11 Questions with Adriaan Louw

Adriaan Louw is a busy man.  Between running ISPI (International Spine & Pain Institute), performing research, treating patients, drinking beer, and watching football he doesn't have a lot of free time.  However, he was kind enough to answer some quick questions to help me understand pain, central sensitization, and the clinical application of neuroscience.  As always, his answers were very helpful and I thought I'd share them with everyone else.I first met Adriaan when I took the NOI Mobilization of the Nervous System course.  Check out my review of the course to catch up on some of the latest concepts.  He is not only an extremely knowledgable clinician, but he is a very entertaining speaker as well.  I cannot recommend taking a course with him enough.  You'll learn a ton, have a paradigm shift, and laugh a lot.Adriaan is an expert on pain science and the clinical management of pain.  He is also a Certified Spinal Manual Therapist and incorporates manual treatment with pain science to achieve the best results.  He is a published author, lectures internationally, and recently completed his Ph.D. on therapeutic neuroscience education and spinal disorders.

11 Questions with Adriaan Louw

These questions are directed towards the clinical application of pain science.  They will augment a background understanding of pain science and central sensitization.1) You discussed a study in which just the mention of testing a nerve caused the subjects SLR to decrease due to anxiety.  I'm having trouble trying to explain neurodynamics to my patients in regards to what I'm testing and what I'm treating.  What type of language do you use for the peripheral nerve stuff?• There are over 45 miles of nerves in your body. For normal function they glide and slide while we move. When nerves get hindered in their movement or become sensitive they tend to “tighten up” a little. The test we are doing is a way to see how easy your nerve can move; how far it moves and how sensitive it is. The treatment is a series of nerve glides to help the nerve move better and help calm it down (something like that).2) What could be happening in those patients that perform exercises with no pain when they’re in the clinic with you, but then come back and report that they had a ton of pain at night?  I know pain is an output, but if I can’t explain the mechanism I feel like I’m losing some “buy in” power.• Latent pain can be from various aspects: Afterglow effect of inflammation - we know DJD increases inflammation with use, i.e., grandma walks ++ Christmas shopping, and pays for it that even when she gets home. With increased use - maybe a little inflammation, wakes up the nerves as the day goes on.• Focus - busy during the day and when a patient sits still and thinks about it, becomes "aware" back hurts.• Depending on work - back pain at work may not be an option for the brain - really need the job; rumors about layoffs, etc.• Likely the way I will go: The alarm system (nervous system) gets activated throughout the day and steadily creeps closer to the threshold and at the end of the day - alarm goes off• Obviously you will need to examine/ask and see which fits best. Bottom line - various reasons; we can explain it, and can make it better....3) What could be happening when someone has no pain during the movement, but then pain immediately after they stop?  I see this happen often in shoulders.• Pain after muscle contraction• Muscles heal in short amounts of time• No/minimal pain during contraction = good; muscles = good• 45 miles of nerve in the body; intertwined through tissue, including muscle. Contracting a muscle can also set of the neighboring alarm system – i.e., nerves. This may validate muscle is OK, but the adjacent nerves are extra sensitive and now you're well on your way with pain education....Now the paradigm shifts to calming the nervous system down....4) What is one of your favorite stories/examples to help patients understand pain.  I often use the story you told us about the guy with leg pain that laid on a railroad track to self amputate and sill had pain after (phantom limb pain).• I don’t think it’s a story as much as a metaphor that can easily be applied to them. Sure – a person cutting their leg off or hiker Aaron Ralston cutting his arm off is interesting, but not personal. Maybe your patient saw Kevin Ware earlier this year in the NCAA basketball tournament break his leg on national TV, but did not scream “pain” – but rather “win the game”• My biggest “ah-ha” moments come with simple paradigm shifts like this:

• Suzy – if you sprained your ankle, would it hurt?

• Suzy – if you sprained your ankle, while crossing a busy street and a bus is coming straight for you, does it hurt?  You can see the gears turning

• NO PATIENT has ever told me yes – obviously no

• We discuss:

• Bigger threat wins

• Pain is an output

• Tissue injury and pain are not the same

• I’ve had many people say: “So pain is a decision by the brain?”

