Embracing Complexity: The Mountain Stream Metaphor

• "For every complex problem there is an answer that is clear, simple, and wrong" -H.L. Menken

Keeping “it” simple is important at times.  It prevents us from becoming overwhelmed, clarifies concepts, aids in general understanding, and directs the focus towards a single goal.  Most importantly, keeping it simple is necessary when communicating new topics or concepts to others.  However, the problem occurs when keeping it simple is used a substitute for understanding the complexity.When we oversimplify complexity it increases the chances of a blunder occurring.  Assumptions, cognitive biases, and ignorance all become more prevalent when we start to overlook the dynamic and intricate patterns of problems, situations, and systems.  This can be seen in everything from politics to healthcare.  Even everyday discussions are often plagued with people over simplifying a topic to support their perspective (whether they know it or not).Thus, to avoid these cognitive traps and mental errors it is important to embrace complexity and attempt to identify and study it, not to ignore or eliminate it.One way to understand complexity is through the Dynamic Systems Theory.  More specifically, I have found the following metaphor from Esther Thelen to be an interesting  thought experiment.  She invites you to become aware of the ever-changing complexity of something as “simple” as a mountain stream.

The Mountain Stream Metaphor

“The metaphor is of a fast-moving mountain stream. At some places, the water flows smoothly in small ripples. Nearby may be a small whirlpool or a large turbulent eddy. Still other places may show waves or spray. These patterns persist hour after hour and even day after day, but after a storm or a long dry spell, new patterns may appear. Where do they come from? Why do they persist and why do they change?No one would assign any geological plan or grand hydraulic design to the patterns in a mountain stream. Rather, the regularities patently emerge from multiple factors: The rate of flow of the water downstream, the configuration of the stream bed, the current weather conditions that determine evaporation rate and rainfall, and the important quality of water molecules under particular constraints to self-organize into different patterns of flow. But what we see in the here-and-now is just part of the picture. The particular patterns evident are also produced by unseen constraints, acting over many different scales of time. The geological history of the mountains determined the incline of the stream bed and the erosion of the rocks. The long-range climate of the region led to particular vegetation on the mountain and the consequent patterns of water absorption and runoff. The climate during the past year or two affected the snow on the mountain and the rate of melting. The configuration of the mountain just upstream influenced the flow rate downstream. And so on. Moreover, we can see the relative importance of these constraints in maintaining a stable pattern. If a small rock falls into a pool, nothing may change. As falling rocks get larger and larger, at some point, the stream may split into two, or create a new, faster channel. What endures and what changes?”

A Movement Assessment Example

Let’s take the example of someone who can’t touch their toes.It may be useful to give this person a specific, simple exercise (ex. KB ASLR) and education (ex. thought viruses) to help cause an immediate shift in their movement pattern - kind of like a rain storm quickly altering the way the stream runs.  The benefit of this approach is that it offers control and predictability, which are two main factors when working with stressed and painful systems.  However, as many of us have experienced in the clinic, these quick changes are usually temporary and are neither complete nor permanent fixes in themselves.  The rain storm passes and the stream returns to it’s former pattern.  To truly affect the path of the stream it’s important to direct some attention to the entire mountain system.In the example of someone who can’t touch her  toes it is important to acknowledge the mountainous (sorry, couldn’t resist) complexity of “why”... Maybe she can’t touch her toes because she has a stiffer body that lays down more collagen - her parents can’t touch her toes and their parents’ parents couldn’t touch their toes (epigenetics?).  Maybe her allostatic load is too high because she’s overstressed from her job or relationships.  Maybe she’s not motivated.  Maybe she has a psychological issue - depression, anxiety, history of trauma, etc.  Maybe it’s behavioral.  Maybe she grew up in a very sedentary lifestyle and prefered to read or play video games for the first 26 years of her life.  Maybe she was taught to lift weights or perform athletic techniques improperly and hammered those patterns into her body over many years.  Maybe she believes that rounding her back or lengthening her hamstring is dangerous.  Maybe she has a cold (neuro-immune connection).  Maybe her microbiome is a mess.  Maybe she doesn’t sleep well and has a circadian mismatch.  Maybe it’s her vestibular system, stomatognathic system, or vision.  Maybe it’s neurodynamics.  Maybe it’s her respiration.  Maybe it’s an osseous abnormality.  Maybe she can’t IR her femur because of her pelvis position.  Maybe a joint is tight in her cervical spine that decentrates the rest of the body.  Maybe it’s a forefoot varus.  Maybe it’s her posterior hip capsule.  Maybe her paraspinals are unable to eccentrically control the movement.  Maybe it’s her core. Or maybe it’s one of the other many things that could prevent any human from touching their toes.It’s important to acknowledge the intricate, evolving interaction of these variables, which then becomes another variable in and of itself.  It’s the perspective of “the whole is greater than the sum of its parts”. Once all this is considered it will be easier to determine which variables can act as a control parameter to cause the desired phase shift of the system. In other words, maybe for the aforementioned patient a neurodynamic exercise would provide an adequate stimulus to shift her system into a place where she can perform a full, pain free toe touch.  Or maybe it will require a combination of stimuli such as a core strengthening program, improved sleep hygiene, and graded exposure.  Or maybe...The success does not lie in the intervention, but how the system responds as a whole.This complexity is why one exercise, manual technique, or communication style will work well with one patient, but have no effect on another “similar” patient.  Or why someone may not do well with physical therapy, but feels better after going to a dietician or getting a new job.Some people may be able to alter their stream easily with a simple passing weather pattern, while others will need a long-term tectonic shift.  The art is finding where the change needs to come from.Simple will work at times, but it is not a solution for all.  The human species is far too complex to be simple.

Bottom Line

It’s great to keep it simple on some levels.  But don’t make the blunder of convincing yourself that it is simple.  Instead, embrace the complexity.  How do you do this?Dig deeper.  Try to gain a better understanding.   Always look to learn more.   Learn to enjoy the state of not knowing - curiosity.  Find the quality.  Never be satisfied.  Always ask why.  Then ask why several more times.  And dedicate yourself to the lifelong effort of finding the elusive truth.Again, to reiterate, this isn't to say simple is bad. It's just that oftentimes I find the beauty of simplicity comes from understanding its complexity.

• “A philosopher is a person who knows less and less about more and more, until he knows nothing about everything.” -John Ziman

Thelen, E. and Smith, L. B. 2007. Dynamic Systems Theories. Handbook of Child Psychology. I:6.-- 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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March Hits (2016)

The Hits

This is just a collection of some of my favorite articles from the past month.  I bolded the numbers of the articles that I found most remarkable.  Of course, this is just my bias.  I think all the articles here have value.  I just realize that some readers may be looking for something more brief.Also, I want to encourage any reader to share their favorite articles, books, or podcasts of the month in the comments below.  There’s only so much information that I can go through in a month.  I know there’s a ton of great stuff out there that isn’t on my radar.  It will not only help introduce me to new perspectives, but it will provide other readers this opportunity as well.

Phone Addiction

• “Only one thing made him happy and now that it was gone everything made him happy.” -Leonard Cohen

A big part of our ability to live longer comes from the knowledge of what harms us.  Smoking, aluminum production, lead, high fructose corn syrup, artificial sweeteners, poor sleep, sitting, and now smartphones.Unfortunately, not many people are open to the idea that their cell phones are bad for them.  At least not beyond a surface level acknowledgement.I wrote this article on 25 reasons why your cell phone is bad for you.  It has a ton of resources for many different categories.  Hopefully it will serve as a resource to bring awareness of the hazards of smartphone overuse.  Share it with those that you think need to hear it.Here’s a similar article with detailed recommendations on how to “Break Your Smartphone Addiction”

Clinical

• “What gets measured gets managed.” -Peter Drucker

1) “Proprioception is the same way, it is an active process, not a passive one. Many of the our movements have a primarily epistemic purpose – they are not done so much to directly accomplish a physical goal, but to create proprioceptive information that optimizes or simplifies motor control.“ -Todd Hargrove with another great post on the importance of feel2) The insurance problem and how to get patients to understand by Aaron LeBaur3) How much true ankle dorsiflexion does your patient have in a squat?  Have them lift their toes and THEN squat.  Removes the ability to pronate as a compensation.4) Gait Guys teach you about the dreaded banana toe and offer some solutions (rocker bottom shoes, FHL exercises).5) I remember during my cardiopulmonary affiliation I asked why nose breathing was better.  No one could supply a detailed answer.  Some PTs had a vague idea, most MDs just dogmatically believed it.  Luckily, Noah Harrison lays out an in depth article on the benefits nose breathing and hyperventilation.  He covers a ton and this is well worth the time.  Very good work here.6) The STarT LBP Tool - “Overall, the results of this study indicated that stratified management of patients with LBP lead to improved efficiency of care, better outcomes and reduced costs. Significant improvements in secondary measures were also noted.”7) If you have any interest in asthma or the reasons why nose breathing is superior, then you should read this article from Noah Harrison.8) Erson goes over 5 reasons why thoracic manipulations are good.9) If you want to know more about the PosteroLateral Corner of the knee read this post.  I think I’m going to start incorporating that prone dial tests.  Provides some solid information when used in conjunction with knowledge of osseous structures and active ROM (i.e. torsions).  This post also made me think about how the popliteus and lateral hamstrings both attach to the same area, but can function as antagonists (open chain: poplitieus IR tibia, biceps femoris ER tibia)10) Acupressure Mats?11) Erson shares some great TMJ exercises / correctives / resets to give your patients.12) When someone has cross-over gait, “ the time usually used to move sagittally will be partially used to move into, and back out of, the frontal plane. This will necessitate some abbreviations in the left stance phase timely mechanical events. Some biomechanical events will have to be abbreviated or sped through and then the right limb will have to adapt to those changes.”13) "Improving thoracic "extension" is not about extending the thorax and/or thoracic spine, particularly over an object of some kind (I.e. foam roller). It is about influencing the tipping of the thoracic vertebrae in the horizontal plane and the corresponding ribs in the rotational plane, although it is a rotational influence affecting the horizontal resting position. If the anterior aspect of the thoracic vertebrae is tipped up, it's extended." -Michael Mullin14) Small study size, but interesting content.  "The comparison of all chews showed a highly significant preference towards the R side" (via Michael Mullin)15) This one from the Gait Guys starts out as a simple pronation compensation for lack of hip IR and ends up with a complex movement thought experiment - “If the hips are not clean, gait is not clean, and that means repetitive arm swing-thoracic-respiratory mechanics are not clean.”16) Gait assessment is always important - slower gait associated with a higher mortality risk.17) “The point here today, if you have loss of external hip rotation, it could be crying for you to evaluate the range of motion of the 1st MTP joint , it could be crying for you to evaluate the skill of toe extension, strength or endurance or all of the above. Impairment of the 1st MTP has great inroads into ineffective locomotion. You must have decent range of motion to effectively supinate, to effectively toe off, to externally rotate the limb, to effectively acquire hip extension to maximize gluteal use.  Thus, one could easily say that impaired hallux/great toe extension (skill, ability, endurance, strength) can impair hip extension (and clean hip extension patterning) and result in possible terminal propulsive gait extension occurring through the lumbar spine instead of through the hip joint proper.” -Gait Guys #ExternalRotationHappensWithHipExtension 18) Inform Your Patients on the Dangers of Sitting with this easy 3 minute video - Deskbound by Kelly Starrett19) Another interesting movement thought experiment from the Gait Guys “One last thing, rushing to the right forefoot will force an early departure off that right limb during gait, which will have to be caught by the left quad to dampen the premature load on the left. They will also likely have a left frontal plane pelvis drift which will also have to be addressed at some point or concurrently. This could set up a cross over gait in some folks, so watch for that as well.“20) The Gait Guys offer some rational advice on how to view the short foot exercise - "The foot has to be prepared at the time of contact with its’ most competent arch, not busy reacting after the fact trying to achieve the competent structure. The value in the short foot is earning competence in its loading ability and learning to control its adaptive eccentric lengthening, this must be possible in both toe extension and toe flexion (ground contact)."21) Quick Book Reviews

Cranial Intelligence by Ged Sumner and Steve Haines

Ron Hruska recommended this book.  It is very well written and goes over craniosacral concepts from a modern science perspective.  Some of these concepts are far fetched, while others provide a solid connection to the questions many clinicians have.  I really enjoyed the humble and holistic approach.  Overall, it gave me a novel view on the human species and another method for assessment and intervention.  

