience

21) "For true healing to take place, you need to learn how to move out of the intellectual realm and into an experiential one. For instance, if you were hurt and afraid in your past, then you need to be guided to refind feelings of safety and security on an experiential and body level." -Dovid Meshchaninov, MS22) Great write up on pain and diet/microbiome from Andrew Rothschild - "an imbalance between bacteria in our guts can interact with our immune system causing the release of inflammatory chemicals and stress hormones, kicking off our body’s natural stress response, even when we are not truly in a stressful situation."23) Great read on Chunking

“Consciousness and chunking allow us to turn the dull sludge of independent episodes in our lives into a shimmering, dense web, interlinked by all the myriad patterns we spot. It becomes a positive feedback loop, making the detection of new connections even easier, and creates a domain ripe for understanding how things actually work, of reaching that supremely powerful realm of discerning the mechanism of things. At the same time, our memory system becomes far more efficient, effective — and intelligent — than it could ever be without such refined methods to extract useful structure from raw data.”

24) "it's the lack of "other things to do" or be aware of that really flares up the pain at night" -Erson with a great post on a question that patients often ask us25) "Sleep deprivation is associated with disturbance in descending pain inhibitory control mechanisms and results in increased pain sensitivity." Great read on pain and sleep from Rayner & Smale26) "providing contrasting information is a known and effective way to promote optimal learning" It's also best to use 2 examples with this approach. #Education27) Many of the best clinicians have struggled with their own injury. "This finding suggests that pain empathy is grounded in neural responses and neurotransmitter activity related to first-hand pain."28) “The part of the brain that is responsible for seeing, for the apparently ‘simple’ act of generating the picture in our mind’s eye, turns out to have the ability to do something akin to choosing, as it actively switches between different interpretations of the visual input without any help from traditional ‘higher level’ areas of the brain.”29) “Our study hypothesis was supported.  Individuals with more alpha asymmetry (reflecting greater left than right sided frontal alpha; that is, a relative suppression of left frontal activity) reported more subsequent catastrophizing”30) "Researchers have demonstrated that the music we prefer has greater positive effects on pain tolerance and perception, reduces anxiety and increases feelings of control over pain. In older people with dementia, listening to preferred music has been linked with decreasing agitated behaviour."31) "In adults, it has been well-documented that stress promotes habits and reduces cognitive flexibility"32) This is a big part of why my bosses are so successful in treating patients - "The results show that pain thresholds are significantly higher after laughter than in the control condition. This pain-tolerance effect is due to laughter itself and not simply due to a change in positive affect. We suggest that laughter, through an endorphin-mediated opiate effect, may play a crucial role in social bonding."

Training

33) You should share this with your patients in a newsletter or print it out for the waiting room.  3 Signs that your relationship with exercise is unhealthy:

Cancel social plans to exercise

Exercise to make up for your diet

Continue to exercise despite fatigue, illnesses, and/or injuries

34) Interesting read on using mindfulness for performance.35) Here are some nice tips on coaching and cueing from Eric Cressey. For a more detailed overview on coaching and cueing, check out my new series that simplifies cues into easy to understand categories.36) 6 things you should focus on with your baseball players (attributes of elite hitters)37) Always good coaching cues from Eric Cressy38) "In many ways, fitness should be viewed as a long-term concept, much like saving for retirement." -Dean Somerset39) You should do some cardio40) Reverse engineer to meet your goals. Use the the SMART method (Specific, Measurable, Attainable, Realistic, Time-Bound).41) Some must read advice from Eric Cressey

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Research

42) Very interesting article on cranial biomechanics - “It is proposed that the cranium behaves somewhat as if constructed of cardboard, with the sutures acting as pre-folded lines or perforations.”43) “A careful analysis of EMG activity and kinematics during gait suggests that, in the transverse plane, the adductors may be eccentrically controlling internal rotation of the femur at the hip during the loading response, rather than the previously reported role as concentric internal rotators. In addition, these muscles may also concentrically produce external rotation of the femur at the hip during terminal stance and preswing.”44) “The consensus in the research is that the tendon gap will gradually fill in with tendon-like tissue and be nearly healed between 2 & 3 years.”45) Sleep and your cardiovascular system.  "Findings showed that adults who slept less than five hours a night had 50 percent more calcium in their coronary arteries than those who slept seven hours. Those who slept nine hours or more a night had even worse outcomes, with 70 percent more coronary calcium compared to those who slept seven hours."46) Pelvis thorax counter rotation. "This is because during bipedal walking in humans, the ribcage and arms rotate in one direction, while the legs and pelvis move in the opposite direction. You can see this as your arms and legs move in opposite directions when you walk. These opposite rotations are beneficial because they help to conserve a physical quantity called ‘angular momentum’. The angular momentum of the upper body cancels out the angular momentum of the lower body. In humans, this helps to reduce work, and saves energy during locomotion."47) Mindfulness improves performance and skill acquisition.48) ACLs that were reconstructed with allografts had three times higher failure rates than autograft reconstruction49) Fascinating read on how the jaw/mouth can profoundly influence the rest of the body.  “In fact, unilateral anesthesia of the trigeminous causes a shift in body weight onto the contralateral limb, which leads the homolateral inferior limb to contract.”  Probably one of the best articles I’ve read in a while.50) The moment I got on one of these I knew it had some value.  It requires good frontal plane control, single leg stability, focus and attention, and allows for full kinetic chain integration.  It was only a matter of time - Slackline was shown to improve postural control in this study.51) “It was shown that young adult men with cam-type FAI presented with excessively inverted hindfoot at heel strike with a reduction in the overall maximum eversion during stance phase.”52) “Tendon-related issues seem to have increased inflammation, while torn tendons have significantly lower inflammation than tendon-related conditions in intact tendons.”53) “A single resistance training bout of isometric contractions reduced tendon pain immediately for at least 45 min postintervention and increased MVIC. The reduction in pain was paralleled by a reduction in cortical inhibition, providing insight into potential mechanisms.”54) The importance of the mouth - “These findings suggest that it is advisable to use a customized bite-aligning mouthpiece to improve strength and power performance.”55) Cellular Mechanotransduction - “The presence of isometric tension (prestress) at all levels of these multiscale networks ensures that various molecular scale mechanochemical transduction mechanisms proceed simultaneously and produce a concerted response. Future research in this area will therefore require analysis, understanding, and modeling of tensionally integrated (tensegrity) systems of mechanochemical control.”

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Other Good Stuff

  • "Time is a created thing. To say 'I don't have time,' is like saying, 'I don't want to.” ― Lao Tzu

56) If somebody is unsure about a decision, their pupils dilate

“We think of persuasive people as good talkers, but maybe they’re also observing the decision-making process,” he says. “Maybe good salespeople can spot the exact moment you’re wavering towards a certain choice, and then offer you a discount or change their pitch.” #Communication

57) Before you give advice (#Communication):

1. Listen for emotional undertone

2. Name the core emotion

3. Relate to the emotion to show understanding (mirroring, vulnerability, validation)

4. Withhold Judgement

5. Offer Advice Last 

58) "So empathy is distinct from expressions of sympathy — such as pity or feeling sorry for somebody — because these do not involve trying to understand the other person’s emotions or point of view." Listen, practice loving kindness meditation, read fiction, and get a dog to increase your empathy.59) True experts are able to say they don't know something. "Accepted knowledge can get in the way of healthy ignorance" -David Butler on the importance of ignorance60) Diet and Depression #Variables61) A nice quick review of the vagus nerve and 9 things it's good for62) 9 great tips on how to read emotions and influence people. #psychology63) Control your emotions by labeling them - "affect labeling seems to pull us out of an emotional quagmire by engaging our executive brain."64) "the previous week’s effort influenced this week’s passion, such that more effort led to more passion."65) "Touching is incredibly powerful. We just don’t give it enough credit. It makes you more persuasive, increases team performance, improves your flirting… heck, it even boosts math skills."66) ““Never Make ‘Em Feel Stupid.” – The Cardinal Law of Persuasion” #Communication

Gif of the Month

 How some of my patients perform their exercises                   [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 6 - Proprioceptive Cues)

This is a very common intervention in movement coaching (whether the practitioner knows it or not).  Simply changing an exercise to achieve the same goal is essentially a proprioceptive cue.  Changing from a clamshell to a fire-hydrant can be a proprioceptive cue by altering the ascending sensory information during an isolated transverse plane glute strengthening exercise.There are plenty of resources out there on this aspect of coaching, so I’ll keep this section of the post brief.As mentioned in the previous posts, the top-down cortical aspect of movement will have profound effects on body awareness and thus proprioception.  Since these topics were already discussed, this post will focus on the novel “bottom-up” proprioceptive sensory changes.The concept of proprioceptive cueing can be summed up on one sentence:

  • Sometimes the best cue is to shut your mouth and change the physical environment.

Proprioceptive cues come down to the simple concept that changing the body’s input will lead to a change in movement output.  It’s common sense.  The better the information, the better the resulting decisions.Here are some (of many) easy ways to create a proprioceptive sensory change through the environment.