• Now we’re heading down a neat and interesting path

5) What is one of your favorite metaphors to help describe the process of pain to patients?• See above• Another one: If you step in a rusted nail, do you want to know about it? – explaining nerve functioning as an alarm system, action potential, danger message to the brain and action taken.• Another one: What would you do if a big roaring African lion jumped into this room right now? Stress response and multiple systems activating to protect you6) What is the best way not to offend patients when you are basically telling them that their pain (or at least some of it) is in their head?• Pre-empt it. Rusted nail example above – brain has to know there is a nail, so yes; it has to go to the brain. Is the pain in your head? Yes - but in your brain; in your head and biological and real.7) I’ve had patients where I’ve tried to explain pain to them about a thousand times.  No matter what approach I use, they won’t budge.  I’m sure a big part of it is that I must not be explaining it in the best way for them to understand it.  But what do you do in cases where someone refuses to believe anything other than that their tissues are causing pain?• Cannot fix all. The art of therapy is matching the patient to the treatment and vice-versa. It’s no different than manipulating a patient and they get worse. Pain is complex and so many factors determine the outcome.• If we find resistance, we don’t force it, but look for a back door. A recent patient wanted some trigger point therapy and “none of this cognitive nonsense you do here.” We did a thorough examination on her, set her up for some trigger point therapy and as she calmed (over a few sessions) we started educating her about pain while doing “traditional therapy.” Simple questions (nails; ankles sprains) and even the big ones” What do you think is going on with your neck?” “Why do you think therapy has not helped before?” etc.8) What is the biggest mistake you see clinicians making when treating the nervous system (peripheral or central)?• Several (sorry)• They become nerve heads and believe everything is a nerve• They view nerves as the “next” magic tissue. We’re bored with joints, muscles and fascia so we find the next magic “tissue.”• Underestimate our ability to impact the nervous system and brain with novel therapies• Overly aggressive – i.e., neural “tension”• Forget the nervous system is an emotional, living, breathing organism in close contact with its cousins the immune system and endocrine system and ultimately attached to a 100 billion neuron brain!9) What are your thoughts on chronic tendinopathies?  We know that in these chronic tendinopathies there can be a  histological change in tissue,  dysfunctional healing, pain, and weakness (J Cook, P Malliaras, K Khan).  Many recommend exercises that help stimulate and reorganize the tendon, even though they cause might pain.  How do you treat this in your paradigm?  Is explaining pain enough, or do you address the dysfunctional tendon tissue?• Clockwise ultrasound• I’m a nerve head – and I’ve read some neat stuff by Kharim Khan on this. All I know – the longer pain lasts, the more the nervous system, immune system and brain will be involved.  BTW – tendons don’t cause pain – pain is 100% from the brain.• Exercise may help pain, but is it purely due to its effect on the tendon?• Treatment: The clinical issue – I will make sure the patient get’s a whopping dose of neuroscience education; strategies to help the physical health of the nervous system ALONG with the cool “tendon stuff.”• We know you can think your ankle swollen. Any lasting pain causing a “worry” will lead to such an event and likely contribute – hence – a physically and emotionally healthy nervous system.               10) Pain science is really blowing up these days.  It is really changing the way we approach pain.  Both our profession and our patients are benefiting from it.  However, some are such strong advocates of pain science that it seems like they’d prefer PT’s to treat their patients mentally on a couch rather than physically on a plinth.  Where do you see our profession going with the new pain paradigm shift in the future?• We cannot keep up with the university lectures we get invited to. I tell students very bluntly:

• Graduate

• Enjoy therapy

• Resent therapy

• Hit rock bottom

• Start drinking (or drink more)

• Seek a new paradigm – welcome to pain science

• Turner and Whitfield showed 97% of what a PT uses in his/her practice is based on what PT school taught them. If that paradigm embraces the Cartesian model of pain (pain and tissue injury is synonymous) you’re screwed. If your school has updated to the Pain Gate – you’ll be good at putting TENS units on patients, but Ron Melzack who designed the Pain Gate with Patrick Wall has taken us to the brain and The Neuromatrix, which is where we need to be; but don’t camp out there too long – people like Mick Thacker is taking PT to the immune world….and more.• Paradigms change when you need them to change. Maitland (immense respect for him) worked for a while for me and sure helps many of my patients today, but the more chronic pain we see; the more a pain science or neuroscience view is needed.• To answer the question:

• If a joint is stiff and a patient cannot move = PT’s job to treat the patient (mobilization and manipulation)

• If a muscle is not contracting and a patient cannot move = PT’s job to treat the patient (motor control)

• If a trigger point is causing loss of ROM and pain and a patient cannot move = PT’s job to treat the patient (trigger point therapy)

• Then – if a patient won’t move or exercise because they have bad beliefs (i.e., I have a bulging disc or arthritis), why does it become psychology? PT uses therapeutic neuroscience education to alter beliefs; reorganize the patient’s belief, they have less fear and move better….