Fully Present by Diana Winston and Susan Smalley

This is a must read for any clinician.  Each chapter has a thorough evidence-based science section and an accompanying “art” section that goes over practical implications.  The book is very concise, yet very dense with useful information.  It will make both the clinician and the patient better.  And if you either think mindfulness is new-age fluff or are worried about religious implications, then you should read this book as it will reverse those assumptions.

22) I listened to Aaron LeBauer’s lecture on Cash-Based PT and marketing.  He had a very important point - we shouldn’t refer to physicians, surgeons, general practitioners, internists, cardiologists, etc. as doctors.  Because as physical therapists we are doctors!  Asking patients “what their doctor said” not only empowers the other professional, but it belittles us.  We should all jump on board with this.  We shouldn’t be discrediting our profession by referring to our peers as something above us.  #DirectAccess

Pain, Neuroscience, & Psychology

• “Everything we hear is an opinion, not a fact.  Everything we see is a perspective, not the truth” -Marcus Aurelius

23) “This tension is not only physical, that of the neuromuscular system, but also cognitive such that thoughts become repetitive and lack flexibility. ​When the gap between our self-image and our perception of the environment is large and pervasive enough across several domains, we experience these tensions in a way that is difficult to relieve and affects both function and performance.” -Seth Oberst24) “Inability to avoid visual distractions linked to poor short-term memory”25) “Mastering the art of ignoring makes people more efficient”26) “When you combine pleasure and meaning, you’ve got happiness.” -Eric Barker on 5 ways to find happiness27) Why bromances are a good thing - “Human studies show that social interactions increase the level of the hormone oxytocin in the brain, and that oxytocin helps people bond and socialize more, increasing their resilience in the face of stress and leading to longer, healthier lives.”28) “A socially engaged lifestyle often involves cognitive stimulation and physical activity, which in turn may protect against the neurological and physical factors underlying cognitive decline,” 29) A good read from Tim Cocks and David Butler on Though Viruses “If a person says “it hurts”, then no one can say it doesn’t – there is only one witness to the event.”30) Erson shares a video that goes over his patient pain education approach31) “A series of studies have found a connection between economic insecurity and physical pain.”32) Maybe we were wrong. Maybe there are no limits to willpower. "The more we begin to see that we can learn effectively and believe that our effort and stamina is not exhaustible, the more we develop resilience in the face of challenges."33) "Don’t use the term “depression,” which is loaded with negative and clinical connotations, without considering other labels that might be more appropriate. “Loneliness” or “isolation” are two common substitutes which are not just more precise but more actionable (the term “depression” doesn’t suggest a solution)."-Tim Ferris with a great post on depression and gives some useful advice34) Jeffrey Schwartz 4 Step Process to Improve Behavior

Step 1: Relabel

Step 2: Reattribute

Step 3: Refocus

Step 4: Revalue

Training

• “Enjoyment depends on increasing complexity.” -Mihaly Csikszentmihalyi

35) Mike Robertson shares 5 mistakes he’s made with training the core: too much supine work, not training hip flexion, avoiding spinal flexion, not having more progression, not including contextual core training in the warm-up.  

“I’ve never seen an athlete meekly flex their hip, and then powerfully extend it back. There needs to be balance on both sides of the joint, both for safety and control.”

36) The devil is in the detail...or the triceps in the deadlift.37) 5 Ways to Increase Your HRV by Joel Jamieson38) Great article on Steph Curry's ankle problems39) Dean Somerset goes over mobility in a very FRC kind of way.  Solid explanations in this one.40) Hex-Bar Deadlift vs. Conventional Deadlift

“the net joint moment in the straight-bar deadlift is for knee flexion, which is produced by the hamstrings, while in the hex-bar deadlift it is knee extension, which is produced by the quadriceps. Because of co-contraction, both muscle groups will be contracting hard, but this still indicates that there is a difference in terms of which muscle group is exerting the most force in each variation”

“not only does the hex-bar deadlift make the quadriceps work harder, but also cuts the low back, hip extensors, and ankle plantar flexors some slack into the bargain.”

“the hex-bar deadlift is probably more effective for developing force and power in the lower body, compared to the conventional, straight-bar deadlift.”

41) The Landmine Press - “if you have clients that struggle to go overhead, this is a great way to “bridge the gap” between horizontal and vertical pressing”42) Here’s a thorough review of cryotherapy from Travis Bruce (Part 1 & Part 2) - “Ice baths blunt the acute molecular response to resistance training and impair long-term gains in muscle mass and strength. Athletes should reconsider using ice baths after strength training, particularly in the off-season or preparatory period when the focus is on adaptation rather than performance.”43) I think the power of the mind in training is one of the most overlooked exercises by all movement enthusiasts.  Here’s a great article that goes over how to use motor imagery for weight lifting.  Overall, you want to make it as similar to the real life situation.  You can do this by using PETTLEP.  Which is Physical, Environment, Task, Timing, Learning, Emotion, and Perspective.44) Eddie Hall Broke the World Deadlift Record at 1025 Pounds

Quiet Eye Technique

45) The Quiet Eye Technique “refers a gaze behaviour observed immediately prior to movement in aiming tasks”.   “Theories as to why the QE is so effective as a trait of expert performance appear to base around the increased processing time.  When more time is taken to view the target before initiating a movement more relevant information can be processed subconsciously about the target and what is required to hit it.“  Or like Lexi Thompson, you could putt with your eyes closed.  #FinalFixation #ContactPoint

Research

• “Intuition tells the thinking mind where to look” -Jonas Salk

46) ““This means two things: that facial imitation is, at least in part, lateralized – that is, it copies the expression it observes – and that it is asymmetrical in an anatomical rather than specular manner”, explains Korb. Therefore, when we observe an expression that begins on the left side of the face, we mimic it with the left side of our face, and not with the right side as if we were in front of a mirror.”47) “Six weeks of a dynamic injury prevention warm-up program results in biomechanical improvements that last up to 6 months after stopping the program.”48) "Participants with CAI (chronic ankle instability) display hip-centred changes in movement and motor control patterns during a DVJ (drop vertical jump) task compared to LAS (lateral ankle sprain) copers. "49) Aerobic exercise is better than high-intensity interval training which is better than strength training for neurogenesis.  #ExerciseForYourBrain #BDNF50) “Contrary to popular belief, shoes with cleats that improve their grip on grass surfaces are likely to be associated with less stability than flat-soled shoes.”51) “The researchers found that, during moderate-speed running in lightweight, zero-drop shoes, foot orthoses designed to limit arch compression by 80% increased metabolic cost by about 6%—a figure that would likely be higher at faster running speeds.”52) "the soleus motoneuron pool excitability increased following lumbar paraspinal fatigue" #GottaStayUpright53) Crack ‘em.  “A significant difference was present between the manipulation group and the mobilisation/ exercise group. Statistical analyses show that patients in the upper cervical and upper thoracic manipulation group experienced less frequent headaches.”54) Every once in awhile the human body will give me a WTF moment.  Here’s a recent one - “Neck-tongue syndrome (NTS) is defined as neck and/or head pain accompanied by ipsilateral dysesthesia of the tongue with sudden rotation of the head. Proposed causes include compression or irritation of the C2 nerve root as it courses behind the atlantoaxial joint or hypertrophy of the inferior oblique muscle.”55) “The current study established that heightened levels of myofascial tenderness in the upper trapezius and temporalis muscles showed a positive correlation between high levels of jaw and neck dysfunction...The fact that neck and jaw disability are strongly related stresses the importance of assessing and treating these two separate body segments concurrently.”56) “the potential effects of WBV (whole body vibration) on muscle strength (facilitating neuromuscular conditioning by stabilizing joints via the tonic vibration reflex) balance (for obvious reasons) and neuropathic pain are promising.”57) “This study investigated the novel approach of combining the squat exercise with local muscle vibration (LMV), whole body vibration (WBV) and compared the results to the squat exercise without any vibration. The group which had received the WBV, as well as the LMV group showed significant improvements of the quadriceps function compared to the group without vibration.”