Motor Chunking

Motor chunking is when a movement is broken down into segmental pieces and slowly put together as a whole.  Motor chunking “is thought to be necessary for overcoming the limited number of items humans can consciously hold at any given time within working memory”.  While this could easily be apart of the internal cues section, I’m going to include it in this post because it can allow for easier proprioceptive processing and the assimilation of complex movements.In movement coaching, it is common to see someone have a difficult time with a certain exercise.  However, it’s not a problem from a tissue load capacity perspective, it’s a problem from a cognitive perspective.  Some people just can’t put all the proprioceptive pieces together to complete the whole movement.  This is where “chunking” the movement into smaller proprioceptive pieces can allow for the individual to understand the whole movement better.Instead of giving 8 steps or attempting various different cues, it might be best to break down the movement into smaller proprioceptive chunks.  It can become pretty formulaic:

  • Master Chunk #1
  • Master Chunk #2
  • Master Assimilation of Chunk #1 + Chunk #2 = Chunk A
  • Master Chunk #3
  • Master Assimilation of Chunk A + Chunk #3 = Chunk B

For example, coaching the reachback requires proper thoracic centration with eccentric upper extremity control (Chunk B).  First you need to coach them to fully exhale (Chunk #1).  Then coach them to exhale and keep their ribs down with their obliques (Chunk #2).  Then have them practice both those movement together (becomes Chunk A).  Once they have this, you work on the eccentric reach back part of the movement (Chunk #3).  Then you put it all together for a nice clean, compensation-free reachback (Chunk A + Chunk #3 = Chunk B).How many chunks you need and how much time it takes depends on the patient.  Athletes can usually handle larger chunks over shorter amounts of time, where as my sedentary patients require more attention focus on the basics and more time to master the movement.

SFMA/TPI 4x4 Matrix

 Each column contains a way to progress or regress the exercise This is a very user friendly system that provides a step by step approach to progress (or regress) movement to achieve the desired output.  It uses the developmental progression with a graded exposure to load, gravity, and degrees of freedom.  This is great for everyone from your chronic pain patient to your elite athlete (who often have holes in regressed postures).To keep with the theme of this series, here's a deadlift proprioceptive cue example.  If some has difficulty keeping their ankles in neutral and preventing anterior translation of the tibia requires a lot of real estate in the brain, then there’s no way the patient will be able to focus on their hips/low back dissociation.  So you can alter the proprioceptive input by regressing the posture and putting the person on their knees.  This alters the sensory input and allows for more brain real estate to focus on the proprioceptive input from the hips/low back instead of having to deal with all the input from below the knee.  Or in SFMA terms, this takes it from 4/4 to 3/4.Regressing the posture is another way to alter the afferent proprioceptive input.

Taping / Tactile Cuing

Simply providing more sensory information to a specific area via tape or tactile cueing can improve the cortex’s ability to process it.  It’s like adding cutaneous mechanoreceptors to an area that may have a “smudged” homunculus.

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If you don’t have tape you can simply use your hands.  For example, lightly touching someone’s spine during a quadruped exercise can help increase their sensation to that specific area, thus potentially improving the motor control.

Foot-Environment Interface

The feet have quite a lot of mechanoreceptors.  They take up a lot of space in the homonculus.  Thus, they provide a lot of information regarding proprioception and set the stage for the rest of the body.  Changing shoes, orthotics, and/or ground surface can have a huge impact on proprioception.However, footwear is a very complex topic and requires in depth understanding to  properly prescribe foot surface interfaces.  The wrong advice could have serious consequences on movement mechanics.  For more information regarding foot mechanics check out the Gait Guys website and biomechanics course.

Resistance

 

Load

It’s common sense to lighten the resistance if someone can’t perform a movement without compensatory motion.  However, I’ve also found it helpful to add resistance when patients are having a difficult time “feeling” the movement.  Loading up the body will add compressive forces to stimulate the joint mechanoreceptors (approximation=stabilization), increase the magnitude of the muscle contraction, and apply greater tension to fascial structures.  Plus, it can reduce the variables in an exercise.  Kettlebell enthusiasts have been coaching people to go heavier with their swings for this exact reason.  A heavier weight promotes the proper muscle activation patterns and to removes the option of lifting the bell with their arms.However, it doesn't just have to be a modulation in weight.  It can also be intensity.  Using high intensity local exercises to increase the proprioceptive input for a specific area.  For example, if someone can’t feel their hamstrings during a single leg deadlift then I will have them perform a prone hamstring physioball squeeze.  Then return them to the previous exercise.  It’s pretty much just using the post-activation potentiation concept for lower level exercises.  Not just for hamstring strengthening.  

Type

Altering the type of resistance can provide a profound sensory change.  Going from dumbbells to kettlebells, cable to elastic bands, or kettlebell to barbell provides a significant proprioceptive change.  The type of resistance is limited by your imagination (medicine balls, body weight postures, chains, indian clubs, tires, trail running, boulders, significant others, pets, etc.) .  Just look at people who exercise outdoors to see an example of this creativity.Different vector forces will result in different muscle activation will result in different movement patterns. #BiomechanicsMatter 

Reactive Neuromuscular Training (RNT)

      • "The main objective of the RNT program is to facilitate the unconscious process of interpreting and integrating the peripheral sensations received by the central nervous system (CNS) into appropriate motor responses" -John Guido, Jr

 https://www.youtube.com/watch?v=KMe8YpYvoW8RNT is a great way to use resistance to correct aberrant movement patterns.  You don't have to set up any targets, educate the patient on the movement correction, or give specific directions.  You simply pull the patient into their compensation and watch their system react to this perturbation by over correcting the faulty movement.In RNT the example above, the resistance is pulling the patient lateral over their base of support (trendelenberg moment).  To prevent falling over, the patient will have to fire their frontal plane muscles to prevent from falling over.  This is obviously useful for patients that don't have frontal plane stability and have difficulty with contralateral hip drop.The RNT example below is great for patients who try to perform the single leg deadlift with an upright trunk (squatting the hinge).  Holding the bands will pull the trunk upright.  To counteract this movement, the patient will have to flex their trunk down to counteract the band's resistance.

A video posted by Aaron Swanson (@aswansonpt) on

 

Summary

Proprioceptive changes are  an easy way to troubleshoot an aberrant movement pattern.  The options are many and the results are profound.  But keep in mind that improving movement is rarely a linear process.  There are a ton of variables when it comes to movement.  And these variables interact with one another to create an infinite amount of movement situations.  Thus, due to the dynamic systems involved with movement, you cannot perfectly predict the exact movement output that will result from new input, but changing the proprioceptive environment is one variable that often has a positive impact.  Assess, cue, re-assess.

Giving Credit

My understanding of proprioceptive cues, environmental influence, and the nervous system bias of movement was heavily influenced by Gray Cook and SFMA/FMS System.  Studying his work opened my mind to a new way of changing movement patterns and provided an important foundation for my continued education.

References in Previous Articles

Coaching & Cueing

Part I – IntroPart II – The CategoriesPart III – Verbal Cues – ExternalPart IV – Verbal Cues – InternalPart V – VisualPart VI – ProprioceptivePart VI – Summary Knowing how to influence movement with cues starts with understanding the different types of cues  --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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September Hits (2015)

Clinical

1) Dan Pope shares another awesome video exercise progression - this time it’s on jump variations.  He literally shows you how to bridge the gap in this one.  Great stuff.2) Leon Chaitow goes over pulsed muscle energy technique.  A much safer and more effective intervention than cranking on joints with aggressive stretching.  Take note of his communication in the video - calm, slow, speaking - external cues - takes his time to get the patient to perform exactly what he wants.  #Variables3) Tom Goom writes some of the best running articles out there.  Here’s a great post on the importance of load capacity, the envelope of function, kinetic chain load, and the non-tissue issues.  This might be the most important concept in rehab.4) Here’s a nice shoulder exercise - Horizontal Abduction with Press.  This can also be used to improve rotation.5) Visual cues may be the easiest way to immediately correct faulty movement patterns.6) Zac Cupples reminds you about the ZOA and teaches some good subscap stuff in this I&I review.7) Read this great review of static foot posture and arch height correlations.  Even if you don’t like the foot, reading this will give you a great biomechanical thought experiment and strengthen your movement knowledge.

Sure, you don’t want to make too many assumptions when assessing static foot postures, but “low-arched runners exhibited more knee, soft tissue, and medial injuries (e.g., adductor strain, medial knee and ankle injury, and sesamoid/first metatarsophalangeal joint injury), while high-arched runners had a greater prevalence of bony injuries (e.g., stress fractures) and lateral injuries (e.g., greater trochanter bursitis, iliotibial band friction syndrome, and/or lateral ankle sprains).”

“During midstance, because the adducted talus is held in a fixed position by superimposed body weight, the external rotation moment created by the swing limb is unable to generate a force strong enough to abduct the talus. As a result, the torsional forces associated with this external rotation moment must be temporarily stored in the stance limb. The release of these stored torsional forces is occasionally evidenced by a sudden “abductory twist” of the rearfoot as heel lift occurs; i.e., because ground reaction forces no longer maintain the plantar heel, the entire rearfoot is free to snap medially, as though released from a loaded spring.” 