• Putting all of this into perspective: I started in pain science in 1998 and 1/7 Americans had persistent pain. It’s now 1/3 = 100 million. No way of hiding this. Either learn about this or find yourself working at Lowes or Home Depot in the near future. (Make sure you lift with your legs; right……?)11) There’s so much information out there that it can become overwhelming.  Could you recommend some good places for people to go to learn more?• Self serving: www.ispinstitute.com – courses, books, articles. We just launched a textbook Therapeutic Neuroscience Education with the aim of getting it into PT school.• AAOMPT has some pain information• IASP – world body on pain• Louis Gifford’s blog• Soma Simple• NOI• Body In Mind• Read this book: The Brain That Changes It Self

Dig Deeper

Books for Patient Pain EducationSomaSimple Adriaan Louw InterviewSign up for ISPI Newsletters, it's free quality information

BSMPG 2013 Summer Seminar (Video)

WCPT Congress - Focused Symposium: Pain Management (Video)

Research--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 (2013)

1) Human movement isn't always as simple as basic kinesiology and anatomy.  James Speck gives a great example of this in his detailed article describing the soleus as a knee extender.  "When a muscle contracts, it doesn’t think about which direction in needs to pull. It just shortens."2) More on pain science: "...they used newer MRI technology to see how flexible people could be in responding to pain. The mind-wanderers were more flexible."  Pain isn't a pathological structure; it's a central processed perception.3) I recently had a medial elbow tendinosis patient.  When I screened him with the SFMA his single leg balance was terrible.  He had some severe ankle/foot stability deficits.  This study was in a recent JOSPT.  Regional interdependence.  SFMA.4) Dr. Andreo Spina is a very smart man and has done more research than most.  You should read this interview from Patrick Ward's site.  "...BioFlow anatomy, it can be generally defined as a term used to describe, and conceptualize the extent of continuity found in human tissue at the microscopic level...Specifically how tissues seemingly ‘flows’ from one form to another.  This concept vastly alters not only ones perception of anatomy, but also their understanding of tissue assessment, treatment, rehabilitation, and training."5) Wait, what?  Bacteria directly activates sensory nerves (not via inflammatory mediators).  New immune-pain concepts.6) Postural Restoration Institute (PRI) is a great addition to any rehab approach.  I made this table to help myself understand some of the concepts of their postural respiration course.7) Erson has 5 MDT Exercises for the Cervical Spine.  "All of your magic hands hocus pocus means nothing if the patient cannot keep the improvements between visits."8) Interesting reflective post from David Butler.  "What bugs me is that it took so long to realize that it was I myself who was probably the main variable in outcomes – not the techniques."9) "Mechanotransduction refers to the process by which the body converts mechanical loading into cellular response."-KM Khan.  Mechanotransduction is an extremely important aspect of rehabilitation as it promotes tissue repair and remodeling.  Learn more about it from Khan in this podcast (article in website).10) Crawling is more than just physical reciprocal movement.  It activates reciprocal brain activity.  Meaning the left and right hemispheres must communicate with each other to coordinate the movement.  This developmental functional movement is the basis for Primal Move.  Look at their reference page for more information.11) Seth Oberst has a great article on prioritizing motor control for mobility.  " it's also likely that underlying poor motor control of the spine is negatively affecting mobility and ultimately performance of the extremities and spine."12) It's amazing how many people think MDT (McKenzie) is just an extension based exercise system.  It's a lot more than extension and exercise.  Check out this months post for more information.13) The Gait Guys do a nice neuro review of facilitation.  "When a stimulus takes them closer to firing, we say they are “facilitating” the neuron. If it affects a “pool” of neurons, then that neuronal pool is facilitated. If that pool of neurons happens to fire extensor muscles, then that “extensor pool” is facilitated."14) A Weingroffism on an olympic lifting patient with medial elbow pain: C-6/7 innervates the medial elbow.  A hyperextended neck during lifts compresses C6-7 facets and irritates nerve roots.  Nerves can cause inflammation (neurogenic inflammation).  Proximal influence of elbow pain.  PACK YOUR NECK!      [subscribe2] 

23 Things I Learned From McKenzie Part A

I have been following Erson Religioso, a PT and blogger, for quite some time now.  He has repeatedly (no pun intended) discussed the effectiveness of Mechanical Diagnosis & Therapy (The McKenzie Method or MDT).  He's a very knowledgable clinician and runs his social media with integrity.  Over the years he has provided a great deal of clinically applicable information and I have seen results in my practice using some of his methods.I decided I had to check out MDT first hand and learn about their method.  This past July I took McKenzie Part A - The Lumbar Spine with Dave Oliver.