Other Good Stuff

• “If someone succeeds in provoking you, realize that your mind is complicit in the provocation.” -Epictetus

58) “When a life or plan feels ultimately unsatisfying, I find it’s because I’ve forgotten to include:”

what makes me happy

what’s smart (long-term good for me)

what’s useful to others

Diet

59) 6 Foods That Cause Inflammation: Sugar/High-Fructose Corn Syrup, Artificial Trans Fats, Vegetable and Seed Oils, Refined Carbohydrates, Excessive Alcohol, Processed Meats60) Anti-Inflammatory Diet - great overview of the latest evidence of the causes and treatments61) 13 Anti-Inflammatory Foods: Berries, Fatty Fish, Broccoli, Avocados, Green Tea, Peppers, Mushrooms, Grapes, Turmeric, Extra Virgin Olive Oil, Dark Chocolate & Cocoa, Tomatoes, Cherries62) Inulin supports the growth of beneficial gut bacteria. This keeps the gut bacteria balanced and may have various health benefits.63) 9 Ways to Influence Your Hormones to Lose Weight64) “New evidence suggests when the gut is inflamed, it may affect the brain and lead to psychological dysfunction.”65) 20 Nutrition Myths Debunked with Research66) 50 Reasons Why You Should Buy Organic67) “the results of a huge new meta-analysis published this week in the British Journal of Nutrition adds to the evidence that organic production can boost key nutrients in foods”

Sleep

68) Sleeping <7 hours per night is associated with increased risk for obesity, diabetes, high blood pressure, coronary heart disease, stroke, frequent mental distress, and all-cause mortality

An Important Perspective

• "You are never dedicated to something you have complete confidence in. No one is fanatically shouting that the sun is going to rise tomorrow. They know it's going to rise tomorrow. When people are fanatically dedicated to political or religious faiths or any other kind of dogmas or goals, it's always because these dogmas or goals are in doubt." -Robert Pirsig

--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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The Problem with Smartphones

• "Men have become the tools of their tools." -Henry David Thoreau

Before I proceed and alienate everyone, I first want to clarify that I am not against technology and I don’t think smartphones are inherently bad.  I’m not trying to pull a John Connor and convince you to rage against the machine and destroy your cell phone.  In fact, I think technology is a critical component of our culture’s development.  Smartphones can be extremely helpful.  Not only can they end many arguments with instant fact-checking, but they provide an  endless supply of free information and the ability to connect with almost anyone in a first world country.  This creates many opportunities that wouldn’t exist otherwise.But like my mom always says, “everything is okay...in moderation.”The problem arises when smartphones go from a tool to a behavior.  Soon after this, addiction ensues.  Next thing you know you’re so dependent on your cell phone that you’re looking for outlets in public places.I know what you’re thinking, a cell phone addiction isn’t that bad as far as addictions go.   It’s just a cell phone, right?  I would strongly disagree.  Not only are all addictions/attachments are bad, but cell phone addiction can have some serious side effects.  To make this evident, I’ve created this list to help people understand the dangers of a cell phone addiction.

25 Reasons Why Your Cell Phone is Bad for You

1. It’s an Addiction (like a drug) 2. Promotes Static Posture (text neck, text claw, slump back, decreased novel sensory input, etc.)3. It’s a Distraction4. Exposure to Radio Frequency Electromagnetic Fields5. Increases Stress6. Can Damage Your Hands7. Blue Light8. Damages Vision / Eyes (Myopia)9. Reduces Downtime10. Reduces Situational Awareness11. Endangers Kids12. Makes You A Bad Parent13. Impairs Gait (disturbs the way you walk)14. Increases Sedentary Lifestyle and Risk of Obesity (even the blue light alone alters metabolism)15. Disrupts Sleep (click here to understand why sleep is important for your health)16. Decreases Attention Span and Capacity17. Decreases Quality of Interactions with Those Around You (damages relationships)18. Tends to promote shallow work instead of deep work19. Prevents Creativity and Daydreaming20. Makes You A Dangerous Driver21. Creates Unnecessary “Work”22. Increases Risk of Mental Health Problems (depression, anxiety, narcissism, etc.) - especially social media use23. Harvests More Bacteria Than a Toilet24. Inhibits Interactions With Surrounding Environment/Nature25. Makes You Less Homo Sapien

• “The danger always exists that our technology will serve as a buffer between us and nature, a block between us and the deeper dimensions of our own experience.”-Rollo May

10 Things That Will Help

1. Treat it like an addiction2. Become aware of your phone use (use an app to assess the time you’re on your phone, yes, I do appreciate the irony of this)3. Leave your phone in another room4. Limit the amount of times you check social media per day5. Don't check social media or emails until late morning/early afternoon6. Put your phone out of reach when you’re spending time with others or doing activities that require attention7. Turn off notifications8. Focus on other things (mindfulness, hobbies, books, etc.)9. Shut off all screens at least one hour before bed10. Take a Digital Sabbatical--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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February Hits (2016)

The Hits

This is just a collection of some of my favorite articles from the past month.  The bolded the numbers of the articles that I found most remarkable.  Of course, this is just my bias.  I think all the articles here have value.  However, I realize that some readers may be looking for something more brief.Also, I want to encourage any reader to share their favorite articles, books, or podcasts of the month in the comments below.  There’s only so much information that I can go through in a month.  I know there’s a ton of great stuff out there that isn’t on my radar.  It will not only help introduce me to new perspectives, but it will provide other readers this opportunity as well.

Clinical

• “The job of a skilled therapist is to detect where the system is open to change, to provide the appropriate new input to destabilize the old pattern, and to facilitate the person’s seeking of new solutions” -Esther Thelen (via Seth Oberst)

1) One of the better ACL articles I’ve read in a while.  Read this post - especially the part on terminal knee flexion.  Great explanations and quick video demonstrations.  Very useful for the clinic tomorrow.  Here’s one gem from the article series - “The ability of the hamstring to pull the heel to butt is a necessary pre-requisite for dorsiflexion.”2) The Longus Capitus attaches to the foramen magnum?  How did I overlook that?3) Sick of patients asking for you to put their pelvis/SIJ back in place?  Try these 3 steps to change their thought virus.

Challenge a Concept

Provide an Alternative Concept

Provide Evidence for a New Concept

4) It’s important to be able to screen for the serious stuff, like cervical myelopathy. 5) Sometimes I feel we can get carried away with giving all of our attention to the newest tricks, theories, and/or concepts.  Often, the real clinical issues are overlooked.  Here’s a great, honest post on healing time frames.  I agree, most people think they’re supposed to get better quicker than they should and most patients and PTs overlook the long-term plan of care (>12 months).6) If you enjoy reading about evolution you should check out this strong article by Noah Harrison. "Whether we sit or stand, humans do not tolerate stasis well."7) Read this slowly - “Ankle eversion ROM and peak eversion velocity were greater in uninjured runners while peak eversion angle was greater in injured runners. “  Interesting.8) Christine Ruffolo shows you how to relax your neck and gives the best one sentence summary of the FRC system - “The basic premise of Functional Range Conditioning is to capture passive ranges of motion in the end range and make them more active.”9) A nice post reminding us of the hazards of sitting.  Supported with links to research.10) Mike Reinold shares his overhead shoulder mobility assessment for soft tissue vs. other factors.  He internally rotates the shoulder to slacken the teres minor and lat.11) Erson shares 5 spinal flexion myths.  After reading that, If you’re still not sure about spinal flexion read the book The Spinal Engine.  Then if you’re still uncertain about spinal flexion you should quit your job as a physical therapist.12) An informative post on the latest Lumbar Radiculopathy vs. Sciatica and enhanced specificity of surgical referral - “Lumbosacral radicular syndrome is a more explicit term. As our understanding of this condition sharpens to be more accurate in terms of both the clinical features and related patho-anatomy, it is helpful if we move away from the term ‘sciatica’ and embrace ‘lumbosacral radicular syndrome’.”13) The therapist-effect. This study shows PTs who are calmer, more relaxed, secure, and resilient have better outcomes with patients with chronic diseases. 14) I see a lot of extension based back pain.  Dave Tilly has an article series on how to address this problem in the athletic population.15) I enjoyed these great sound bites from Cinemasays’ 2015 Interviewing Summary post16) Erson shares 5 questions you should ask yourself regularly17) The deep squat is always a hot topic.  Dan Pope provides a new article series investigating the safety of the exercise.18) LER Magazine is always solid - good stuff from this one

Why the half-kneeling ankle mobilization is not the end all be all to ankle dorsiflexion problems - “In 2002, DiGiovanni and colleagues authored a study that showed 88% of healthy patients with forefoot or midfoot pathologies or both presented with posterior muscle group tightness.  More specifically, they, like others, found the majority of the patients suffered from an isolated gastrocnemius equinus, as opposed to a gastroc-soleus complex equinus.”  Which is why I often give a version of this exercise to my patients with decreased ankle DF

"Typically, the center of pressure on the foot can be measured 6 cm anterior to the ankle during gait, but with equinus, it is shifted distally and laterally.”

Biomechanical vs. Anatomical Breathing

19) I was talking to Cameron Yuen at a recent course about my love for kettlebells and desire to someday become SFG certified.  I mentioned how I’m not sure I could pass the snatch test.  Cameron asked if I had tried anatomical breathing.  I told him I hadn’t even heard of it.I went home and did some research on the topic.  Not only was there very little on this method, but the quality was poor.  I reached out to Cameron and asked if he would do a guest post to clear things up for me.  Luckily, he obliged.Here’s a solid post on the difference between Biomechanical and Anatomical Breathing. I’ve been able to integrate this into practice immediately.

Pain & Neuroscience

• Tension is who you think you should be.  Relaxation is who you are.

20) “Modern neuroscience indicates quite clearly (read Subliminal) that our subconscious interpretation of sensory input is largely viewed thru a predictive lens informed by our past behaviors and experiences.”-Seth Oberst21) "Once we identify with something it becomes uncomfortable to let go of, even if we want to. So many of the persistent pain clients I work with struggle to "let go" of THEIR pain, in part because of an identification with it. IT has become part of them and is reinforced both neurologically and psychologically by every x-ray and MRI reading and every stressor that elicits the symptoms."22) “Pain is recognised as part of the human experience. So we tend to assume that communicating about pain will seamlessly cross cultural boundaries. But people in pain are subject to the ways their cultures have trained them to experience and express pain.”23) “the biophysical substrates of conscious states (including pain and suffering) in any species, including humans, cannot yet be confidently identified“24) "According to these results people with symptoms of depression have nearly 60% increased odds of developing an episode of low back pain compared to those without depression symptomatology, with the risk being higher in patients with more severe levels of depression."25) Spend some time with this one.  Top Ten Neuroscience Breakthroughs of 2015.  Very important one to read.26) Great read on acceptance and commitment therapy - “From the perspective of radical behaviorism, the problem here is not limited to avoidance and its associated problems, further problems are likely when avoidance behavior persists in spite of equally persistent failures to achieve its objective (i.e., pain reduction or elimination) over the longer term.” :|: “Thus, the issue is not to just “accept it”, but to determine if there are areas in life that are worth the experience of pain.”27) Anxiety makes blindfolded people walk more towards the left28) Todd Hargrove summarizes Andy Clark’s Extended Mind concept - “we generally fail to appreciate how much information processing gets done in interactions between the brain, body and environment”

Training

• “If you are going to include an exercise in a program, you absolutely have to be able to justify how it's going to create the training effect you want” -Eric Cressey

29) One of the best reads this month from Pavel - “In training, you can achieve flow by learning to love the process, by treating it as a quest for technical mastery rather than a mindless smoker. You must go deeper into your skills rather than broader. Prof. Csíkszentmihályi reminds us that, “Enjoyment depends on increasing complexity.””30) Nice article on bottoms-up kettlebell training with exercise examples and quick summaries of the benefits (centration, stability, focus, irradiation, etc).  I’m not sure if it’s funny or sad that the title is “the weirdest training method that works”31) Sports Science Infographics shows you the dangers of fatigue and how it can have lasting effects32) Eric Cressey coaches the Offset Kettlebell TRX Row33) The last several months I’ve really been interested in hamstring strength.  I think it’s often overlooked and under appreciated.  Here’s the Poor Man’s Hamstring/Leg Curl.34) Mike Robertson goes over the cat-camel exercise.35) Eric Cressey shares 5 of his favorite exercises that "over deliver"36) Add upward rotation, shoulder abduction, elbow flexion, or core control to make the waiters carry more effective.37) 3 Ways to Make Exercises More Difficult: 1) Increase the ROM 2) Change the Tempo 3) Internal Cues or Focused Tension38) It’s important to ensure proximal control throughout the continuum of movement - not just in the high-threshold patterns.  Here’s an article on regressed core exercise.39) Some fat loss templates by Mike Robertson40) ”early-morning exercise in the fasted state is more potent than an identical amount of exercise in the fed state for maintaining healthy waistlines”41) I really like Dean’s research summary and his half kneeling passive to active ankle dosiflexion rock back exercise.42) “The abs are crucial for multi-directional speed. If you can’t control the pelvis, you can’t load the hip.”-Mike Robertson with 31 thoughts on speed and agility

Exercise of the Month

https://www.youtube.com/watch?v=lkUx1ZBYWyEScales are a great way to improve open and closed chain strength and motor control.  There are an infinite amount of motor patterns to work on.  Lately, I've been working on my open chain hip flexion in this pattern (standing ASLR).  It's a much better option than aggressively stretching the posterior chain.Notice how I lean back to compensate for my lack of motor control.  I didn't know I was doing this until my wife filmed me for this video.  I've been able to consciously correct it, but it's a reminder of the importance of showing the individual the movement error.