8) Here’s one reason why your jaw may be a compensator “your body loaded the TMJ with the most amount of proprioception per surface area of any other moveable joint.”.9) A good read from Charlie Weingroff on the difference between a warm up and corrective exercises. Hint: they are not analogous.10) “Consider someone who has a femoral retroversion will likely have a bone to bone contact sooner in a flexion range of motion compared to someone who has more of an anteversion alignment, and if that difference is 20 degrees or more, that could be the difference between squatting above parallel and sitting your hamstring comfortably on your calves.” -Dean Somerset with an awesome article on hip morphology.  Seriously, read this one.11) The eyes are window to the soul, the nails are a window to foot biomechanics?  Interesting post from the Gait Guys on how pincer nails develop - ““the pincer nail group had significantly lower pressure on the first toe than the control group. In both the barefoot and shod state, the peak pressure area was mostly the metatarsal head area in the pincer nail group, whereas it was mostly the first toe area in the control group.”12) “I don’t believe breathing drills will cure everything.  However, I do believe that utilizing good breathing mechanics along with other intervention is an essential part of optimal function mentally and physically.“ -Kento Kamiyama13) While I think muscle slings are fairly limiting and over-simplified terms for clinicians, they’re great for patient communication.  Here’s a nice easy article with some great graphics on the “muscle slings”14) Very interesting TED talk from Peter Lovatt on dance, thinking, and hormones.  He has another TED talk on psychology and dance.  Thanks for the share Suzanne Fuchs.15) Erson shares some useful wrist directional preference cases.  16) “So it is good to remember that our capacity to think and feel is supported in large part by the neural hardware and software that creates our ability to move and perceive. By developing one we develop the other. It’s all connected of course.” -Great post by Todd Hargrove with quotes on the importance of movement

Pain & Neuroscience

  • "One of my biggest clinical mistakes is forgetting graded exposure rules apply to explaining pain" -Zac Cupples

17) An rare, honest article on explaining pain18) Intrinsic focus improves tactile sensation in new study. For more information on this concept and how it relates to movement science read this article (int cue art).19) “Be suspicious of any statement that says a brain area is a center responsible for some function. The notion of functions being products of brain areas or centers is left over from the days when most evidence about brain function was based on the effects of brain lesions localized to specific areas.  Today, we think of functions as products of systems rather than of areas. Neurons in areas contribute because they are part of a system. The amygdala, for example, contributes to threat detection because it is part of a threat detection system.  And just because the amygdala contributes to threat detection does not mean that threat detection is the only function to which it contributes. Amygdala neurons, for example, are also components of systems that process the significance of stimuli related to eating, drinking, sex, and addictive drugs.” -Joseph E LeDoux Ph.D.20) Pain is always a translation.  21) Pain is also a verb.22) An interesting way to use imagery to work with a patient with a thought virus.23) Well this is disappointing..."Of 100 studies published in top-ranking journals in 2008, 75% of social psychology experiments and half of cognitive studies failed the replication test". Another reminder that research isn't always the gold standard. Difference between evidence based practice and research based practice is huge.

Training

24) Michael Mullins shares a great warm-up routine that focuses on “centering, grounding, alternating and reciprocal, and proprioceptive integration.”25) “The vertical tibia requirement is an intention and not a “reality” for many people. The ability to keep the shins vertical (another way of saying vertical tibia) is highly dependent on structure, and an individual should not give up the stability of their spine in order to achieve the intended “vertical shin”.” -Bret Jones on the perfect swing and a great car analogy for individual structure #Variables26) Energy production is pretty important - Joel Jameison on Energy Systems27) Work Capacity is the buzz word, but really it’s just conditioning.  Here’s a great article from Joel Jameison on Conditioning.  It goes over all the important concepts.28) “When I think aerobic training, I think recovery, energy development, and fatigue buffer.” -Lance Goyke29) Probably the best hip mobility drill out there by Andreo Spina30) Great cues from Dean Somerset | Rows - “keep your head behind your chest”  Squat - “aim your butt to your heels”31) "So this is another piece of evidence that one of the benefits of hard training is that you learn to tolerate more pain”32) Look at #1 from Bret Contreras - anatomy is not a death sentence.  Scoliosis, Lamar Grant, and monster deadlifts.33) “With overhead athletes, stick with the overhand grip on the dominant side during alternate grip movements.”-Eric Cressey34) One of the better “__ Steps to Improve ___” I’ve read in a while.  Read this by Alexandre 'Alexey' Senart if you want to improve your pistol squat or coach it better.  “The idea behind this first tip is to prevent our internal “alarm” from going off by taking away half of our bodyweight—source of “danger”—and by maintaining the closest control over our position all the while.”35) Interesting visual cue to improve the squat - “Think of your femurs as being on sliders rather than being hinged on a single pivot point. The intent is to think that they can be shifted away from the pelvis, “making space for the hips” on these imaginary sliders.”  Make sure to watch the video for a better understanding.36) Here’s a nice easy read on the vagus nerve and yoga.37) Research based deep squat defense by Felix Sempf38) Here’s an advanced supine trunk rotation exercise from Brian Schiff.  If this is too difficult or if you patient has pain with rotation, then try this regression.

Exercise of the Month

Contralateral Cross-Crawl Creep

https://www.youtube.com/watch?v=eKr334-7L0AThis had strange origins.  Some believed that you could reverse brain damage, developmental delays, autism, and other neurocognitive problems just by correcting the “missed” stage.  This theory has been disproven and most in the field do not consider it a valid approach.  That said, we don’t need to partake in the common social media act of throwing the baby out with the bathwater.  Cross-crawl patterns and the neurodevelopmental postures are still very useful.  Good movement is good for the brain.  Especially for brains that have dysfunctional movement.When people have dysfunctional movement in the standing posture, one way to reduce the difficulty is to decrease the load on the body and the demands on the brain.  An easy way to accomplish this is to move them down to the ground.  Feldenkrais has been doing this for decades.The contralateral cross-crawl creep not only takes people to the ground, but it does so in a very sensory rich fashion.  It provides a ton of feedback (tactile, visual, vestibular, proprioceptive).  In the prone position the body (and the brain) has to do a lot less work - it doesn’t have to manage as many kinetic forces, there’s not as many degrees of freedom in the system, the center of gravity is much lower, the base of support is much larger, force is distributed across a greater area - and because of this, it’s a safer position.  Plus, there's no need to progress the body forward - even less variables.  It’s basically free movement.Flip Flops Promote

reflex integration

body awareness

gross motor coordination

spatial orientation

tons of tactile stimulation

proprioceptive input

stimulates both sides of the brain/body

reciprocal motion

hand development and eye hand co-ordination.

development of fine motor skills, rhythm and timing

When I Use This

Sling Dysfunction

Decreased Rotation

Proximal Dysfunction

Over Toned (stuck in High Threshold)

Over Stressed (loss of attention and mindfulness)

Begin with simple “chunking” exercises.  Then perform the full movement together.  Then progress towards full, rhythmic, reciprocal movement with no pause between movements.Look at the hand, go slow, be mindful, feel the movement.Common Problem: surface friction - it may help to place towels or slide pads underneath the knee and/or hand.  Too much friction can turn this nice low-threshold exercise into an uncomfortable, high-threshold, grind.--For more information on the brain, movement, and development I highly recommend looking into Dynamic Systems Theory and Sensory Integration concepts.Special thanks to Perry Nickelston for introducing me to this exercise and to Shante Cofield for hooking me up with this article that goes over some of the concepts discussed above.

Research

39) “Well, there you have it. The “E” in EBP doesn’t translate efficiently into the clinic, will not protect you in lawsuits, and has it’s own inherent (even worse, hidden) biases. On top of that, it could make you delusionally overconfident, despite at least 50% of it being false.”-Cinema Air40) Research shows that sleeping on your side improves waste removal from the brain.41) You know what they say...when you assume...“Our findings suggest that the FPI (foot posture index) may not be an accurate representation of rearfoot or midfoot movement during walking regardless of the measurement technique employed.”42) “Peak knee flexion moment and flexion moment impulse during the second half of stance are related to the progression of PFJ OA “  Correct the variables that affect early knee flexion, then correct the gait pattern.  43) “Although the Thessaly and deep squat tests have a moderate level of reliability, neither test is sufficiently accurate to help in the diagnosis of meniscal tears in primary care. Future research should focus on other relevant patient variables instead of on physical examination tests in the detection of meniscal tears.”  I guess primary care will have to focus on more than just pathoanatomy...44) Great interview with Kathleen Cullen.  Worth a read.  

Here’s one of the best explanations of movement variability I’ve heard - “You probably don't think about it that often but even if you're working on a tennis serve and you feel you've got the movement down perfectly, your muscles are still changing. They’re fatiguing. You have to be updating your motor commands constantly in order to deal with the fact that your motor system is dynamic and changing over time. Put another way, because the  biomechanical properties of the motor system constantly change over time we need to keep it calibrated.”

“The sensory prediction error is the difference between the sensory inflow your brain is expecting if you generate a movement vs. the actual sensory inflow it pulls in.“  #MotorStates

45) “With increased physical development improved messages flow to the brain from all the senses.“-Great article from The Learning Connections Program (thanks Shante)

Other Good Stuff

46) There’s not a ton of this out there in the social media world unfortunately - “positive emotions broaden the scopes of attention and cognition, and, by consequence, initiate upward spirals toward increasing emotional well-being” #StopBeingSoNegative47) “A confident and positive mindset can be both the cause of your actions and the result of them.” -James Clear48) “Socratic questioning helps patients examine the validity of their negative thoughts and gain a broader, more realistic perspective.” #Communication49) Trouble sleeping?  Try Sleep Restriction Therapy.  Great concept that makes a lot of sense.50) “Asking people to eat less, he says, is like asking them to breathe less. It sounds reasonable, so long as you don’t expect them to keep it up for long….Much of the obesity research for the past century has focused on elucidating behavioral techniques that could induce the obese to eat less, tolerate hunger better, and so, by this logic, lose weight. The obesity epidemic suggests that it has failed.” -Gary Taubes51) Here’s how to build mental toughness from Eric Barker52) James Clear goes over what’s overrated and underrated in life.  Some great points in this article.53) Mind-Gut Connection - Higher Anxiety Risk for People with IBD - Another reason for the importance of diet?54) Great video on the science of persuasion #Communication

Instagram

My good friend and outstanding PT, Shante Cofield, has introduced me into the world of Instagram.  It's taken me longer than it should to understand it, but I've really come to enjoy it.  The focus is on quick visual content, so there's much less trolling, negativity, and emotional nonsense than twitter and facebook.  Plus, some people share some beautiful movement, great exercises, and novel interventions.  I don't have much of those on my account, but if you'd like to see pictures of my awesome dog, Rigby, and a couple exercises, then you can follow me here.Here are a few of my favorites from this past month:

A video posted by @kettlebellexercises on

A video posted by @kathy0805 on

Tweets of the Month

Gif of the Month

 Even dogs understand the importance of teaching the creep cross-crawl          [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 5 - Visual Cues)

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

Visual Cueing

External Visual Cue

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

  1. Create a Barrier
  2. Create a Target

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

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

Internal Visual Cue - Motor Imagery

Motor imagery can be defined as:

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

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

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

 Strengthening the body without using the body?  Pretty profound stuff.Motor Imagery might be the most underutilized cue in movement practice

Vision

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

Summary

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

References in Previous Articles

Coaching & Cueing

Part I – IntroPart II – The CategoriesPart III – Verbal Cues – ExternalPart IV – Verbal Cues – InternalPart V – VisualPart VI – ProprioceptivePart VI – SummaryKnowing how to influence movement with cues starts with understanding the different types of cues[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.