23 Things I Learned

1) Physical Therapy is a mechanical profession.  We should look for mechanical problems.  If it's not a mechanical problem, refer out.2) Pathoanatomy is for surgeons.  It can cause a ton of fear / centralization if we start diagnosing pathoanatomy.3) MDT is not tissue specific.  It is a symptomatic and mechanically driven system.4) Don't give up so easy.  I used to stop people 3 or 4 reps into their repetitive motion if they had pain.  I learned in this class that if it's a derrangement you need to push through to get a true assessment.  Often times the pain doesn't only go away, but it gets better (green light).5) Don't be so afraid of testing flexion.  People flex thousands of times a day.  If you don't test it, they'll test it when they get back into their car after the eval.6) Practice changing quote: "When you put your hands on a patient it empowers YOURSELF.  When you teach a patient an exercise it empowers THEM."7) Chase their mechanical problems using the stop light system.  Red light is only if the pain remains after testing.8) Exhaust the sagittal plane of movement before giving up.  Don't stop at standing repetitive extension.  Push through all the way to extension in lying with overpressure before saying it doesn't work (as long as it's "stop light" appropriate).  See picture below for example of progression.9) If you're going to chase symptoms, it's best to do it through movement (MDT).10) Plus, if you find a derangement you can resolve their symptoms immediately and then start working on their movement dysfunction (SFMA).11) You're looking for 4 things during the evaluation:

Origin (where pain is coming from)

Classification (derangement, dysfunction, postural)

Direction (relation to symptoms)

Force (overpressure, repetitions)

12) Derangements often have variable symptoms (time, severity, flare ups)13) Derangement is when the joint is de-centrated (not in optimal alignment)14) Finding someone with a derangement makes your job ALOT easier.  You can then use repeated motion to clear their pain.  Since using this system the past few months, patients are amazed by how quickly their pain resolves.15) End-range extension in lying is when you lock out the elbows, exhale, and let the lumbar spine/pelvis relax (Lock, Blow, & Sag).16) Resolving a MDT dysfunction will be uncomfortable.  You have to remodel tissue.  It takes time.17) If there is a lateral shift, you need to fix it before going to extension18) Fixing a lateral shift can sometimes be like "pushing a rock up a hill"19) It's NOT an extension-based system!20) It's a end-range, repetitive motion system.21) End-range is extremely important.  Make sure you get there.22) Patient compliance and lifestyle (postures, ADLs) can make or break the outcomes23) Exercises taught to manage pain can also empower the patient during a potential future injury

My Thoughts

Overall it was a great course and I'm glad to have a better handle on the MDT system.I think it is a great system to use for any patients with pain.  People come into the clinic because they're in pain, not because they have a movement dysfunction.  Clearing out their pain is their #1 priority, therefore, it's your #1 priority too.  Plus, preventing acute pain from becoming chronic is one of the most important aspects of physical therapy.The only problem I have with MDT is their lack/disbelief of stability.  An example of this problem was evident during one of the live case studies.  A woman came in with back pain.  She had excessive motion in every direction (and probably a positive beighton laxity test).  Repeatitive motion exercises only made her worse.  Over the 3 days both directions were tried, and both increased her pain.  She was getting worse.  Without a stability approach what would happen with the rest of her plan of care if you were only using the MDT system?That's not to say it didn't work with the other 5 live case studies.  In fact, besides the hypermobile woman, all 5 patients had a significant decreases in pain after 3 days.  And 3 out of 5 of them were flexion based!MDT is an easy system to integrate into your practice.  It's more than just press-ups for disc herniations.  It teaches you how to use mechanics (repetitive motion) to assess and treat your patients symptoms.  There's no downside to testing repetitive motion and the potential upside is that you can resolve your patients pain in a matter of minutes.  Not a bad deal...

Dig Deeper

Erson's site is really the best place to go for more information on clinical MDT integrationMcKenzie --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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November Hits