Research

43) Intrinsic foot muscles have the capacity to control deformation of the longitudinal arch44) Want to improve performance?  Get more sleep.  “Athletes who obtained less than 5 hours of sleep performed worse on ImPact computerized neurocognitive testing than those who slept more”45) “Although the medical literature has not yet provided definitive evidence of effectiveness, a number of existing studies suggest that yoga interventions are associated with improved physical and mental health outcomes among adults with knee osteoarthritis.”46) “The Amsterdam Wrist Clinical Prediction rule showed a high sensitivity (98%) and negative predictive value (90%) for fractures of the wrist”47) Study on visceral manipulation - “64 patients with LBP were included and were randomized into two blinded groups. 32 patients received a standard physiotherapy treatment plus visceral manipulation and 32 patients received the standard physiotherapy treatment plus a placebo visceral manipulation over a period of 6 weeks. The placebo therapy was performed on abdominal areas which are not involved in any sense to any visceral issues.  After 6 weeks of intervention no differences in pain could be identified.”48) “This study demonstrates that vagus nerve stimulation appears to improve the recovery that stroke patients make”49) “The findings suggest that tactile acuity deficits may be characteristic of chronic pain.”  If this confuses you, check out this article on threshold strategies and then this one on sensory awareness.50) “Disc bulging was frequently observed in asymptomatic subjects, even including those in their 20s.” #Imaging #VOMIT51) “In this essay, I review the evidence that persuades me of the importance of intrinsic activity and then briefly survey the material presently available regarding its properties and functions.” #TheRestlessBrain52) “This review provides the reader with the up-to-date evidence-based basis for prescribing exercise as medicine in the treatment of 26 different diseases: psychiatric diseases (depression, anxiety, stress, schizophrenia); neurological diseases (dementia, Parkinson's disease, multiple sclerosis); metabolic diseases (obesity, hyperlipidemia, metabolic syndrome, polycystic ovarian syndrome, type 2 diabetes, type 1 diabetes); cardiovascular diseases (hypertension, coronary heart disease, heart failure, cerebral apoplexy, and claudication intermittent); pulmonary diseases (chronic obstructive pulmonary disease, asthma, cystic fibrosis); musculo-skeletal disorders (osteoarthritis, osteoporosis, back pain, rheumatoid arthritis); and cancer.” #ExerciseIsMedicine53) “The biological health-related benefits occur because mindfulness meditation training fundamentally alters brain network functional connectivity patterns and the brain changes statistically explain the improvements in inflammation.”54) “Social networks as important as exercise and diet across the span of our lives.” :|: ““The relationship between health and the degree to which people are integrated in large social networks is strongest at the beginning and at the end of life, and not so important in middle adulthood, when the quality, not the quantity, of social relationships matters,” #psychoSOCIAL 55) “These findings are the first to demonstrate that non-emotional training that improves the ability to ignore irrelevant information can result in reduced brain reactions to emotional events and alter brain connections”56) “Resistance to infections needs to be coupled with tolerance to the delicacy of the system.  Our work identifies a mechanism by which neurons work with immune cells to help intestinal tissue respond to perturbations without going too far.”57) “Dartmouth researchers have found the first direct evidence showing how the vestibular system’s horizontal canals play a key role in sensing our direction in the environment.”

Clinical Question

58) Does anyone know where the whole 2 minutes for stretching to be effective comes from?  I’ve asked around and I usually only get general answers such as authors, books, or the non-answer of "it’s a culmination of a bunch of research and physiology".  Does anyone have a single research article that literally supports the 2 minute theory?

Other Good Stuff

Psychology and Communication

59) “A new study has found that there are three main categories of foolish behaviour – confident ignorance, lack of control and absentmindedness”60) The right question is “How do I get them talking about what they’re interested in?“ #Communication61) "Shelly Gable, professor of psychology at the University of California at Santa Barbara, has demonstrated that how you celebrate is more predictive of strong relations than how you fight."62) “Neuroscience research shows nothing beats a story when it comes to convincing you of something.” #Communication63) "We might be better off, in every way, when we succeed in dialing down the experience of being the center of the universe."64) “It’s the attention residue problem again. Any time you are reacting to new stimuli it pulls you out of focus. And then that can linger in your head, draining your ability to concentrate on what’s important.”65) “If you’re optimistic, you’ll have more energy. If you’re pessimistic, you’ll be more stressed. It’s all about how you interpret what is going on, not what is actually happening.”

Diet

66) Evidence suggests sugar consumption plays greater role in heart disease than saturated fat67) Low-carb beats low-fat in a meta-analysis of 17 clinical trials. Obese and overweight adults on low-carb diets lost more weight and had lower atherosclerotic cardiovascular disease risk.68) “A new study found that eating less fiber, more saturated fat and more sugar is associated with lighter, less restorative, and more disrupted sleep.”

Sleep

69) Solid article on why you should fix your circadian cycle.  It provides a good summary of the results of poor #sleep.70) “These results reveal that, without sleep, the mere recognition of what is an emotional and what is a neutral event is disrupted. We may experience similar emotional provocations from all incoming events, even neutral ones, and lose our ability to sort out more or less important information. This can lead to biased cognitive processing and poor judgment as well as anxiety,”71) Want your kids to get better grades? Have them get more sleep. Or argue for schools to start later as children age so their environment supports a healthier lifestyle. "A new study that my colleagues and I have worked on illustrated how an optimal quantity of sleep leads to more effective learning in terms of knowledge acquisition and memory consolidation. Poor quality of sleep – caused by lots of waking up during the night – has also been reported to be a strong predictor of lower academic performance, reduced capacity for attention, poor executive function and challenging behaviours during the day."

Reading

• “I took a speed-reading course and read War and Peace in twenty minutes. It involves Russia.” -Woody Allen

72) I’ve always thought reading is a lot like drinking wine.  If you sip it over time you’ll have a great appreciation for the taste and complexity.  If you chug it you won’t remember much, but will likely brag to others about how quickly you drank it.  A new study supports my theory, “Examining decades’ worth of research on the science of reading, a team of psychological scientists finds little evidence to support speed reading as a shortcut to understanding and remembering large volumes of written content in a short period of time.”The speed-accuracy trade off applies here.Take your time if you’re reading to learn.

Other Useful Stuff

73) Great read on how to improve creativity (get new experience, go for walks, take a shower, get some me time, outsiders mindset, keep trying) - “It’s important to encounter new and unusual experiences. It really helps with your cognitive flexibility. Any exposure to things that take you out of your normal way of viewing the world really increases cognitive flexibility, and is a core part of creativity.”74) Powerful 1 minute read - The Story of the Taoist Farmer75) “When there is negation of all those things that thought has brought about psychologically, only then is there love, which is compassion and intelligence.” -Krishnamurti76) “You have more willpower in the morning so push yourself to do that thing you’ll regret not having done. Afterwards, you’ll feel good about yourself. And the rest of the day will look comparatively easy.”-Eric Barker on 7 morning ritual habits77) Put it away you addict!  “Replication study confirms: Mere presence of your smartphone harms your conversations”--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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Guest Post: Biomechanical vs. Anatomical Breathing

Guest Post: Biomechanical vs. Anatomical Breathing

By Cameron Yuen

This post was inspired by a discussion I had with Aaron about the StrongFirst snatch test. This test, which basically involves snatching a 24kg kettlebell 100 times within 5 minutes, is well known for it’s ability to leave even the most conditioned athletes gasping for air. Training for this test usually involves working on technique, strength, and endurance. However, training to improve breathing efficiency is often overlooked. After all, we breathe automatically for the most part, and when we do become conscious of our breath during exercise, we generally just default to breathing harder and faster. But this doesn’t have to be the case; changing your breathing pattern is one of the easiest approaches to improving performance.This article will highlight two of these strategies. Biomechanical breathing, which is ideal for short and intense exercise, and anatomical breathing, which is best suited for exercise requiring endurance and efficiency. These breathing styles follow the idea that just as there are different movement strategies depending on the type and goal of exercise, there are multiple ways to breathe depending on the demands of exercise.

Diaphragmatic Breathing

Learning to use your diaphragm is key for maintaining tension in biomechanical breathing, and relaxation in anatomical breathing. So before getting into the nuances of each strategy, I highly recommend you check out Aaron’s articles on breathing here and here. He does a great job breaking down the anatomy and mechanics of the diaphragm, and how to start implementing diaphragmatic breathing in treatment/training sessions. To get comfortable with diaphragmatic breathing, try this quick and easy supine breathing drill:https://www.youtube.com/watch?v=qxiE-bX1FjgTry to breathe down into your stomach so that your bottom hand rises and falls with each breath. The top hand will rise automatically as the ribs expand. After you get comfortable with this, place your hands around your waist, and try to make your breath expand laterally and posteriorly to push out against your hands. Ideally, your abdomen should be expanding from all sides as you breathe in.

Biomechanical Breathing

If you have ever lifted weights, you have probably used biomechanical breathing. Inhaling is matched with the eccentric phase of a movement, and exhalation is matched with the concentric phase. In biomechanical breathing, breath is used to increase intra-abdominal pressure (IAP), and optimize force production and transfer by creating a rigid core.  This strategy works well with ballistic movements, when external loads are high, and when a lot of tension is needed for a short amount of time. Here is an example of biomechanical breathing used during an overhead press:https://www.youtube.com/watch?v=hUCcfA7acJ0Similarly, for a barbell back squat, you would begin the descent (eccentric) by bracing your trunk in a neutral position, followed by a large diaphragmatic breath. Co-contracting the muscles of the core, and then pressurizing the compartment with the diaphragm increases IAP, and creates a very stable trunk. As you ascend from of the bottom of the squat (concentric) you exhale slowly. This lifts the diaphragm and decreases IAP. By breathing in this manner, you increase IAP as you flex your hips, which protects your spine by buffering the large flexion moment created by the weight. However, this strategy can be very fatiguing since you are using your diaphragm to create core stability and breathe at the same time. Therefore, biomechanical breathing should be reserved for anaerobic exercises requiring a large amount of core stability and tension.