 

August Hits (2015)

Clinical

1) Read this one - the most detailed and thorough blog post on movement variability.  Great stuff from Dave Tilley.

"With movement practice, it is believed by some that coordinative variability decreases (better able to synergies motor patterns for general movement planning) while elemental variability increases (more strategies to generate real time adjustments or handle different conditions while still successfully completing the given task or skill)."

"It also has been suggested that there is an optimal amount of variability for skills. Too little variability in their skill, and the person is stuck with an inflexible system that has very limited adaptability. Too much variability (especially coordinative) in their skill and the person may be all over the place unable to narrow in on the important performance components that lead to skill success."

2) “Mini-strokes affect up to half of the population over forty, but usually go unnoticed until damage builds.”3) Erson has had a busy month as always.  He goes over directional preference and why it's a novel stimulus to the nervous system, provides a quick presentation on the true effects of Spinal Manipulation, goes over 5 tips to improve compliance.   This is a nice explanation of MDT/McKenzie Cervical interventions.  And I like the idea of palpating a tender point and immediately assessing the effects of breathing - Erson’s 5 Breathing Tips.4) “A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous deformity that induces subtalar joint pronation, whereas forefoot supinatus is acquired and develops because of subtalar joint pronation.”-Gait Guys5) Zac Cupples shares his opinion on manual therapy.  He makes some great points - everything works, patient preference is paramount, and use it with an assessment technique.6) Very thorough and interesting series on the big toe (mechanics, part 1, 2, 3).  

Hallux DF = Roll, Slide, Compression

7) It’s important to keep in mind that there is no “magical linchpin” in the human body.  Most foot patients aren’t able to progress through their big toe.  And there are a ton of reasons why (rearfoot position, midfoot mobility, forefoot position, pathomechanics, morphology, motor patterns, proximal influence, habit, shoewear, ankle rocker, etc.).  Be thorough.  Use a scalpel instead of a shotgun.8) Quadratus Plantae muscle testing by the Gait Guys9) “The problem with conditioned patterns lies in the inability to get out of them when the task/environment requires it.” -Seth Oberst with another great post.  At the very least, spend some time studying this picture.10) Don’t be afraid of the placebo effect.  Making someone feel better is not a bad thing (as long as you have a plan of care to treat the cause as well).11) “a fatigued muscle decreases the body’s ability to attenuate shock from running” | “The results suggested that the lower extremity is able to adapt to fatigue though altering kinematics at impact and redistributing work to larger proximal muscles.”12) The best training modality may be The Floor

“the floor acts as a mirror to help us complete our self-image"

“It's harder to sit still for long periods of time when seated on the floor, and that's a good thing. Sitting on the floor makes it necessary to squirm and adjust position periodically to stay comfortable. It helps develop a better kinesthetic awareness that leads to a more dynamic posture.”

13) “Our real problem here is when we simply discuss tightness or weakness of a muscle, we can go down the rabbit hole thinking it’s a muscle problem. Very often, it’s a command problem.” -Gray Cook elaborates on his movement theory - sometimes mobility problems are really motor control problems14) Erson displays what Gray goes over in #13 with this motor control fix to a “mobility” problem.15) How do you know when to bring a motor control fix to a mobility problem?

SFMA (if they touch their palms to the floor and drop into a full squat you can probably bring out the motor control exercises)

Beighton Laxity

Developmental Stability

Sport History (swimming, yoga, baseball vs. rock climbing, powerlifting, football)

History of Mobility Exercises Not Working

Internal Awareness

I have an interesting patient population.  Most of them are very type A, very stressed out, over educated, sedentary, workaholic New Yorkers.  The normal interventions that work so well with athletes are usually less effective with these stressed out patients.  Below are two articles that discuss an approach I tend to use with these patients.  It's not a strict theory or set of rules, it's simply just a different way to apply what you already do.16) Sure, external cues are better for performance, but what about all the other variables?  We need to stop the tunnel vision and consider internal cues as an important part of improving movement.17) Sometimes the best way to change the processing is from within - here’s how mindfulness/body scan can be used to decrease stress and improve sensory processing.

Calf Strength

Not everyone can resolve all their impairments and move perfectly.  Sometimes compensations are necessary.  One important compensation is plantarflexion strength (especially in older patients).18) “Of particular importance were the compensatory mechanisms provided by the plantar flexors, which were shown to be able to compensate for many musculoskeletal deficits, including diminished muscle strength in the hip and knee flexors and extensors and increased hip joint stiffness. This importance was further highlighted when a normal walking pattern could not be achieved through compensatory action of other muscle groups when the uniarticular and biarticular plantar flexor strength was decreased as a group.”19) “From these results we can conclude that the most important muscle groups compensating for reduced strength in knee and hip muscles are the ankle plantarflexors, hip rotators and hip abductors.”20) “These findings indicate that aging is associated with reduced plantarflexion strength of the toes”21) “When the walking cycle is accompanied by weight bearing, plantar flexion produces a greater blood velocity.”22) It’s not just dorsiflexion ROM - “The strength of the plantar flexors and amount of dorsiflexion excursion were identified as significant predictors of an Achilles tendon overuse injury.”23) Supination = Plantarflexion + Adduction + Inversion

Pain & Neuroscience

24) The importance of building a curriculum to educate your patients - great read from David Butler.  “As with any educational intervention, we should have a curriculum, based on what we determine the key educational performance indicators (KEPIs) are, i.e. the bits of knowledge they really need to “get”.”25) Exercise is medicine.  “Certain types of exercise, namely aerobic, are thought to counteract these age-related drops in BDNF and can restore young levels of BDNF in the aging brain.”26) The Cerebellum

“Although the cerebellum is only 10 percent of the entire brain, it contains more than half of all of the neurons in the brain.”

“Tennis legend Arthur Ashe said famously, "There is a syndrome in sports called 'paralysis by analysis.'" In my opinion, when the cerebrum is overthinking, and the cerebellum is disengaged, "flow" is inhibited and an athlete chokes. I believe this new research confirms that the cerebellum may be at the heart of breaking the vicious cycle of paralysis by analysis by 'unclamping' the cerebrum from overthinking during sports.”

“In order to learn a new motor skill, the researchers found that the cerebellum makes an estimate of the expected sensory inflow that it should get from your sensory system. Then, the cerebellum automatically uses this prediction to compute the difference between what you intended to do and what you actually did. This cerebellar process is key to creating flow and achieving what I call "superfluidity" both on and off the court.”

“Through practice and repetition, the cerebellum also gets better at predicting the unexpected and making lightning fast corrections and readjustments necessary for peak performance.”

27) “Taken together, these findings suggests that at some point in our evolutionary history, we evolved an additional attention network—perhaps in order to better process the world around us,” -Dr. Patel.28) Maybe have them try writing about their pain?  “Some researchers believe that by writing and then editing our own stories, we can change our perceptions of ourselves and identify obstacles that stand in the way of better health.”29) Erson goes over pain science and education.  Regarding discs - make it as easy as simple math “"flexion = +1, extension = -1" keep the equation balanced”.  And here's some great examples of how to educate patients on pain and imaging.30) “As great as a threat pain can be, outputs such as fear, thirst, and hunger will usually trump pain. These outputs occur in response to threats greater than potential tissue damage. Comparing pain to these outputs can be enlightening for patients.” -Zac Cupples reviews Moseley’s pain course.  Great broken bone example/logic in this post.31) ALPIM Syndrome #Variables

A = Anxiety disorder (mostly panic disorder)

L = Ligamentous laxity (joint hypermobility syndrome, scoliosis, double-jointedness, mitral valve prolapse, easy bruising)

P = Pain (fibromyalgia, migraine and chronic daily headache, irritable bowel syndrome, prostatitis/cystitis)

I = Immune disorders (hypothyroidism, asthma, nasal allergies, chronic fatigue syndrome)

M = Mood disorders (major depression, Bipolar II and Bipolar III disorder, tachyphylaxis. Two thirds of patients in the study with mood disorder had diagnosable bipolar disorder and most of those patients had lost response to antidepressants)

32) 10 Research backed Mind-Body Connections.  It always goes back to the Mature Organism Model - inputs influence the processing which influences the output which influences the inputs which influences the...33) Have you considered their vision?  “Vision is typically the predominant sensory system used for guiding locomotion.”34) To be a good physical therapist you must have a solid knowledge of anatomy, physiology, and biomechanics as well as a deep understanding of pain and neuroscience.  However, the most important part of being a good healthcare provider is understanding the person in front of you.  This is often the missing piece when exercise, manual therapy, and education fail to make people feel better.  Read this classic article on the complexity of chronic illness and how it leads to suffering - Loss of self: a fundamental form of suffering in the chronically ill - Charmaz K

“A narrow medicalized view of suffering, solely defined as physical discomfort, ignores or minimizes the broader significance of the suffering experienced by debilitated chronically ill adults.”

“As a result of their illnesses, these individuals suffer from (1) leading restricted lives, (2) experiencing social isolation, (3) being discredited and (4) burdening others. Each of these four scores of suffering is analysed in relation to its effects on the consciousness of the ill person.”