1)  Down and back isn't always right for our shoulder patients.  In fact, some people need the opposite.  This months article goes over how to assess and treat someone for overhead shoulder exercises.2) This is awesome - slow-mo clean & jerk video with analysis from olympic lifting coach Jim Schmitz.3) A new knee ligament?  Researchers have found an Anterolateral Ligament (ALL) in the knee.  Is this a profound advancement in anatomy?  Or is this just a carved out fascial thickening?4) Great perspective on hamstring tightness.  Mike Reinold discusses how a tight hip flexor can pull the pelvis into an anterior pelvic tilt, thus decreasing the contralateral straight leg raise.  You could use the 90-90 active posterior chain test in hooklying to further determine if it's true posterior tissue extensibility.  The hooklying position takes out the hip flexors and anterior pelvic tilt.  Just understand that with ankle dorsiflexion it would be more of a neural bias and keeping the foot in neutral would be more of a soft tissue bias.5) The Subjective Examination.  Patients recall from memory the events and factors the influence their injury.  But how accurate is it?  Watch this interesting TED talk on memory.6) Mike Robertson put together a great guide for learning and correcting the front squat.7) If you're interested in performance you should check out this post on the different types of speed.  "To evaluate an athlete properly, several options exist to discovering the fitness and speed of an athlete. "8) Don't forget to train your upper dorsimus.9) Erson's 5's - Mistakes He's Learned From.   A great and humble post with some valuable clinical advice.  I recently have been learning from my mistake of thinking I can fix everyone.  I have a hard time "giving up".  This sometimes causes patients treatment duration to last longer than it should.  After 10+ visits of no significant change a lot of bad things can happen.  I am on board with Erson's rule of referring out if there are no change after 4-6 visits /1 month.10) “Graded Motor Imagery changes the brain’s neurosignature,” says Robert Johnson.  Here's a quick article explaining GMI.11) Activating the T-Spine extensors and lower trapezius is often a difficult task (especially in the patients that love to hinge at their TL junction).  I find this exercise very helpful for this problem.  The deep squat posture locks out the lumbar spine, thus forcing the thoracic extensors and lower traps to do all the work.12) Moseley's 4 Key Points to Understand Pain

1. Pain does not provide a measure of the state of the tissues;
2. Pain is modulated by many factors from across somatic, psychological and social domains
3. The relationship between pain and the state of the tissues becomes less predictable as pain persists
4. Pain can be conceptualized as a conscious correlate of the implicit perception that tissue is in danger

13) I think the SFMA should include this in their stability breakouts     [subscribe2]   

The New Overhead Concept (Part II)

In Part I you learned the concepts behind upward rotation and the overhead shoulder.  This article builds off of these concepts and will show you how to properly assess and treat for the overhead shoulder.I cannot emphasize enough how important a thorough assessment is before prescribing overhead shoulder exercises.  Without an assessment to determine any impairments or movement dysfunctions you will not be able to properly prescribe the correct exercises.  Before someone starts overhead movements you should make sure they're clear in all of the overhead shoulder characteristics (Part I).  Failure to do so could result in injury.However, a full biomechanical assessment is beyond the scope of this article.  Only general shoulder type and posture will be addressed in the assessment.

Assessment

Once you have cleared their shoulder biomechanics you can start to look back at the movement and shoulder type.There are several ways to assess the scapula position and shoulder type.  The Kibler Scapula Classification is one of the more common assessments.However, as we learned in part I, the scapula is only part of the kinetic chain.You need to also look globally.  And lucky for us, one of the best ways to assess global shoulder types is by simply looking at posture.

Posture

Don't just look at the glenohumeral joint, or even just the scapula.  You need to start at the center and work your way out.  Each level will determine what part of overhead training the patient will need to focus on.

Lumbar Spine: Look for the degree of their lordosis/anterior pelvic tilt.  If someone is hyperextended and hinges at the T-L junction you will need to address their anterior core before going overhead.

Thoracic Spine: You will usually either see a kyphotic thoracic spine or a flat thoracic spine.  Both cases will have difficulty stabilizing their scapula.  This needs to be addressed so that the scapula can move efficiently.  The scapula can be viewed like the patella; "it's not the train that needs fixin', its the tracks".

Clavicle: Due to its attachments, it will be a giveaway for the scapula.  You want to see a 6-20° upslope.

Scapula: This is the biggest giveaway.  The scapula is the "liaison" between the arm and the trunk.  But remember it moves in many planes, not just forward in back.

• Anteriorly or Posteriorly Tilted (Sagittal)• Upward or Downwardly Rotated (Frontal)• Elevated or Depressed (Frontal)• Internally Rotated (Winged) or Externally Rotated (Transverse)

Even a quick global view will give you a good indication.  For example, look at the picture to the left.Mr. Burns is a mess.  All his time obsessing about money and abusing his employees has left his shoulders depressed and his thoracic spine kyphotic.On the other hand, Juggernaut's uncontrollable rage has left his shoulders so high he appears to have no neck.These two would respond completely differently to an overhead program and require completely different exercises and cues.

Shoulder Flexion / Abduction

Once you have a good postural/static assessment you can then assess how they move dynamically when going overhead.  This movement pattern assessment will be a very valuable insight to their compensatory strategies.Have the patient flex and/or abduct their arms all the way overhead.  Look for fluid motion.  It shouldn't be a struggle for someone to get their arm overhead.You want to look for similar things that you do during the postural assessment, but you can focus on 3 things.