Anatomical Breathing

Anatomical breathing on the other hand, matches breath with movement to decrease the amount of work needed for breathing. This approach is commonly used in yoga, pilates, and some martial arts, but can really be used for any type of movement with a high endurance component and lower external loads.Simply put, any time a movement compresses the rib cage and lungs, you exhale, and naturally let the pressure exerted on your lungs drive the air out. Whenever a movement causes your rib cage and lungs to expand, or when the ribs spring back from being compressed, you inhale. This strategy takes advantage of the passive elasticity and compliance of the rib cage to drive air in and out of the lungs, and decreases the workload on the respiratory muscles.For example, if you were to do kettlebell swings for high repetitions, you would exhale as you flex your hips and swing the bell between your legs. In this position, you would be compressing your ribs and abdomen with your arms, which naturally forces some of the air out of your lungs. As you swing the bell forward and your arms float to the front of your body, you inhale. Your ribs spring back and expand as you extend your hips, allowing some air to flow into your lungs. Of course, your respiratory muscles still have to work with this strategy, but they are assisted by passive movement of the ribs, and don’t have to fight against external compression.https://www.youtube.com/watch?v=ejXajYcbFsEIn this video, I take a relaxed inhale as the kettlebell floats up, then exhale as my arms compress my ribs during hip flexion. As you progress from swings to snatches, there are quite a few different ways to implement anatomical breathing:https://www.youtube.com/watch?v=KOIEtsxtxsoIn addition to lower intensity exercise, anatomical breathing can be used to facilitate mobility drills, especially those involving the rib cage and thoracic spine. Take for example a side lying windmill movement. By taking in a large breath as you begin the movement, the rib cage expands and drives thoracic rotation as you continue reaching. This can be repeated with each inhale driving more thoracic rotation and shoulder flexion.https://www.youtube.com/watch?v=VUBtk-9GeEkIn this video, I inhale as I begin the movement, then exhale as I come back to the hands together position. I then take larger and larger breaths as my ribs and thoracic spine open with each repetition.

Summary

These breathing strategies can feel foreign at first, but give them a shot during your next training session. If you are lifting heavy weights and require a lot of tension, biomechanical breathing is a good choice. If you need more relaxation and endurance, try out anatomical breathing. It may take a bit of concentration at first, but learning to breathe differently depending on your activity can have a profound impact on your performance.

About Cameron Yuen

 Cameron is currently a PT student at New York University, and research assistant at the Human Performance Lab at Lehman College. Before moving to New York, he was a strength and conditioning coach in San Diego, California. Outside of school, Cameron enjoys reading, practicing martial arts, and spending time with his two dogs. More of his writing can be found at his website: www.CameronYuen.com      [subscribe2]

The Best of 2015

News

As you may or may not have read in a previous article, I’m leaving NYC and moving to Asheville, NC.  My girlfriend and I have decided to take advantage of this transition and are taking a small “sabbatical”.  Part of this time off involves a selfish 3 week trip to New Zealand this month.  Unfortunately, this means I won’t be able to get a “January Hits” post out this month.  I do have posts scheduled on my Facebook account, but other than that you guys are on your own!

Top Hits of the Hits

During the process of going through all the previous Hits, it was interesting to see how one small blog article can change my practice and help me develop a greater understanding over time.  These were some of the ones that had a lasting impact on my practice.  Small waves eventually change coastlines.1) “Based on animal studies, it has been proposed that central sensitization associated to nociception (maladaptive plasticity) and plasticity related to the sensorimotor learning (adaptive plasticity) share similar neural mechanisms and compete with each other.” 2) Here’s a great 3 minute video that goes over both the cause and treatment of tendinopathies.3) “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)4) Tom Purvis goes over squat biomechanics and body proportions.5) Zac Cupples teaches you about Salience, inputs, processing, and pain.6) Are your patients using their Short Head Biceps Femoris to compensate for a lack of hip extension in closed chain movement patterns?  Kathy Dooley thinks so and discusses more clinical pearls in this phenomenal anatomy post.7) Erson’s 5 Rules for Resets: 1) It has to be Novel 2) Hit the End-Range 3) Frequent Reinforcement 4) No Pain 5) Education8) The Cynefin Framework9) Top 10 Bodyweight Exercises From GMB – Squat, Frogger, Monkey, Cartwheel, Pull-Up, Bear, Push-Up, Hollow Body Hold, Scales, L-Sit, and Handstand.10) 12 Ways to Make Better Exercise Choices by Eric Cressey11) Dan Pope literally bridged the gap - exercise progressions.  Scapula - Part 1 – Closed Chain & Part 2 – Open Chain |:| Jump/Plyometric Double Leg Jump Progression - Single Leg Jump Progressions - Advanced Double Leg Jumps - Advanced Single Leg Jumps12) ““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.” -Gait Guys13) 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.  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.14) Dave Tilly on Movement Variability - “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.”15) Here’s a great post from Tom Goom 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.16) “When I think aerobic training, I think recovery, energy development, and fatigue buffer.” -Lance Goyke17) The stress section in the October Hits18) 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.”19) “When you change your beliefs about a situation, your brain changes the emotions you feel.”  And remember...pain is an emotion.20) “Overextension refers to not just a position of one or more joints, but also a state of mind.” -Michael Mullin21) “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?”22) “Lubricin is a protein that mixes with hyaluronic acid and other molecules to form a nearly frictionless environment.” “Words and phrases to power up the nugget include “lubricin is cytoprotective and chondroprotective”, “you can build up a lubricin reservoir in your joints with healthy movement” and “marvel how your eyelids slide on your eye – that’s lubricin“.”23) “The nerve plays a role in a vast range of the body’s functions. It controls heart rate and blood pressure as well as digestion, inflammation and immunity. It’s even responsible for sweating and the gag reflex. “The vagus is a huge communicator between the brain and the rest of the body,” says cardiologist Brian Olshansky of the University of Iowa in Iowa City. “There really isn’t any other nerve like that.””24) “Muscular power, especially in the legs — which are the largest muscles in the body — is widely accepted as a marker of healthy aging. Older people with relatively powerful leg muscles get around better than those with weak legs. They also tend to have sharper minds, studies show.”

Top 5 Research Reads

1) Esther Thelen - Dynamic Systems Theory2) Bogduk’s Cervical Biomechanics3) If you’re into injury prevention, you should also be into fatigue prevention - “Following a fatiguing exercise protocol, participants showed increased anterior tibial translation, compressive force, and knee flexion range of motion during the transition from non-weight-bearing to weight-bearing. This illustrates an inability of the lower extremity muscles to stabilize the knee joint.” (there were a couple other articles in the Hits supporting this concept throughout the year as well)4) The subtle cavus foot5) Loss of self: a fundamental form of suffering in the chronically ill – Charmaz K

Top Exercises

https://www.youtube.com/watch?v=xAKUU3Q-7VEhttps://www.youtube.com/watch?v=lG1BjEplYsQhttps://www.youtube.com/watch?v=zzQaxR2tjlYhttps://www.youtube.com/watch?v=2fwjGJ2MDsAhttps://www.youtube.com/watch?v=E9EU08OD-M0https://www.youtube.com/watch?v=t7NcR2inqN0

Top 2 Courses

1) Ron Hruska’s Cervical Revolution

God damn!  Ron is answering questions that no one is even asking.  I can’t say enough about this course.  I’ve taken over 30 continuing education classes.  This one blows them all away.  He’s not selling anything.  He’s sharing as much information as he can in a jam packed 2 days.  I appreciated him taking the time to go over the complexity of the human body.  He helped everyone in the class gain a better understanding of the human species.   There are too many continuing ed classes out there that are dumbing it down or over simplifying it for profit and social media attention.  There are two things I look for in a class: 1) something I can use in the clinic the next day 2) information or direction on where to learn more and dig deeper.  This class accomplished these two things on a level I didn’t even know existed.Link to Course

2) Gait Guy’s Advanced Biomechanics Course

Just like Ron’s class, the Gait Guys don’t dumb it down.  It took me about 4 months to get through the 40 modules included in their online biomechanics course (not the shoe fit program).  I’m sure it could have been done quicker, but taking the time to understand every detail and biomechanical thought experiment was important for me.  Not only did my foot/ankle skills increase dramatically, but my overall understanding of biomechanics was also taken to another level.Link to Course

Top Books

• Mindless Eating - Brian Wansink
• Nerve - Taylor Clark
• Quiet Leadership - David Rock
• Spinal Engine - Serge Gracovetsky
• The Only Dance There Is - Ram Dass

My Articles

What I Thought Were The Most Important Articles

1. Coaching & Cueing Series - Internal Cues
2. Andreo Spina Course Review
3. 5 Things I’ve Learned in 5 Years at Dynamic Sports Physical Therapy

What Actually Were…

I write this blog to improve myself and help others.  Not for popularity.  For this reason, I only check my google analytics once a year, at this time, to see what were the most popular articles of the year.  I’m surprised every year.

1. Andreo Spina Course Review
2. My Secret Acupuncture Experiment
3. Coaching & Cueing Series - External Cues

Writing Around the Internet

WODMedic - Tying KnotsMovement Maestro - 7 Rules for Staying Injury FreePhysioSpot - Using Physics to Increase Glute Med ActivityLayman’s Article on CureJoy - 5 Minute Fix for an Aching BackDr. Suzanne Fuchs - Avoiding Hip TightnessNew Grad Physical Therapy - 5 Things Learned in 5 YearsDynamic Sports Physical Therapy - 12 Things I Wish Every Patient Knew

Clinical Self Review

4 Mistakes I Have Learned From

• 1) Pain Language  

I used to avoid mentioning pathoanatomical structures or anything that could be interpreted in a negative way.  I would take this kind of approach.  But the reality is that my patients are going to see it on google, from another healthcare/fitness professional, or from one of their friends.  So instead of using pain science as a substitute, I’ve started using it as an supplement.  For example, I used to avoid telling people about excessive medial knee stress and MCL/ACL strain biomechanics during a dynamic valgus moment at the knee.  Instead, I would often discuss pain science, the alarm system, movement patterns, load capacity, strength, and resilience.  Now I realize that it all needs to be addressed.  Since taking this approach I’ve had a much greater success communicating with patients and educating them on what their situation is from all angles.  #Educating #Lawyering

• 2) Are They Ready?

This goes with the prior mistake - I often had a goal in mind or a point to make, but I didn’t consider where the patient was on the Transtheoretical Model of Change.  It’s important to understand where they are on the path to changing behavior.