Training

35) I like the elbow crawling variation.36) Here’s an advanced hip mobility drill - 90/90 Hip Flow Transfers37) PRIing the Push-Up - breathe into the posterior mediastinum at the top, exhale to lock abs, perform push-up.38) More words of wisdom from the great Eric Cressey39) The 100 Hardest Bodyweight Exercises40) Dean Somerset shares 5 pieces of advice for training the low back/hip complex - “For speed and power development, inhales are best with more of a sniffing action where air is taken in quickly and with some development of negative pressure through the ribs and abdomen, and exhaled forcefully and quickly, much like a martial artist throwing a strike.”41) Dan Pope cleans up your Pistol Squat (Mobility & Stability)  

Exercises of the Month

42) This has been my favorite frontal plane exercise progression.  You can also use it to challenge their working memory, which is great for the older population.43) This is a great idea from Zach Long - ½ Kneeling Hip Hinge Landmine Press*share your favorite exercises in the comments section

Research

44) “The lunge, dead lift, and kettle swings were low intensity (<50% MVIC) and all showed higher EMG activity for semitendinosus than for biceps femoris. Bridge was low but approaching medium intensity, and the TRX, hamstring bridge, and hamstring curl were all medium intensity exercises (≥50% or <80% MVIC). The Nordic, fitball, and slide leg exercises were all high intensity exercises. Only the fitball exercise showed higher EMG activity in the biceps femoris compared with the semitendinosus. Only lunge and kettle swings showed peak EMG in the muscle-tendon unit lengthening phase and both these exercises involved faster speed.”45) “Some research on why some people don’t respond to exercise “In the following review I will discuss new developments linking genetic and transcript abundance variability to an individual's potential to improve their aerobic capacity or endurance performance or induce muscle hypertrophy.“46) It’s all in the hips.  “The presence of LBP correlated with higher BMI, gluteus medius weakness, low back tenderness, and a positive Trendelenburg sign, particularly on the affected side for those with unilateral LBP.”47) One of the oldest movement modalities should be considered more often - “The research described here demonstrates dance’s ability to penetrate one of the most challenging human conditions: the gradual degeneration of the ability to move.”

“Adapted tango, a version of traditional Argentine tango modified to address motor impairments, has been shown to improve balance, mobility, and cognition in older adults and patients with Parkinson disease, with better compliance than conventional rehabilitation.”

48) An update on NSAIDs - increased risk of heart attack/stroke.  Tell your patients.49) ““All participants had their working memory tested at the start and two hours later (after climbing trees, running barefoot, and walking on a balance beam) and the researchers found that while the control groups showed no change, those who completed the proprioceptively dynamic tasks had a 50% jump in their working memory capacity.”50) Quadruped - “this study’s results provide strong evidence that actively engaging the forelimbs improves hindlimb function and that one likely mechanism underlying these effects is the reorganization and re-engagement of rostrocaudal spinal interneuronal networks.”51) Why not only use the objective numbers (load, reps, sets) for your patients workouts?  Because of the variables.  What if they didn’t sleep well, eat well, drank too much, are stressed at home, did too much activity yesterday, or aren’t feeling motivated?  When the variables change, the output can change.  One way to help avoid overloading athletes is to use rating of perceived exertion (RPE) and/or repetitions in reserve (RIR).52) Bret Contreras published his first paper on the hip thrust vs the squats.  You know which one came out on top.53) “In exercises that were performed in the upright position (i.e. scaption and both external rotation exercises), ipsilateral trunk rotation led to increased LT activation and increased scapular external rotation and posterior tilt. In the exercises during which the subjects lay prone, UT activation increased, thereby positively influencing (decreasing) UT/MT and UT/LT ratios.”54) “mental imagery has the potential to influence pain-related decision and evaluative processing”55) "They found that the subjects who developed LBP during prolonged standing had significantly larger lumbar lordosis than the subjects who did not develop LBP. Larger lordosis angles were linked to increased pain intensity"56) Medial tibial stress syndrome risk factors : BMI, navicular drop, landing with increased plantarflexion, increased hip ER.

Other Good Stuff

57) 11 Tips for Public Speaking #Communication58) “Most people, including many scientists, believe that emotions are distinct, locatable entities inside us — but they’re not.”  If you like this article you should also see the movie Inside Out.  Seriously.59) Understanding biases is a prerequisite to understanding the world around you.  

If you want more information I would read the first half of Daniel Kahneman’s Thinking, Fast and Slow.  It’s very powerful stuff that you can apply to everyday situations, but gets redundant and a little boring with too many vanilla examples at the end.

60) “Want to lose abdominal fat, get smarter and live longer? New research that periodically adopting a diet that mimics the effects of fasting may yield a wide range of health benefits.”61) How Playing Music Benefits Your Brain More than Any Other Activity62) Eric Cressey with a great article on the hazards of a coffee addiction

“You can't display your work capacity if you can't leverage your recovery capacity”

“Small hinges can swing big doors”

63) 6 Communication Tips from Eric Barker64) Mindless Eating is a must read - for everyone.  It solves the overeating epidemic without a solution of a depriving diet.65) This is sad, funny, and true - 22 Images on How Smartphones Have Taken Over Our Life66) Get Five 90 Minute Cycles a Day. #Sleep67) Find the right environment, make friends, and share friends. How context and social circles influence you.

Tweets of the Month

  •  - Only loading will increase capacity of tendon to tolerate load, passive treatments have no long term effect
  •  - Frontal plane & frontal lobe activity are pretty similar--both involve ability to project future consequences resulting from current actions
  •  - "Confidence is silent, insecurities are loud"
  •  - Definition of hypermobilty = not strong enough for what you do
  •  - "We must perceive in order to move, but we must also move in order to perceive" - Gibson 1981
  •  - Great coaching can make good science look great; while good coaching can make great science look good. Science doesn't coach itself.
  •  - Most of the time, the difference between an expert and a "guru" is that the prior is trying to educate and the latter is trying to sell.

Gif of the Month

 Probably doesn't need a mobility exercise                 [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.

 

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Problem & Solution

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Our brain is quite complicated.  It is constantly going through extremely complex processing to achieve many different outputs (movement, speech, vision, thoughts, emotion, pain, allostasis, etc.).STRESS is one of the most influential factors on our brain's ability to process efficiently.  And in today's society everyone has had it, many people live in it, and some people can never escape it.Stress an epidemic and it will likely get worse with time.

  • “Stress-related ailments cost the United States an estimated $300 billion per year in medical bills and lost productivity, and our usage of sedative drugs has shot off the charts: between 1997 and 2004, Americans more than doubled their yearly spending on antianxiety medications like Xanax and Valium, from $900 million to $2.1 billion. And as the psychologist and anxiety specialist Robert Leahy has pointed out, the seeds of modern worry get planted early. “The average high school kid today has the same level of anxiety as the average psychiatric patient in the early 1950s,” he writes. Security and modernity haven’t brought us calm; they’ve somehow put us out of touch with how to handle our fears” | Excerpt From: Clark, Taylor. “Nerve.”

Fortunately, this situation can be improved with mindfulness.But first, it is important to understand why stress is a problem for the brain.

The Problem = Stress

Arnsten, Amy F. T. "Stress Signalling Pathways That Impair Prefrontal Cortex Structure and Function." Nature Reviews Neuroscience Nat Rev Neurosci 10.6 (2009): 410-22

  • “Stress impairs higher-order PFC (Prefrontal Cortex) abilities such as working memory and attention regulation.  Thus, attention regulation switches from thoughtful ‘top-down’ control by the PFC that is based on what is most relevant to the task at hand to ‘bottom-up’ control by the sensory cortices, whereby the salience of the stimulus (for example, whether it is brightly coloured, loud or moving) captures our attention.”

Stress clogs up the brain's processing ability.  It creates excessive noise (e.g. increased alpha power) and disrupts the system's ability to process normal sensory information (among other things). Major functions of the Prefrontal Cortex

The Solution = Mindfulness

Kerr, Catherine E., Matthew D. Sacchet, Sara W. Lazaret al. "Mindfulness Starts with the Body: Somatosensory Attention and Top-down Modulation of Cortical Alpha Rhythms in Mindfulness Meditation." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013)

  • “Higher-order cognitive processes including selective attention and working memory are enabled by the basic ability to filter irrelevant sensory information while focusing on relevant information”
  • “Localized attention to body sensations enables subsequent gains in emotional and cognitive regulation by enhancing sensory information processing in the brain”

Mindfulness practice of specific internal sensations (e.g. body scan) helps to modulate the noise in the system (improved alpha power regulation) and promotes improved sensory information processing. How attention focus can modulate the alpha power and decrease the system's noise levels

An Analogy - Your Brain as a Concert

Let's consider the brain as the concert venue and the people as the different parts of the brain.When you have stress the concert venue (brain) becomes a loud rock show in a small club.  You can't really hear anything else that's going on (increased alpha power).  You can't communicate with anyone without shouting (why you only feel pain and discomfort when you're stressed).  You can barely move.  People keep bumping through because they "know someone up front" (poor attention).  That guy that's crowd surfing kicks you in the head.  Someone spills their drink down your back.  You can't see the stage because some idiot in front of you is trying to film it with his iPhone.  And it's just a matter of time before someone starts to yell out something no one wants to hear - "freebird!".Needless to say, this is not the best environment for communicating and organizing plans.In contrast, when you focus on the present sensations within your body the concert venue (brain) becomes a calm symphony concert at an outdoor amphitheater.  Everyone has space.  It's not too loud, you can have a conversation with the person next to you (decreased alpha power).  You can easily walk over to the other side of the venue (attention regulation).  You can not only the stage, but the rest of the venue as well.  And no one is shouting anything you don't want to hear.Don't get me wrong, I love going to rock shows just as much as anyone else.It's important to make sure the noise comes from the Marshall Stacks and not from inside your head.Stress turns your brain into a loud rock show. Mindfulness turns your brain into an outdoor symphony.