1. Centrated Spine (lack of rib flare)
2. Full Scapular Upward Rotation (55-60°).
3. Level Hands in Full Flexion

Intervention

After your assessment you will have a better idea of what your patient needs.  Their needs and movement patterns displayed in the assessment will dictate where to start.My progression usually starts with the anterior core integration, then goes to unloaded overhead, then to loaded overhead.  I know this is vague, but its more about making sure you aren't missing a step in the process.  Going to a loaded press without assuring correct unloaded movement patterns or anterior core stability is a dangerous way to treat.

Compensations / Substitutions

Before you start pressing away, it's important to know what common compensations occur with overhead shoulder movement.  Here is a list of the most common strategies I see (this is not conclusive, some people find amazing ways to compensate).

• Rib Flare
• Lumber Hyperextension
• Cervical Protusion
• Inadequate Upward Rotation
• Elbow Flexion
• Scapular Protraction/Anterior Tilt
• Trunk Lateral Shift

Cues

It is important to have the right cues to prevent compensations.  Each individual will require a different cue depending on their movement patterns and potential compensations/substitutions.Eric Cressey uses 4 Different Cues depending on the athlete:

1) For Lumbar Hyperextension / Lordosis / Rib Flare = cues to engage antere core and keep ribs down

2)For Kyphotic "Desk Jockeys" = cues to keep chest up (posteriorly rotate rib cage, not lumbar extension)

3) For Depressed Sloping Shoulder Blades = cues to shrug as arms go overhead (not before) to get full upward rotation

4) For Upper Trap Dominant = cue posterior tilt of the scapula

The Exercises

Basic Anterior Core Integration

I always find it advantageous to start with some basic anterior core integration.  Many people have difficulty with this concept.  If you skip this step and start training scapular upward rotation on a weak/inhibited core you will only be setting them up for failure in the future.  Without the core, the shoulder has to do twice as much work.The reachback / pullover exercise is a great place to start.  If the patient has difficulty getting their ribs down, you may need to regress the exercise a simple breathing drill (full exhale helps achieve "down" position and engages core).http://www.youtube.com/watch?v=blJcjYIRiokOn the other side of the difficulty continuum, the standing anti-extension exercise is a great way to integrate the core with shoulder flexion.  I find this exercise very challenging when done correctly.http://www.youtube.com/watch?v=nxkawQ_sanc

Unloaded Overhead Training

After you integrate the core it's time to start training overhead.  But before you load it up you want to make sure your movement patterns are clean.  Start "greasing the groove" without resistance or load first.  These are also great warm-ups for advanced patients.

• Unloaded PNF D2 Patterns (supine, half/tall-kneeling, quadruped, standing)

• Reach, Roll, & Lift

• Prone Y's & ILY's

• Wall Slides

• Back-to-Wall Shoulder Flexion

• Bilateral Shoulder Flexion in Deep Squat

3 Loaded Overhead Training Progressions

• 1. Static Load in Full Flexion

Often times when people have difficulty squatting or deadlifting we start from the bottom and/or shorten the range (i.e. box squats, FMS corrective squat, rack pulls).  We can apply the same logic to the same with the press.  We can start from the top and shorten the range.The top down press (Rack Press) is essentially working from the full overhead position and progressing your way down.  This allows the patient to reap the benefits of the overhead position without going through the provocative motions to get there.  Remember from Part I, this loaded full overhead position is where you reap all of the benefits (core, scapula, t-spine, RTC, etc.).http://www.youtube.com/watch?v=EZAIDV7vMOIThe emphasis for the rack press should be the static loaded hold in full flexion.  I usually have my patients hold this position for at least 3 breaths per repetition.  The more time in this position, the better.Other exercises include:

Bottoms-Up Kettlebell Overhead Hold / Farmers Walk

Reactive Neuromuscular Training (RNT) with Lower Extremity (the possibilities are endless)

• 2. Progressive Angles

Another great way to progress loaded overhead training is with progressive angles.  I learned this one from Eric Cressey.  Starting with angled presses/pulls decreases the provocative positions while allowing for overhead adaptation.

Landmine Press (Angled Press)

Angled Pull-Down

Resisted PNF D2 Flexion

1/4 Turkish Get-Up (to elbow)

• 3. Full Range Overhead Training

Once your patient is able to handle all the exercises above it is safe to progress to full overhead training.  From this point it is more about the SAID principle and maintaining clean movement.

Yoga Push-Up (at 2:10 in this video)

Full Turkish Get-Ups

Resisted Y's (TRX Y's)

Kettlebell Overhead Press

Push-Press

Barbell Overhead Press (OHP)

Pull-Ups (eccentric → concentric)

Bottom Line

Sometimes just mentioning overhead shoulder work makes people cringe and grab their shoulders.  It is often avoided in rehab and is performed/progressed incorrectly in performance training.Everyone should be able to get their arm overhead.  This position is incredible for the human body.  With this article series you should be able to better assess and prescribe exercises for overhead shoulder work.