• 3) Tough Love

I try to always be kind, encouraging, and motivating.  But maybe I need to be a little more stern when people aren’t helping themselves (not doing HEP, lifestyle, beliefs, etc.).

• 4) Complete Rehab Takes Time

I re-injured my shoulder earlier in the year and, learning from my past mistakes, I spent a full 3 months rehabbing it and another 3 months after that with advanced rehab and integrative exercises.  I still do a good amount of healthy shoulder movements in my workouts to keep it functioning well.  Chris Johnson always said something like “You are only as good as your last injury and the extent to which you rehabbed it”.  I understand that now.

8 Clinical Epiphanies

1. Maybe it's not always a stability or a mobility problem. Maybe it's just a matter of getting comfortable in uncomfortable positions.
2. Isometrics are the best thing in the world.  Sure, it’s phenomenal for tendinopathies, strength, motor control, mechanotransduction, and true mobility work.  But I think it’s one of the best ways to work on the prior epiphany.
3. A lot of it is about being calm in stressful situations.  Being calm for yourself.  Being calm for the patient.  Being calm with their injury and impairments.  Being calm with their complaints and emotions.  Most of them don’t have anyone else doing that for them.
4. The older I get the more I realize that rigid opinions, theories, and beliefs are just another opportunity to be wrong.
5. I don’t force a specific set of reps and sets on people.  There are too many variables to control (diet, sleep, motivation, emotions, etc.).  I look at how their moving.  I listen to how they feel.  I try to adapt my prescription in realtime.  #ComfortableInTheUncomfortable
6. Attention focus is extremely important.  For everything.  See #31, Eric Barker & Internal Cues.
7. The more I treat, the more I realize I just spend most of my time slowing people down (breathing, movement, speech, thoughts, mind).
8. The neck has always been difficult for me to treat.  It’s not that all of a sudden I’ve become a the neck whisperer, but at least now I know why it’s difficult.  “Amongst its several functions, the head can be regarded as a platform that houses the sensory apparatus for hearing, vision, smell, taste and related lingual and labial sensations. In order to function optimally, these sensory organs must be able to scan the environment and be delivered towards objects of interest. It is the cervical spine that subserves these facilities. The cervical spine constitutes a device that supports the sensory platform, and moves and orientates it in three-dimensional space.” -Bogduk

---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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December Hits (2015)

News

Unfortunately, my time in NYC is coming to an end. I’ve spent over 8 years here and I’ve enjoyed the buzz, the people, the music, and the late night slices . However, I’m ready for a lower cost of living, a little less concrete, a little more nature, and a slower pace. So I’m moving to Asheville, North Carolina in January.I wrote this article on 5 things I’ve learned from my mentorship at Dynamic Sports Physical Therapy.  I feel that one thing missing from the movement social media world is a discussion on the things that happen “behind the scenes” that make the difference between a good clinician and a great one.  While evidence, trendy semantics, cool neuro language, the latest performance enhancement, and arguments over what someone else is doing can be fun to read, they don’t always translate to improving clinical performance.  If there’s anything I’ve learned from my 5 years as a PT in NYC, it’s that there’s a lot more to treating patients than what you can read in a journal, book, or blog.  Hopefully the article above will help explain this concept (yes, I know it’s a blog and I’ve just contradicted myself, but if you read it you’ll get the point).

Clinical

• “It is the mark of an educated mind to be able to entertain a thought without accepting it” -Aristotle

1) Great stuff from Kathy Dooley on the Jaw - “Because the TMJ has more proprioception per surface area than any other joint in the human body, you will go where your jaw shifts you to go. If the body perceives a missing link in motor control, it will go to the jaw to compensate, since the jaw muscles and joint capsule are innervated by Midpons (mandibular division of trigeminal nerve).”

Protrusion puts COM anteriorly, down regulating the posterior chain

Retrusion puts COM posteriorly, down regulating the anterior chain

2) Listen carefully to this one..."when a thorax is protracted and externally rotated, it could lose its mobility in all three planes" -Kento3) "Lubricin is a protein that mixes with hyaluronic acid and other molecules to form a nearly frictionless environment." "Words and phrases to power up the nugget include “lubricin is cytoprotective and chondroprotective”, “you can build up a lubricin reservoir in your joints with healthy movement” and “marvel how your eyelids slide on your eye – that’s lubricin“."5) "Task complexity and diversity should increase with the addition of more reference points. This will serve to inhibit the old pattern is as they have to maintain an attentional focus on what's being asked of them."-Seth Oberst6) Great article on the subconscious cues that can make a patient feel more comfortable and safe.7) Trying to improve mobility?  Erson reminds you to give some PNF a try.8) A “new” test shows good inter-rater reliability.  I learned this one from TPI a few years ago.9) Erson shares 5 manual techniques for the ankle.10) 3 Reasons Why It’s Important to Know Why a Treatment Works by Todd Hargrove11) Great stuff from Noah Harrison - “Adaptation cannot occur overnight in most cases, and the rate of loading the challenge needs to match the bodies rate of ability to adapt. Load the skin with friction slowly and often: you will form a callus. Load it too quickly for the tissue to adapt: a blister forms instead.”12) Dave Tilly goes over 10 common teachings with gymnasts. #ForrestBehindTheTrees13) Interesting read on vision from Zac Cupples and PRI - "one must recognize peripheral space to contact ground (peripheral contact), ands notice objects in the periphery passing by (peripheral optic flow) as the body progresses forwardly via limb reaching (peripheral propulsion)"14) Sian shares a good shoulder impingement series that looks at evidence, clinical reasoning, and exercise.15) A ton of information on PRI in a question and answer format from Rob Palmer.  Even if you don’t practice the PRI approach, there is still a lot of good information here - “Flexion allows for movement variability.”16) 12 Things I Wish Every Patient Knew17) Great article on the Vagus Nerve 

"The nerve plays a role in a vast range of the body’s functions. It controls heart rate and blood pressure as well as digestion, inflammation and immunity. It’s even responsible for sweating and the gag reflex. “The vagus is a huge communicator between the brain and the rest of the body,” says cardiologist Brian Olshansky of the University of Iowa in Iowa City. “There really isn’t any other nerve like that.”"

18) “Footwear resulted in a significant increase in step length, stance duration, and peak vertical ground reaction force compared with barefoot walking. Peak acoustic velocity in the Achilles tendon (P1, P2) was significantly higher with running shoes.”19) "nothing empowers the patient like the ability to both self assess and self treat" -Erson20) “We should move well enough to respond and often enough to adapt.” -Gray Cook21) Do you know about the Transtheoretical Model or Fitts and Posners Stages of Motor Learning?  If not you might be missing out on some great techniques to improve your patients’ movement.  Check out the last installment of the Coaching & Cueing series for more information.22) "One of biology’s great journeys is the flow of axoplasm – the “nerve juice” inside an axon. This nerve juice is quite thick – at least five time thicker than water, and it has to flow both ways within the longest cells in our bodies" Keep it liquid, not gelatinous”23) A quick and easy trick to isolate lumbar extension by blocking the hips with a table.  It’s essentially a prone press-up standing up.24) "The growth is found in the middle of the discomfort." One of 10 lessons in 10 years from Brad Beer

Bill Hartman

25) Bill recently put out a bunch of great informative videos

Posture Matters

Complexity of knee position, movement variability, and individualism

Head Position and Stability

Breathing Affects Movement - Concept

Breathing Affects Movement - Example

Why Necks Are Stiff

Running

26) "Rather than thinking of running as a series of jumps – leaping off one foot and landing again on the other – runners should view their sport as a series of falls, aided by gravity"27) The Spinal Engine has an interesting take on running and the effects of gravity.  #UsingGravity #PotentialToKineticEnergy28) Fatigued training is rarely good training.29) I met up with my old friend, Chris Johnson, for an update on his approach.  Check out this review.  There’s stuff you can use tomorrow in the clinic.  #ControlParameter

Pain & Neuroscience

• “Focus is the new IQ.” -Cal Newport

30) Great analogy on pain with a Chinese Finger Trap - “The consequences of fighting harder, in this case, are not the consequences we want. In fact the consequences we want require us to do something a bit paradoxical, which is to push in, to the experience. To move a little bit more flexibly with the experience, to more a little bit more gently with the experience…”31) A great article on pain from Lorimer. It's easy to read and understand. Print it out for your patients. "A very effective way to reduce pain is to make something else seem more important to the brain – this is called distraction. Only being unconscious or dead provide greater pain relief than distraction."32) Make sure to inform and educate them, but be careful with your word choice. "A critical task in pain psychology is therefore to help people learn to rephrase their inner monologue so it becomes more realistic and supportive."33) "Pain is like climate change – they are both emergent phenomenon: they are not progressive, sequential events where, say, a 1% increase in contributing factors leads to a 1% change in the output. In emergent phenomena where things just seem to happen, multiple interacting contributing factors combine simultaneously for a collective output. No single factor leads or drives the process- although critically, a shift or change in one component/factor/agent can have massive effects perhaps leading to a system out of control. In relation to a chronic pain state it could be one ‘small’ event – returning to a particular place, a memory triggering smell or sight, a thought or something someone says."34) Always great stuff from Todd Hargrove.  Why Pain is Like Taste - "Placebo can work by learned association. If you pair a pain killing drug with an inert treatment for a while, pretty soon the inert treatment will elicit some pain reduction even in the absence of the active ingredient. People who love running are probably runner's high addicts"35) Loneliness is something we need to take seriously.

"Researchers have found social isolation is a risk factor for disease and premature death. Findings from a recent review of multiple studies indicated that a lack of social connection poses a similar risk of early death to physical indicators such as obesity."

"There is evidence in the literature that suggests loneliness is a risk factor for the development of a concurrent pain, depression and fatigue ‘symptom cluster’ with a possible immunological basis, and recent evidence that suggests that chronic and transitory loneliness are associated with higher daily pain ratings in people diagnosed with fibromyalgia."

36) “In fact, there appears to be a linear relationship between the size of your device and the extent to which it affects you: the smaller the device, the more you must contract your body to use it, and the more shrunken and inward your posture, the more submissive you are likely to become. Your physical posture sculpts your psychological posture, and could be the key to a happier mood and greater self-confidence.”37) A great collection of articles on pain38) One of the better pain science articles I've read in a while. Ben Cormack explains why the pendulum needs to swing back to the middle and away from the "it's in your head" side.

Exercise of the Month

39) If you checked out the exercise of last month, then you probably know many people have no transverse plane control in a single leg stance.  I use this exercise as a regression to help them understand the movement and develop some control.  It’s also great for shoulder patients and people that love a challenge.https://www.youtube.com/watch?v=HrnzLye5CQs

Michael Mullin

40) It’s great when great clinicians share some of their favorite exercises.  We’ve seen Dan Pope do this with lower extremity plyometrics (see previous Hits).  Now Michael Mullin is sharing his favorite ski exercises.  These are awesome and you should definitely check it out.  I’ve been able to incorporate these into my practice immediately.  Thank you Michael!