Conclusion

Unfortunately telling people to quit their jobs, stop paying their mortgage, and hire a nanny are not realistic.  Some people will not be able to modify their lifestyle and will continue to have high stress levels.So what do you do about this?The same thing you would do for someone that has a structural dysfunction that you can't change.  You give them an exercise to help strengthen the system and improve resilience.For these overly stressed individuals this can be anything from a simple body scan meditation to an hour long Qi-Gong class.  It doesn't have to turn them into a vegan hippie, it just has to bring their attention focus to their body.  It has to bring them back to their internal sensations.

  • “If you are depressed you are living in the past.  If you are anxious you are living in the future.  If you are at peace you are living in the present.” ― Lao Tzu

There is nothing more present than your own body and breath, right now.

[subscribe2]*There are many apps, websites, and albums with mindfulness practice.  I've put together a playlist of some of the free body scan meditations below.  Feel free to leave your favorite meditation app or track in the comments.

Coaching & Cueing (Part 4 - Internal Verbal Cues)

Unfortunately, the rise in popularity of external cueing has led to a bad stigma of internal cueing.  After reading the last article in this series you may be thinking why would you ever internally cue someone?Here’s why:

Benefits of Internal Cues

  • Improved Mapping / Body Awareness
  • Creates Reference Points
  • Teaching Technique/Form
  • Muscle Activation - Increased EMG
  • Alter Synergistic Muscle Activation
  • Mindfulness

3 Topics in This Article

  1. Why internal cueing is important
  2. The concepts/science behind internal cueing and body awareness
  3. Elaboration of the benefits

Disclaimer

Unfortunately, the concepts behind internal cueing aren’t quite as simple as those of external cueing.  Many of these concepts (attention, perception, neuroplasticity, mindfulness, interoception, neuroscience, embodiment, etc.) could each be an article series on their own.  I’ll try to summarize them within the context of internal verbal cueing for movement, but it may be worthwhile to dig deeper in order to better understand these concepts.

Why Internal Cueing is Important

It’s Not Always About Motor Learning or Performance

One of the major concepts that is often overlooked is the fact that most of the research and arguments for external cueing has been done through the lens of motor learning and performance.  But what about all the other variables that we work on with our patients?If you remember from Part I, not everyone is trying to PR their deadlift or improve their free throw percentage.  And not everyone has a history of athletic movement and weight lifting.  There are beginners out there that have no idea what their body is doing when they try to accomplish a physical task.  There are people who haven’t tried a new movement in decades.  There are people who only think externally all day.  There are people who have simply lost their body awareness.So why would you use the same cue for someone who is trying to max out their deadlift that you would for someone who can’t even intrinsically feel their pelvis position on the table?Living with constant external stimulus. And some people even stay external as they exercise and watch tv or listen to podcasts as they exercise.

Why is Body Awareness Important

To reiterate, with internal cueing we’re not talking about performance or even motor learning.  We’re talking about body awareness and control.  You can only control what you can feel.  And if you can’t intrinsically feel a part of your body, that’s a problem.If this were any other sensory input this wouldn’t even be a question.Imagine you are a piano teacher.  You are teaching your student the notes of the C scale. If you started playing the notes on a piano one by one, and your student couldn’t hear anything when you hit the E note, you would consider that a big problem.  If you went to a museum and could see everything but the color orange, you would consider it a big problem.  If you went out to a restaurant...you get the point.  So why do we give our bodies a free pass and just move on despite the fact that we may be missing an essential sensory component?For some patients, intrinsic cueing is a prerequisite for more complex motor tasks and external cueing.  It’s like understanding the notes on the piano before you try to learn classical music.You can't teach C major if they can't here the E note. You can't teach complex movement if they can't feel their body.

Semantics - Body Awareness

In the spirit of simplification, I am going to use the term body awareness to express the concept of feeling your body and the associated internal forces.  It’s your brain’s ability to “feel” the internal sensory input.It can get complicated, but it's important to keep some perspectiveHowever, it is important to keep in mind that just because we are simplifying this concept for the sake of the topic, it does not mean it is a simple concept.

  • “Body awareness is hypothesized as the product of an interactive and dynamic, emergent process that a) reflects complex afferent, efferent, forward and back-projecting neural activities, b) includes cognitive appraisal and unconscious gating, and c) is shaped by the person's attitudes, beliefs, experience and learning in a social and cultural context.”-Wolf Mehling

Since most people don’t even see the top of the internal cueing iceberg, arguing about what’s at the bottom is beyond the scope of this article.

Body Awareness Concepts

Attention for Wiring

  • “Remember that it's an attention economy in the brain: where we put our focus determines the wiring that we create.” — David Rock

There is an overwhelming amount of input that is flooding the brain at every moment (visual, auditory, internal processing, viscera, proprioceptive, smell, mechanoreceptors, thoughts, beliefs, etc.).  To avoid going into a seizure, we filter much of this information in order to achieve our “normal” state of being.  One of the things we use to modulate this information is our attention focus.Body awareness is essentially the attention focus of internal sensory information.  This attention focus allows us to “feel” our bodies.Right now there is a plethora of internal sensory information that is ignored so that you can use your attention to read this article.  But if you bring your focus towards feeling your hands you will all of a sudden become “aware” of them. Your hands have not changed, but your attention focus has, which has subsequently changed your brain.This isn’t just a fleeting perceptual change.  It’s a change in the neural connections of your brain.Just like muscles, each time you activate a neural wiring it demands blood flow and nutrients.  This promotes growth and adaptation.  So activating specific neural connections through internal sensory attention focus will “strengthen” one’s body awareness.  It will build the central synaptic body awareness.But it’s not just the “strength” of these neural connections that matters.  The more important part is what these connections represent.This is essentially what happens in your somatosensory cortex when you focus your attention on your body

Homunculizing

By paying attention to internal sensory information, your brain can map a better homunculus.  This improved representation gives the brain a better reference point from which it can select the optimal motor strategy for a task.This concept has been discussed over the years as Cortical Smudging.Without an attention focus of a bottom-up feedback, a  pre-selected top-down pattern could be negatively affected.  When top-down references are “off” it causes dysfunctional bottom-up feedback.  When this happens we usually see pain and poor movement.You first need to be able to feel the isolated raised dots before you can put them together to understand the sentence.An example of this concept is learning braille.  If you just run your fingers over the bumps without paying attention to what you’re feeling, you’ll never learn.  You need the internal cue to “feel” the bottom-up sensory information so that your brain can start to map out the necessary reference points.  An external cue of push into the paper would not help you read braille.

  • “Directing attention to sensory stimulation can increase perceptual sensitivity and modulate neuronal activity” -Heidi Johansen-Berg

Mindfulness

Essentially, internal cues help to improve body awareness through mindfulness.  Research shows mindfulness is  successful for treating various dysfunctions, including stress related responses (anxiety, depression, chronic pain, etc.).We know that stress increases the “noise” in the brain and makes it more difficult to hear other stimuli (i.e. your body).  We see this in the clinic when our patients are struggling to perform a simple exercise despite all the external cues.So how do you quiet the “noise” so that the patient can somatically listen to themselves?Research has shown that paying attention to internal body sensations can help to modulate the alpha rhythms of the brain can quiet the “noise”, thus making it easier to feel internal sensations.Practicing mindfulness with internal cues is like taking them from a rock concert in a small club to an outdoor symphony.

Benefits of Internal Cueing

Internal Cues Provide the Map

One of the factors that influences how we move now is our history (immediately and long term).  And this is where internal cueing can be useful.Take the deadlift for an example.  If someone has had back pain, sits for the majority of their day, hasn’t paid attention or felt their glutes in years, and barely works out, then they will not have their hips mapped out very well in their brains.  They won’t have the body awareness to know the difference between their hips moving and their lumbar spine moving.  Often in the clinic you see these people perform a bridge with an excessive amount of lumbar extension tone.  You ask them where they feel it, and they say their back.  Should you be progressing this person to a deadlift with external cues?Without a proper body map, the motor output will be compromised.  The feedback hasn’t been wired properly, so the feedforward output won’t have a strong reference point.  It’s as if the body will bypass the poorly mapped area (hips) and rely on other areas that are more robustly mapped (back)This is why I think internal cues to improve body awareness are important.  You have to make sure people can intrinsically feel and control their body - which would represent adequate cortical mapping.Once they have this body map awareness, you can confidently progress them to more complex motor tasks and use external cues to achieve the desired output.

  • Internal cues provide the map, external cues give you the directions

Before you can follow specific directions (external cues), you first need to know what town you're in (internal cues).

Changes Focus / Distraction from Pain

Another benefit that I’ve seen clinically from internal cueing is the simple distraction it provides patients.  Often times people will obsess about their pain and it becomes a part of every movement.  Instead of feeling the rest of their body, they focus on the painful area with all of their attention.  Thus, the brain writes more painful wiring for that area.  It’s a vicious cycle.Current research supports this empirical evidence - people in chronic pain have difficulty shifting their attention away from the painful area.Having people focus on internal cues away from the painful site can not only distract them from pain, but it will help the brain wire pain-free movement connections.  And more pain-free movement connections is a great thing for anyone in pain.https://www.youtube.com/watch?v=AGnGRgyLwMs

It Worked for Arnold and the Brosephs

7 time Mr. Olympia, Arnold Schwarzenegger, has discussed his use of internal cues and motor imagery to increase local hypertrophy.  And I think we can all agree that he’s been fairly successful when it comes to local hypertrophy.Ask any bro at the gym what they’re focusing on and the answer will likely be the local muscles.  But don’t judge them, if they’re just trying to increase local hypertrophy then they’re doing the right thing.  We now know that internal cues aren’t great for complex movements due to co-contraction and the constrained hypothesis theory, but they do lead to increased EMG activity.He's not using external cues

Ways to Influence the Internal Map

Internal verbal cues may be enough to help change your patient's internal map.  But when this fails, there are many other options to help facilitate the brain change and improve body awareness.