Dig Deeper

Eric Cressey - Upward Rotation in Athletes - Why You Struggle to Train Overhead & What to Do About itLudewig PM, Cook TM. Alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276-91Johnson G, Bogduk N, Nowitke A.  Anatomy and actions of the trapezius muscles.  Clinical Biomechanics.  1994;9:44-50.Struyf F, Nijs J, Meeus M, Roussel NA, Mottram S.  Does Scapular Positioning Predict Shoulder Pain in Recreational Overhead Athletes?  Int J Sports Med. 2013 Jul 3; --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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October Hits

1) The poor upper trapezius.  It might be the most understood muscle in the body.  It's not a major shoulder elevator and it isn't a big problem in shoulder patients.  In fact it's usually the opposite.  Check out this months post to learn more.2) "Thought viruses" are a big problem in rehab.  Sometimes patients come in with them, other times PT's give them to their patients.  We need to stop using harsh pathoanatomical diagnoses (use movement instead).  I've seen it way too often; a patient comes in with some shoulder pain and leaves with subacromial bursitis, RTC tendonitis, and impingement syndrome.  Don't plant diagnoses into patients minds.  It can cause centralization, it's unfair, and maybe even unethical.  Check out some Erson's pet peeves on thought viruses.3) Cressey has some great advice on how to deadlift forever.  Hint: don't have setbacks!4) The great Pavel writes about the benefits of the 5x5 training program.  If you are trying to get stronger or training to get someone stronger you should pick a lift and give it a try.5) Reciprocal pelvis and thorax motion in gait is extremely important.  Both for mechanical and central mediated neurological factors.  The Gait Guy's talk about it in this article.  "The hip must pass through the internal rotation phase before it starts into hip extension.  This means that the opposite shoulder must do the same thing."6) Fascia is more important than just tensegrity.  "Fascia nevertheless is densely innervated by mechanoreceptors which are responsive to manual pressure. Stimulation of these sensory receptors has been shown to lead to a lowering of sympathetic tonus as well as a change in local tissue viscosity. Additionally smooth muscle cells have been discovered in fascia, which seem to be involved in active fascial contractility. Fascia and the autonomic nervous system appear to be intimately connected. A change in attitude in myofascial practitioners from a mechanical perspective toward an inclusion of the self-regulatory dynamics of the nervous system is suggested." -Robert Schleip (Fascial Plasticity, 2003)7) More Erson's Friday Fives - This is a great one on mobility problems hiding stability problems.  I'm always amazed when someone's cervical patterns will become FN after some core or scapula activation.8) Paul Bach-Y-Rita: “We see with our brains, not with our eyes.”.  Todd Hargrove gives an excerpt from his upcoming book on the difference between sensation and perception.  Great read.9) This is both an assessment and an exercise.  When my patients can do this it usually correlates with pain free return to activities.10) Mike Reinold writes about a problem with the medical professions.  "We have created this “paralysis-by-evidence” situation where some people think you can’t do anything unless it has strong evidence suggesting it is effective.  This approach is challenging and ultimately unrealistic."11) Gray Cooks 3 R's: Reset, Reinforce, Reload.  I've been using this with every patient for every treatment since I first heard about it a couple years ago.  It makes a huge difference and is a great way to treat (regardless of your approach).

Reset: Passive, Reduce Pain & Inflammation, Make Change in System

Reinforce: Behavioral, Lifestyle Changes, Conservative Management, Taping

Reload: Active, Therapeutic/Corrective Exercises, Movement, Motor Pattern Training

12) Dogs will always be better at yoga. [subscribe2]

The New Overhead Shoulder Concept (Part I)

Traditional Down & Back

At this point we all know the importance of a stable and strong scapula for shoulder function.  Almost every PT, athletic trainer, and personal trainer trains the shoulder with a "down and back" cue.  This cue allows for a better stable position of the scapula and enables the rotator cuff to work more effectively.  Kolar has summed this concept up in a single sentence:

• "The muscle may not be weak in itself, but it may not function well because its attachment point is insufficiently fixed."

New Upward Rotation Emphasis

However, in my experience there have been many patients that don't seem to get back to their full function after a shoulder injury despite the scapula strengthening and the down and back shoulder packing.  In my search for answers I came across Eric Cressey's blog several times.  Where most clinicians are terrified of allowing a shoulder to elevate due to the Upper Trap/Lower Trap ratio that we were taught to fear, Cressey advocates the opposite.  He trains many of his clients in an overhead position with an emphasis on upward rotation using the trapezius.