Tweets of the Month

• Nick Winkelman‏@NickWinkelman - "Feeling gratitude and not expressing it is like wrapping a present and not giving it." -William Arthur Ward
• Doug Kechijian‏@greenfeetPT - Gathering new information should not come at the expense of applying that which we already know
• Noah Harrison‏@noahharrisonDPT - Is it time to re-name the pain scale to the "how much does is bother/worry me" scale? Arguably it only measures suffering. #neveruseit
• Eric Cressey‏@EricCressey - Achieving a high level of athletic success is as much about getting in quality rest as it is about getting in quality work.

Training

41) Eric Cressey sharing some of his cues for wall slides: reach, round, and rotate.  I recommend chuncking these first.42) I might be biased, but I think his is a great article and agree with just about everything in it. Here’s some unilateral exercise combinations and some pelvis stability logic from Miguel Aragoncillo.43) Pickle juice and mustard reduce muscle cramps?44) A very unique read on the importance of being a practitioner and not a scientist. "It does not take a rocket scientist to fly a rocket, just a good pilot."45) More great coaching from Cressey - sidelying ER.46) “You need a kyphosis (or subtle rounding of the upper back), because your scapulae are curved as well. If you have a curved scapulae sitting on a flat upper back, you lose passive stability at the shoulder.”47) Some great advice from Dan John - 10 skills coaches need to balance.  #3 - Strive to get pretty good, then strive to get better. #IgnorePerfect48) I love the hip thrust exercise from Bret Contreras.  It’s the bench press of the glutes.  But I started to notice people were using it more as a competitive lift, sacrificing form for numeric achievements.  I started to see tons of people lifting in an anterior pelvic tilt, thus using their lumbar extensors more than their hip extensors.  So I made this video and wrote this post in attempt to change this behavior.  I’m not sure if it had any effect, but now Eric Cressey is pointing out some of the same mistakes in this post.  Hopefully this will help prevent people from turning a great exercise into a dangerous one.49) Mike Robertson shares his assessment process: Joint Mobility and Position, Movement Capacity, Speed/Strength/Explosiveness, Energy System Development50) One of the best articles on aerobic training - "Conversely, "low-fit or deconditioned individuals (read: some strength and power athletes who do no supplemental work at all) may demonstrate increases in cardiorespiratory fitness with exercise intensities of only 40 to 49% HRR or 55-64% HRmax"."51) Here’s 10 Landmine Exercises you can start to add in to your routine.52) I like this.  I’ve been doing it for the past few years without planning.  Two years ago was kettlebells, last year was power lifting, this year is relative strength.  Now I’m going to start planning the macrocycles.  If you only do one thing, you’ll lose adaptability.  #MovementVariability

"Let’s start here: Brady is a quarterback whose daily schedule, both in and out of season, is mapped clearly into his 40s. Every day of it, micromanaged. Treatment. Workouts. Food. Recovery. Practice. Rest. And those schedules aren't just for this week, this month, this season. They're for three years. That allows Brady and Guerrero to work in both the short and long terms to, say, increase muscle mass one year and focus on pliability the next. "The whole idea is to program his body to do what we want it to do," says Guerrero. "We don't let the body dictate to us. We dictate.""

53) This is greathttps://www.youtube.com/watch?feature=youtu.be&v=mDTbPkhfyHw&app=desktop

Research

54) “These results suggest that atrophy of intrinsic foot muscles may be associated with symptoms of plantar fasciitis in runners.“  I usually start my plantar fasciitis patients with one of these exercises for foot intrinsic strength.55) Tai Chi and Cognitive Behavioral Therapy both work to reduce insomnia - “With the improvement in insomnia,” he added, “there’s a reversal of inflammation at the systemic level and the genetic level. Inflammation contributes to cardiovascular disease, depression and cancer.”56) “HIIT (High Intensity Interval Training) lowered blood glucose and increased exercise capacity, food intake, basal activity levels, carbohydrate oxidation and liver and adipose tissue insulin sensitivity in HFD-fed WT and AccDKI mice. These changes occurred independently of weight loss or reductions in adiposity, inflammation and liver lipid content.”57) “Human brains evolved to be more responsive to environmental influences, study finds” #EnvironmentMatters58) "A new study has found that older adults who take more steps either by walking or jogging perform better on memory tasks than those who are more sedentary." #ExerciseIsMedicine59) It's important to not get carried away with pain science and CBT. There's a physical body too. "Pain education and specific training reduce neck pain more than pain education alone in patients with chronic neck pain."60) 5 sets of 45sec isometrics with 2 minute rests improved tendon pain. This article also goes over possible mechanisms.61) "The study revealed there was a significant inter-hemispheric asymmetry of infraspinatus active motor threshold. On the affected side, the active motor threshold was higher compared to unaffected side, indicating decreased corticospinal excitability. Also, the duration of pain (>12 months), but not its intensity, appeared to be a factor related to the lower excitability of the infraspinatus representation."62) This one is for the breathing lovers out there - “Individuals with LBP exhibit propensity for diaphragm fatigue, which was not observed in controls." #AmmoForYourCoworkersOrStubbornEmployers63) Gasp! TENS can be good for something?  “Sensory transcutaneous electrical nerve stimulation may help reduce knee pain and increase quadriceps function among people with knee pain.”  Don’t be a Hipster PT.64) Use Graded Exposure with Chronic Pain Patients65) "Muscular power, especially in the legs — which are the largest muscles in the body — is widely accepted as a marker of healthy aging. Older people with relatively powerful leg muscles get around better than those with weak legs. They also tend to have sharper minds, studies show."66) Breaking News!  Fatigue causes poor biomechanics which can put people at risk for injuries.  “Impaired strength, central activation, and biomechanics were present postfatigue in both groups, suggesting that neuromuscular fatigue may increase noncontact ACL injury risk.”67) Shoulders need exercises, not manual therapy - “Adding manual therapy to an exercise protocol did not enhance improvements in scapular kinematics, function, and pain in individuals with shoulder impingement syndrome. The noted improvements in pain and function are not likely explained by changes in scapular kinematics.”68) "Our results suggest that aerobic exercise may have a positive effect on the medial temporal lobe memory system (which includes the entorhinal cortex) in healthy young adults." #ExerciseIsMedicine69) Chili peppers stop cancer? Great article that makes chemistry interesting.

Other Good Stuff

• “What we think of as “knowing” is holding on to some thing we think applies universally so we don’t have to be open to new situations” -Cheri Huber

Psychology and Communication

70) “Words can deceive, but tone of voice cannot”71) “Visual cues for forming a habit. Get a jar full of paper clips and set an empty jar next to it. Put it somewhere you'll see it everyday. Transfer the paper clips when you complete a positive habit.”72) "My argument is that we should spend less time letting feedback loops shape our lives in invisible ways and more time designing the feedback loops we want and need."73) 8 Secret Ways We Influence Others With Our Body Language #Communication74) A better title for this article would be, healthcare starts using cognitive psychology to improve outcomes. For more on these concepts read the books, "Thinks fast, and slow" and "Mindless Eating". #Communication75) "Don’t and can’t may seem somewhat interchangeable, but they are very different psychologically. And if there is one thing that social psychologists have learned over the years, it’s that even seemingly subtle differences in language can have very powerful affects on our thoughts, feelings and behavior."76) An unfortunate positive feedback loop - "The fatter we are, the more our body appears to produce a protein that inhibits our ability to burn fat, suggests new research. The findings may have implications for the treatment of obesity and other metabolic diseases."77) "As the NYPD HNT likes to say: The more information we have about a subject the more power we have." #Communication78) Not all daydreaming is considered equal. "Other research points to the distinct benefits of daydreaming and imagination for well-being. Asking people to engage in “positive mental time travel”, where they imagine four positive events that will take place the following day, increases levels of happiness."79) Biases and poor communication are the root of most of the world’s problems. "What’s obvious to you is not always obvious to others. We can all have very different interpretations of the same things. It’s a lot better to make things clear than to assume that your needs are obvious and the other person is inherently evil."80) Great article from Eric Barker on managing time and focusing on “deep work”

Sleep

81) Might be my favorite article title for the importance of sleep - “Snoozers Are, Infact, Losers”82) Great article on mental health and sleep. Read this one. "It is now abundantly clear that sleep problems in mental illness is not simply the inconvenience of being unable to sleep at an appropriate time but is an agent that exacerbates or causes serious health problems"83) Another great article on sleep with some great examples to tell patients

“If you run on four hours of sleep a night for a week, it’s the same as drinking a six-pack and then going to work.”

“A week of getting four hours of sleep per night causes your testosterone levels to temporarily dip by an amount equivalent to 11 years of aging.”

“When sleep is cut short, testosterone levels don’t fully replenish, muscles don’t have as much time to build and recover, and the consolidation of new information into long-term memory is cut short. The final quarter of an eight-hour night of sleep, Maas says, is when the cycles include the greatest frequency of sleep spindles, bursts of brain activity in the motor cortex that play a role in forging new muscle memories from that day’s activities”

Diet

84) "Looking back at carbohydrate consumption over the last century reveals some interesting trends. Americans ate about the same amount of total carbohydrates in 1997 as we did in 1909—just not the same kinds. Over this time period, the proportion of carbohydrates from whole grains dropped from more than half of what we consumed to about a third. What replaced whole grains was food products made from different kinds of refined grains. In other words, for the first time in human history we now eat mostly the simple sugar part of a grain (the endosperm) and far less of the complex carbohydrate part of a grain (the bran and the germ)." #Microbiome85) 8 Ways to Eat Mindfully During the Holidays

Coffee

86) “"In our study, we found people who drank three to five cups of coffee per day had about a 15 percent lower [risk of premature] mortality compared to people who didn't drink coffee," says one of the study authors, nutrition researcher Walter Willett of the Harvard School of Public Health”87) I love this study. "Summary of current literature suggests that coffee has beneficial effects on skeletal muscle. Coffee has been shown to induce autophagy, improve insulin sensitivity, stimulate glucose uptake, slow the progression of sarcopenia, and promote the regeneration of injured muscle." #Coffee88) “Repeated coffee consumption was associated with reduced background DNA strand breakage”89) "Drinking coffee daily was associated with a lower risk of deaths from Type 2 diabetes, cardiovascular diseases, and neurological diseases in nonsmokers. Regular consumption of coffee can be included as part of a healthy, balanced diet."90) You should order coffee from this place.  Best in the world.