  • Attention Focus Internal Cues
  • Body Scan / Mindfulness
  • Exercise Modification (isolated, slow, groundwork, load, etc.)
  • Manual Therapy / Acupuncture
  • Dissociation Exercises
  • Stretching (Dynamic & Static)
  • Somatics (Qi Gong, Alexander Technique, Feldenkrais, Yoga, etc.)

Summary

If you’re working in high level athletics with people who need to improve performance, then external cues are preferred.  However, if you’re working with a much wider population that includes non-athletic people, people in pain, or people that live too externally, then internal cues may be very useful in improving movement and/or pain.  If you are unsure if this type of cueing is needed, simply ask your patient during an exercise - “where do you feel this?”.[subscribe2]

Coaching & Cueing

Part I – IntroPart II – The CategoriesPart III – Verbal Cues – ExternalPart IV – Verbal Cues – InternalPart V – VisualPart VI – ProprioceptivePart VI – SummaryKnowing how to influence movement with cues starts with understanding the different types of cues

References

Pincivero, Danny M., and William S. Gear. "Quadriceps Activation and Perceived Exertion during a High Intensity, Steady State Contraction to Failure." Muscle & Nerve Muscle Nerve 23.4 (2000): 514-20.Cafarelli, Enzo. "Peripheral Contributions to the Perception of Effort."Medicine & Science in Sports & Exercise 14.5 (1982)Lind, Erik, Amy S. Welch, and Panteleimon Ekkekakis. "Do ‘Mind over Muscle’ Strategies Work?" Sports Medicine 39.9 (2009): 743-64Lewis, Cara L., and Shirley A. Sahrmann. "Muscle Activation and Movement Patterns During Prone Hip Extension Exercise in Women."Journal of Athletic Training 44.3 (2009): 238-48.Snyder, Benjamin J., and James R. Leech. "Voluntary Increase in Latissimus Dorsi Muscle Activity During the Lat Pull-Down Following Expert Instruction." Journal of Strength and Conditioning Research 23.8 (2009): 2204-209.Clark, B. C., N. K. Mahato, M. Nakazawa, T. D. Law, and J. S. Thomas. "The Power of the Mind: The Cortex as a Critical Determinant of Muscle Strength/weakness." Journal of Neurophysiology 112.12 (2014): 3219-226.Yao, Wan X., Vinoth K. Ranganathan, Didier Allexandre, Vlodek Siemionow, and Guang H. Yue. "Kinesthetic Imagery Training of Forceful Muscle Contractions Increases Brain Signal and Muscle Strength." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013)Ranganathan, Vinoth K., Vlodek Siemionow, Jing Z. Liu, Vinod Sahgal, and Guang H. Yue. "From Mental Power to Muscle Power—gaining Strength by Using the Mind." Neuropsychologia 42.7 (2004): 944-56.Kerr, Catherine E., Stephanie R. Jones, Qian Wan, et al. "Effects of Mindfulness Meditation Training on Anticipatory Alpha Modulation in Primary Somatosensory Cortex." Brain Research Bulletin 85.3-4 (2011): 96-103.Mehling, Wolf E., Judith Wrubel, Jennifer J. Daubenmier, Cynthia J. Price, Catherine E. Kerr, Theresa Silow, Viranjini Gopisetty, and Anita L. Stewart. "Body Awareness: A Phenomenological Inquiry into the Common Ground of Mind-body Therapies." Philos Ethics Humanit Med Philosophy, Ethics, and Humanities in Medicine 6.1 (2011)Lebon, Florent, Christian Collet, and Aymeric Guillot. "Benefits of Motor Imagery Training on Muscle Strength." Journal of Strength and Conditioning Research 24.6 (2010): 1680-687.Fox, Carl Gabbard Ashley. "Using Motor Imagery Therapy to Improve Movement Efficiency and Reduce Fall Injury Risk." Journal of Novel Physiotherapies J Nov Physiother 03.06 (2013)Masters, R. S. W. "Knowledge, Knerves and Know-how: The Role of Explicit versus Implicit Knowledge in the Breakdown of a Complex Motor Skill under Pressure." British Journal of Psychology 83.3 (1992): 343-58.Johansen-Berg, Heidi, and Matthews P. "Attention to Movement Modulates Activity in Sensori-motor Areas, including Primary Motor Cortex." Experimental Brain Research 142.1 (2002): 13-24Gomez-Ramirez, Manuel, Natalie K. Trzcinski, Stefan Mihalas, Ernst Niebur, and Steven S. Hsiao. "Temporal Correlation Mechanisms and Their Role in Feature Selection: A Single-Unit Study in Primate Somatosensory Cortex." PLoS Biol PLoS Biology 12.11 (2014)Clark, B. C., N. K. Mahato, M. Nakazawa, T. D. Law, and J. S. Thomas. "The Power of the Mind: The Cortex as a Critical Determinant of Muscle Strength/weakness." Journal of Neurophysiology 112.12 (2014): 3219-226Stoykov, Mary Ellen, and Sangeetha Madhavan. "Motor Priming in Neurorehabilitation." Journal of Neurologic Physical Therapy 39.1 (2015): 33-42.Wondrusch, C., and C. Schuster-Amft. "A Standardized Motor Imagery Introduction Program (MIIP) for Neuro-rehabilitation: Development and Evaluation." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013):Kerr, Catherine E., Matthew D. Sacchet, Sara W. Lazar, Christopher I. Moore, and Stephanie R. Jones. "Mindfulness Starts with the Body: Somatosensory Attention and Top-down Modulation of Cortical Alpha Rhythms in Mindfulness Meditation." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013)Iriki, Atsushi. "Faculty of 1000 Evaluation for Temporal Dynamics of Plastic Changes in Human Primary Somatosensory Cortex after Finger Webbing." F1000 - Post-publication Peer Review of the Biomedical Literature (2006)Merzenich, Michael M., Randall J. Nelson, Michael P. Stryker, Max S. Cynader, Axel Schoppmann, and John M. Zook. "Somatosensory Cortical Map Changes following Digit Amputation in Adult Monkeys." J. Comp. Neurol. The Journal of Comparative Neurology 224.4 (1984)Lazar, Sara W., Catherine E. Kerr, Rachel H. Wasserman, Jeremy R. Gray, Douglas N. Greve, Michael T. Treadway, Metta Mcgarvey, Brian T. Quinn, Jeffery A. Dusek, Herbert Benson, Scott L. Rauch, Christopher I. Moore, and Bruce Fischl. "Meditation Experience Is Associated with Increased Cortical Thickness." NeuroReport 16.17 (2005): 1893-897.Farb, N. A. S., Z. V. Segal, and A. K. Anderson. "Mindfulness Meditation Training Alters Cortical Representations of Interoceptive Attention."Social Cognitive and Affective Neuroscience 8.1 (2012): 15-26Craig, Ad (Bud). "Interoception: The Sense of the Physiological Condition of the Body." Current Opinion in Neurobiology 13.4 (2003): 500-05.Mehling, Wolf E., Viranjini Gopisetty, Jennifer Daubenmier, Cynthia J. Price, Frederick M. Hecht, and Anita Stewart. "Body Awareness: Construct and Self-Report Measures." PLoS ONE 4.5 (2009)Hamilton, Roy H., and Alvaro Pascual-Leone. "Cortical Plasticity Associated with Braille Learning." Trends in Cognitive Sciences 2.5 (1998): 168-74.Polley, D. B. "Perceptual Learning Directs Auditory Cortical Map Reorganization through Top-Down Influences." Journal of Neuroscience 26.18 (2006): 4970-982.Arnsten, Amy F. T. "Stress Signalling Pathways That Impair Prefrontal Cortex Structure and Function." Nature Reviews Neuroscience Nat Rev Neurosci 10.6 (2009): 410-22Roosink, Meyke, Bradford J. Mcfadyen, Luc J. Hébert, Philip L. Jackson, Laurent J. Bouyer, and Catherine Mercier. "Assessing the Perception of Trunk Movements in Military Personnel with Chronic Non-Specific Low Back Pain Using a Virtual Mirror." PLoS ONE PLOS ONE 10.3 (2015)Arntz, Arnoud, Laura Dreessen, and Harald Merckelbach. "Attention, Not Anxiety, Influences Pain." Behaviour Research and Therapy 29.1 (1991): 41-50.Garrison, Kathleen A., Juan F. Santoyo, Jake H. Davis, et al. "Effortless Awareness: Using Real Time Neurofeedback to Investigate Correlates of Posterior Cingulate Cortex Activity in Meditators' Self-report." Front. Hum. Neurosci. Frontiers in Human Neuroscience 7 (2013)Schabrun, Siobhan M., Edith L. Elgueta-Cancino, and Paul W. Hodges. "Smudging of the Motor Cortex Is Related to the Severity of Low Back Pain." Spine (2015)Rock, David. Quiet Leadership: Help People Think Better -- Don't Tell Them What to Do: Six Steps to Transforming Performance at Work. New York: Collins, 2006.Qi Gong Classes with Tina Zhang.  New York City.  2014-2015.Alexander Technique Inservice - Emily Whyte.  New York City.  2015.Feldenkrais Workshop - Art & Science of the Method with David Zemach-Bersin.  New York City.  2015.--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.