Instagram

A video posted by Ryan Hurst (@ryhurst) on Dec 12, 2015 at 4:02pm PST

A video posted by C. Shante Cofield DPT OCS CSCS (@themvmtmaestro) on Dec 14, 2015 at 8:31am PST

A video posted by Eric Lagoy (@emlagoydpt) on Dec 11, 2015 at 8:00am PST

A video posted by Mat Leigh (@guerrillamovmt) on Dec 9, 2015 at 11:26am PST

A video posted by Aaron Swanson (@aswansonpt) on Dec 9, 2015 at 6:38am PST

A video posted by Funny Fail Videos (@funnyfailvideos) on Dec 6, 2015 at 4:29pm PST

 --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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Course Review: Chris Johnson Treadmill Analysis Workshop

I was very lucky to be mentored by Chris Johnson after PT school.  I observed and worked part-time in his clinic for almost a year.  I learned a tremendous amount from him and was excited to get an update on his approach during his Treadmill Analysis Workshop this past Wednesday.Chris is the premier running expert.  He doesn’t practice what he preaches, he’s a master of it (2x Kona Qualifier).  He dives deep into research to stay current on the latest evidence and to improve care.  And most importantly, he spends a ton of time treating and training endurance athletes.Needless to say, he has some valuable information to share.

Take Home

It’s all about cadence.  Increasing step rate is a control parameter that causes many advantageous changes (decreased stress on knees, hip, less vertical mass oscillation, less energy absorption, decreased ground reaction forces, etc.).  You want people to be around 170-180 steps/minute.  Assessing cadence should be a priority in your running analysis.

4 S’s to Look at

• Strike (Rearfoot, Midfoot, Forefoot)
• Sound (Overstrike, Slap, Clunk)
• Step Rate (# of contacts/min)
• Shoes

17 Random Things I Learned During the Course

*many of these are either quotes from Chris or paraphrased1) #1 activity outside of running is lifting weights2) If you run and you don't lift, you'll get injured3) Fastest runners he sees tend to over pronate and be toe out (pathomechanics aren’t the end all be all)4) Strike patterns will likely change during the race5) Most injuries occur at knee and below (endurance running)6) Faster you run, the more the forces shift proximally 7) My Favorite Quote From the Course - "It’s not born to run, it's built to run"8) Strength, control, and range requirement increase with increased time on ground9) Increased step rate of 10% did not increase O2 consumption or HR.  Chris recommends increasing between 5-10%, depending on the individual.10) A step rate below 160 is a problem11) Glute max not important for endurance runners. It's more about the glute med.12) Say "Full footed stride" instead of heel strike. Heel strike has a negative connotation now.  #PsychologicalPriming13) Overall Goal - get people running barefoot in shoes14) Have people run with a metronome15) Music matters16) Pump arms faster and your feet will catch up (increasing cadence) 17) Running is rhythm and timing

The Protocol

It so simple it’s mind blowing.  I’ve already done this a couple times in the clinic with great outcomes.

1. Count the steps on one leg for 30 seconds
2. Multiply by 4 (156 on L pic)
3. Increase no more than 10% (164 in this case)
4. Hold up metronome to patient and give only one cue
5. "Run to the beat of the metronome" (right pic)

A video posted by Aaron Swanson (@aswansonpt) on Dec 4, 2015 at 4:54am PST

Exercises

Chris has tons of running drills on his YouTube page.  Many of his exercises deal with practicing the skill of running and preparing the body for an efficient midstance phase.  Why would you let someone run if they can't perform a clean single leg hop?He has an insane attention to detail and, as you can see, is very strict with the movement.I highly recommend checking out his page.https://www.youtube.com/watch?v=gMf6G4M7f9U

Bottom Line

I remember my brother coming home from one of his drumming lesson and he couldn’t wait to show me the new beat that he had just learned.  Apparently, he learned a drum beat that allows you to play 80% of all popular rock and pop songs.  Surely this didn’t allow him to play Buddy Rich, but mastering this pocket beat allowed him to play most songs on the radio.  He could easily jam with many other musicians after learning that beat.Chris didn’t dive into the complexity of running.  Instead, he showed us the most effective “pocket beat” for runners.  It may not fix every runner, but I bet it will help at least 80% of them.  Overall it was a great workshop and I highly recommend to anyone that runs or works with runners.

Dig Deeper

Effects of step rate manipulation on joint mechanics during running.

Energy absorption reduced @ knee & hip when step rate increased above preferred

Increasing step rate by 10%

Reduced impact load

Less vertical center of mass (COM) velocity at landing

Less energy absorption or (-) work Greatest effect @ the knee

Increased step rate 10% did not increase O2 consumption or HR

Hip muscle loads during running at various step rates

With increased step rate, mm forces observed to increase during late swing, particularly from the HS & gluteals

Increasing running step rate reduces patellofemoral joint forcesInfluence of Stride Frequency and Length on Running Mechanics: A Systematic Review

There was consistent evidence that increased stride rate resulted in decreased center of mass vertical excursion, ground reaction force, shock attenuation, and energy absorbed at the hip, knee, and ankle joints.

Decreased ground contact time yielded a sig increase leg stiffness.  Conversely, decreased ground contact time sig increase leg stiffness

Select Injury-Related Variables Are Affected by Stride Length and Foot Strike Style During Running

Increased stride width leads to decreased frontal plane forces (i.e. decreased ITB stress)

Step width increases linearly as stride length decreases

Biomechanical Differences of Foot-Strike Patterns During Running: A Systematic Review With Meta-analysis FOOT STRIKE PATTERNS OF RUNNERS AT THE 15-KM POINT DURING AN ELITE-LEVEL HALF MARATHON Variation in Foot Strike Patterns during Running among Habitually Barefoot Populations Foot strike patterns of recreational and sub-elite runners in a long-distance road raceProspective comparison of running injuries between shod and barefoot runners [subscribe2]

Coaching & Cueing (Part 7 - Phases & Summary)

The minimal effective dose rule goes into effect here.  You want to achieve the necessary movement change with the minimal amount of sensory change.  If you throw too many different cues (verbal, visual, proprioceptive) at the same time, it will clog up the system and wear down the patient.  As mentioned in the previous articles, it comes down to attention economy - you always want the movement to have the spotlight, not the cues.

So where do you start?

The answer to this question is going to change dramatically based on the task and the individual.  Between these two factors, there are a ton of variables (e.g. moving parts, degrees of freedom, environment, load input, tissue stress, exercise history, learning preference, sensory integration, expectations, motivation, etc.).  Each variable have a profound impact on how they respond to coaching and cues.So what do you do?  How do you cut down the variables and choose which cue to use?  How do you manage the movement change?

Four Ways to Manage Coaching & Cueing

So unless you have a homogeneous patient population, it is important to have multiple  different cueing methods to choose from.  This will allow you to better match the individual with a specific cue that achieves the movement outcome you desire.  To become proficient  at the various cueing methods you should do these 4 things:

1. Understand the different types of cues (Parts 2-6)
2. Build a library of cues - spend time learning cues/perspectives from others (use social media, read articles, get many different types of movement experiences)
3. Realize what phase of learning the patient is in
4. Get experience and practice

Since 1 has already been discussed in this series and 2 can only be achieved independently, we’ll focus on 3 and 4 in this post.

3) Phases of Learning

There are many ways to breakdown learning phases.  Here are 3 common paradigms that I use in my practice.  By no means is this list exhaustive or detailed, but it should provide a diving board for deeper knowledge.Keep in mind this is not a general statement about the patient, it’s a specific transient phase that fits the individual and the current task.

Transtheoretical Model

Sometimes I’m jealous of trainers and performance PTs. Working with a motivated population that has a habit of exercising on a regular basis (action/maintenance phase) seems like a nice way to spend your days.  However, in rehab it’s often the opposite.  We are often presented with unmotivated patients that have no idea they need to take an active role in a process that they know nothing about (precontemplation).  Many patients come to see us in rehab so that we can “fix” their pain or pathoanatomical diagnosis.For these patients, this model works very well.  It gives you an approach to take them from precontemplation to maintenance all in one bout of PT.  Understanding the current phase of learning the patient is in is important because there’s no point in teaching someone a DNS Side Lift (active) if they don’t even understand why it’s necessary for them (precontemplation/contemplation).  

Fitts & Posner 3 Stages of Motor Learning Model

This is one of the most common models for motor learning.  And for good reason, it provides a concise method for categorizing your patient into a specific learning phase.  It doesn’t take into consideration the psychosocial inputs that the TTM does, but it does give an easy way to assess the motor learning aspect.  It’s pretty straight forward.  Just simply move them down the list.  But just be aware that the associative phase is often frustrating and takes time to get through.  Rushing through this stage and assuming the patient has automatic control is how you develop bad movement patterns and future injuries.

Movement Compensation

I’m not sure where I heard this.  Maybe from Gray Cook, Greg Rose, SFMA, or TPI?  But it provides a simple flow that you can use to educate your patients.  It’s very user friendly and utilizes language that is easy for the patients to understand.  You can think of it as a combination of the above models.

4) Practice

• Skill = Knowledge + Experience

Attaining the knowledge of coaching and cueing is a great start.  But to develop the skill you need focused practice (experience).To improve your focus during coaching sessions it’s important to perform your mental due diligence and ask yourself questions before, during, and after the movement.  This will help narrow the variables and improve your cue selection.Below are some basic questions I ask myself when coaching movement.

Four Questions Before the Movement

• 1) Is this for a novice, intermediate, or an expert?
• 2) Is it a completely new movement or is it a refining or chunking of a previous one?
• 3) Is this a simple movement or a complex movement?
• 4) Is this for motor control/learning/technique, body awareness, specific isolated muscle activation, performance, movement restoration, or just general exercise for global health?

After You Answer These Questions

Educate the patient on what you want them to do.  Give them the details, the name of the exercise, why it’s good for them, why you want them to do it, what it accomplishes, and what you want them to achieve (later on where they should direct their attention focus).

Two Questions After the Movement

1) Did it look good?  

Assessing the body segments, angles, timing, and overall motion is the easiest way to ensure proper movement.  If it looks bad, then it needs to be cleaned up with some coaching.  If it looks good, then it probably doesn’t need any cues.  However, it’s also important to realize that perfect kinematics does not equal perfect movement patterns.  Aberrant motor patterns, excessive muscle tone, substitutions, subtle de-centrations, and compensations can all occur while the movement kinematically looks good.  So how you check this?

2) Where did they feel it?

With this question you can find out if the patient actually owns the movement.  If they can feel the movement with the right body parts than you can be sure that they get it from both the bottom-up and the top-down levels.  If they can’t feel it, them there’s a disconnect and there will likely be compensations occurring somewhere along the kinetic chain.

Avoid Over Coaching

Sometimes you can clog up the system and confuse the patient by giving them too many cues and too many things to think about, especially for beginners, new movements, or complex movements.It’s important to let them first perform a couple reps without any extra input from your mouth.  The patient needs to be given a chance to feel and process the movement.  The person coaching needs to take some time to see what the most egregious fault is without biasing the movement.

Summary

The good thing about movement is that we can easily assess it.  If you’re not getting the desired result, just try a different cue.  And if different types of cues aren’t working, the problem lies in the practitioner not the patient (pick a different exercise).If there is one take home from this series it’s this: changing movement or developing a skill requires two things: focus and feedback.  It’s your job as a clinician to provide your patients with these two things.

Coaching & Cueing

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