 

July Hits (2015)

Clinical

1) These are awesome - Dan Pope shares a very useful 2 part shoulder rehab progression with a ton of exercise examples (Part 1 - Closed Chain & Part 2 - Open Chain).  And here’s his nice review of scapular dyskinesis.2) Do you know when to use an External Cue?  Do you know why?  If not, here's the answers - External Verbal Cues.3) The Gait Guys teach you about Forefoot Supinatus - “A forefoot varus differs from forefoot supinatus in that a forefoot varus is a congenital osseous where a forefoot supinatus is acquired and develops because of subtalar joint pronation.” 4) Here’s my analysis of the Deep Squat (Part 1 & 2).  Here’s Erson’s Top 5 Ways to Improve the Deep Squat.5) An answer to your patients "how long will this take" question...“Depending on the complexity of the activity, [experiments have required] four and a half months, 144 days or even three months for a new brain map, equal in complexity to an old one, to be created in the motor cortex.” -Swart6) "Extension or a repeated loading strategy is no longer novel if the brain is perceiving loading/WB/extension as a threat." -Erson with a nice post on extension and the clinical bias7) ““Toes up” technique involves consciously firing the anterior compartment muscles, particularly the extensor digitorum longus. It fires more into the extensor pool and assists in firing ALL your extensors through spatial and temporal summation and also helps to shut down flexor tone through reciprocal inhibition. It will also help you to rocker through your stance phase and get more into your hip extensors.”8) “Look down at your toes (neck flexors) and then flex forward at the waist to touch your toes. If the neck flexors are inhibited the nervous system senses threat and instability, so on the way down to touch the toes it stiffens the hamstrings so you don’t fall forward hurting yourself.” -Perry Nickelston with an interesting article on the nervous system’s influence on mobility9) Here’s my layman’s article on how to "fix your back" and improve your toe touch in less than 5 minutes.  Sorry for the click-baiting title - it’s really on how to decrease sympathetic tone, initiate non-threatening lumbar flexion, and activate the anterior core with the diaphragm in the proper position.10) Solid review from Zac Cupples on Dry Needling -

“Endogenous opioids play a huge role here. When this system kicks in, there is decreased immune molecule activity, reduced intracellular sodium, and increased potassium. This change increases resting membrane potential from -70 mV to -150 mV. That change makes it pretty tough for nociceptors to produce action potentials."

"Everyone loves the nervous system, but some aneural cells also stimulate opioid production. Both keratinocytes and fibroblasts have been shown to produce opioids, which may be why many skin-level therapies are effective for pain.”

Intrinsic Motivation

11) “Providing athletes with, choice, a rationale for tasks, opportunities for initiative taking and competence feedback that does not control or direct behavior are believed to be synonymous with positive motivational climates. If a coach can successfully adopt the prescribed behaviors linked to developing autonomy then they are likely to develop intrinsically motivated athletes that, invest more effort (Peltier et al,1995) report higher levels of concentration (Briere et al, 1995) are more persistent (Peltier et al, 2001) and perform better (Beauchamp et al,1996).”12) “As a coach, you can help an athlete develop this internal motivation by encouraging autonomy, self-efficacy, and relatedness.”

You Have to Understand Breathing to Understand Movement

13) Dave Tilly writes a very thorough breathing series (part 1, 2, 3).14) Jon Herting also has a solid breathing series (part 1, 2, 3)15) I’ll shamelessly promote my simple 2 part breathing series here as well (Part 1 & 2)

Tendinopathies

16) If you’ve been following this blog, then you know isometrics have been gaining popularity with respect to decrease tendon pain while providing safe mechanotransduction (#29, #3, #47, #20, #9,  #13, #3, Jill Cook, Andreo Spina Review).  More research (Heavy Slow Resistance, Reduced Cortical Inhibition) and blog posts (Body in Mind, Leon Chaitow - Mechanism) are now surfacing that will hopefully change the medical mainstreams bias of eccentric exercises for all tendinopathies.17) Tom Goom has some of the best tendinopathy posts here (stages, treatment 1, treatment 2).  Probably the best resources to share with your peers that may not know about tendinopathies.

Pain & Neuroscience

18) “The nervous system depends on consistent patterning in a non-threatening environment in order to best learn and perform. Patterns create security (though these patterns may not always be ideal). Security allows for one to pay attention and integrate sensory cues with minimal internal noise or distraction.” -Seth Oberst with another solid post on stress/threat (including some great clinical advice)19) A slightly ranty, but necessary, post by David Butler - “Overall, this is a call to be careful with Explain Pain – to understand what it is, as well as realise what it isn’t, to acknowledge the skills required to effectively deliver Explain Pain, and develop them where necessary, and finally, to recognise the need to think differently and more broadly, bringing in the rich world of education science and psychology, in the effort to achieve the very worthy goal of pain education for all.”20) Erson goes over a cervical case study and how he educated the patient on her pain.21) “A novel finding was that altered motor cortical organisation (number of discrete peaks and map volume) was associated with the severity and location of LBP.” #Smudging22) Psychology may work better than than traditional physical therapy for chronic low back pain.  This is what most pain science advocates have been saying for years.  The difficult part is training physical therapists to understand the complexity of psychology and communicate this with their patients in an effective way.23) “In fact, taking Tylenol can ease social pain just like it does physical pain. To your brain, they’re the same.” -Eric Barker on rejection24) Another reason why the shoulders and trunk are important in neck patients?25) You’re missing out if you haven’t signed up for ISPI’s Newsletter.

Memory

26) "The findings of both animal and human studies provide compelling evidence that stress-induced activation of the amygdala and its interactions with other brain regions involved in processing memory play a critical role in ensuring that emotionally significant experiences are well-remembered."27) Neural synapses store memories.  These synaptic connections last as long as the memories themselves.28) Todd Hargrove writes a great post on pain and memory - “I think one way that therapists can help clients with chronic pain is giving them a new way to frame past experiences of injury, and better ways to respond in an emotional intelligent way to new injuries.”

More on pain and memory - “It is concluded that pain induced by physical exercise is not remembered accurately and the pain and negative affect experienced influence recall.”

Training

29) Should we add rotation and anti-rotation to the Dan John five?  Delaine Ross thinks so.30) Nice review of Andreo Spina’s Controlled Articular Rotation (CARs) by Tom Bumgardner.31) 3 Different Shoulder Cues for 3 Different Shoulder Types for the Wall Shoulder Exercise.32) Dean Somerset shares some thoughts on why you shouldn’t force people to lift with symmetrical feet position.  What’s comfortable for the individual is usually the right posture.33) “The biggest reason I include reaching exercises is to give my athletes their abs back.” -Mike Robertson on 4 ways he’s evolving as a coach.  Great stuff in this article that you can use in your practice.34) Dean Somerset reminds you not to overcoach everyone.  Great infographic in this post.35) “Players are often successful because of traits and not just athleticism” -Eric Cressey on what makes a big league body36) Ryan Davis goes over 3 things Crossfitters need to do - Get Assessed, Practice, Recover37) Dean Somerset provides a humble post on the 5 mistakes he's made in the past.  Very useful commentary - I like the hamstring/sprinter example and the emphasis on cardio for lower level clients.

Research

38) Jeff Rich shared this great article on the subtle cavus foot and how to determine forefoot vs. rearfoot pathomechanics.39) It’s not just magnitude, it’s also about timing - “the application of a prefabricated foot orthosis with a 5° medial rearfoot wedge was associated with a significant delay in the timing of the peak knee abduction moment during the stance phase of running”40) “Synergistic muscles compensate for a fatigued muscle by increased muscle activity.”   Fatigue and compensation is a huge problem.41) Knowing about the Limbic System may help you understand the different responses people have to the same input.  “The monitoring role of anterior cingulate, the trisynaptic hippocampal circuitry underlying cognitive functioning and the significance of hypothalamus in various neurovegetative functions suggest the integral role of the limbic system in understanding human behavior and its aberrations.”42) “This study highlights the likely energy storage role of the ITB, which serves the purpose of increasing efficiency of human running. The anterior and posterior portions of the ITB store energy at different times, i.e. when they undergo stretch-shorten cycle during gait and this corresponds to high muscle EMG activity.”43) Did you know about the two different fiber types of the Subscapularis muscles?  “The line of action of the lower fibres are biomechanically advantaged for controlling or resisting excessive translation superiorly and anteriorly (especially in mid-range shoulder elevation). The upper fibres are advantaged biomechanically for producing internal rotation and horizontal flexion/adduction range of motion and force.”44) “Of 1283 survey respondents, only 27% of athletes reported using mental skills such as goal setting, positive self-talk, imagery, and relaxation. Of the 249 respondents who used mental skills 72% reported they felt it helped expedite their recovery process.”

Other

45) Some great advice on how to develop healthy movement in kids from Andreo Spina: 1) Don’t rush walking 2) Make them go barefoot as much as possible 3) Make them use their toes like fingers 4) Encourage standing and sitting without using hands 5) Let them play46) “Ten minutes of a smartphone in front of your nose is about the equivalent of an hour long walk in bright daylight.”  Get better sleep.47) “After an extended review of literature on prospection (your mental perspective of the future), and depression, they found that the perception of negative futures can trigger depression.”48) “Previous research has indicated that there is a kind of symbiotic relationship between self-focused attention and social anxiety, in that anxiety makes people more likely to draw their focus inward — likewise, focusing on yourself seems to increase anxiety. This new finding may point to a way out of that vicious, anxious circle. Doing small good deeds for other people naturally turns your focus outward, which may leave less room for obsessive self-reflection.”49) Communication skills are often overlooked.  The Laddering Technique can be used to get to someone’s core beliefs and values.50) “Specifically, the study finds that people who walked for 90 minutes in a natural area, as opposed to participants who walked in a high-traffic urban setting, showed decreased activity in a region of the brain associated with a key factor in depression.”51) The Four Foundations of Mindfulness

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 Not the best way to train your hip hinge               [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.

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Phone: (203) 561-5627 Email: bbearpt@gmail.com Fax: (828) 285-1274