• "We may have ruined a whole generation of athletes with the cue back and down" - Eric Cressey

Does the statement above bother you?  Bring up some defensive arguments?  It did for me when I first heard it.  I've been cueing people with "back and down" for years.  However, once I got past my ego and opened up to this concept my shoulder patients started to get MUCH better.

Overhead/Upward Rotation/Upper Trap Concept

While this upper trap/overhead concept may not be brand new or fully original to Eric Cressey (I know Sahrmann is an advocate of this); he is the first I've heard to discuss it with such clarity and clinical relevance.  Most of the time when you hear about a new concept it's really just somebody trying to sell something or someone just offering an interesting perspective with no clinical solutions.  However, Cressey not only helps to define this paradigm shift, but he also offers detailed strategies to address it (for free!).Much of this post series, especially the assessment & intervention (part II), is based upon Cressey's work.It's important to note that this isn't just a protocol you blindly apply to everyone.  It's a detailed concept that requires an individualized assessment to determine if they need more upward rotation (and where they need to get it from).

Why is Overhead Position Important?

We're Losing It

Our current species of the hominin is starting to de-volve.  To understand this, we have to look at where we came from.  First when we used to live in the trees our shoulders were oriented upward and forward.  Then when the climate changed and we were forced to our bipedal states in the savanna, our shoulders re-oriented less upward and more forward to manipulate objects.  Next, to increase our hunting prowess our shoulders re-oriented more laterally facing to allow us to throw objects at our prey.  Now, with all the use of technology and poor postures our shoulders are starting to regress back to facing more forwrard.

Displays Optimal Shoulder Function

The FMS/SFMA had it right with the overhead squat assessment.  For more reasons than I realized.Being able to get both arms overhead without compensatory patterns is a sign of great shoulder function.  If you have any pain, restrictions, weaknesses, or dysfunctional movement patterns you will not be able to do this.  The same cannot be said for non-overhead shoulder positions.

People Like to Use it

Even if you don't buy into the last two, you can't argue with this one.  Most of our patients love to participate in recreational activities and exercise.  For these patients to return to such activities they need to display good overhead shoulder mechanics.  You can't just have them doing sidelying ER and expect them to go out and hit a tennis serve without problems.Even if they're not athletes they'll need it for everyday tasks of putting dishes away, washing your hair, hailing a cab, slapping someone taller, etc.

What is Required for the Overhead Shoulder Position?

Before you can assess and correct the overhead shoulder, you first must truly understand what goes into an overhead shoulder.  Each of these things have their own complexity and should not be underestimated.

What You Get When You Train Overhead?

A cascade of events occur when you lift your arm to the full overhead position with a proper movement pattern.  From a simple perspective it strengthens the upward rotators and lengthens the downward rotators.  Full scapula upward rotation is paramount (increased GH congruency in overhead position).  However, it's much more complex than just upward/downward rotation.First it's important to understand that most people only have about 170 degrees of pure shoulder flexion.  Often time they'll cheat with lumbar/T-L junction hyperextension to get to the full 180.  But if you can teach your patients not to cheat and to actively get to a stable compensatory free full overhead shoulder position, a lot of good things will occur.So what happens when you try to go for the full 180?  A cascade of events occurs leading to a stable shoulder position with activated thoracic extensors, scapula stabilizers, rotator cuff, and anterior core.Load this position with a weight and a ton of great things happen.  The simple physics of it:Long Lever + High COG over Small BOS = Inherent Instability = Reactive Stability.Plus, adding a compressive load gets the reflexive stabilization of the RTC and scapula in this great position.

Is the Upper Trapezius Really a Problem?

The poor upper trap.  It gets blamed for everything.  People often say that it's too tight and too active.  Historically many people have tried to decrease the upper trapezius tone by spending a ton of manual therapy and stretches to "loosen" them up.  Then they try force the little lower trapezius and serratus anterior to do all of the upward rotation work.The problem is that the upper trapezius should be considered with the opposite point of view.  We should look at it as an important shoulder muscle that needs to be strengthened.This concept should be agitating for anyone that went to physical therapy school, as we learned about UT/LT ratio's and how much of a problem the UT can be.To accept and utilize this paradigm shift you have to understand the true function of the upper trapezius.

2 Aspects of the Upper Trap Function

1) The UT is an important part of scapular upward rotation.  Many people know this, but tend to spend all their time on the LT & SA.  If you only focus on the LT and SA then you are missing out on  33% of the upward rotators.  How can you get someone back to full function by only strengthening 66% of their muscles?2) Almost all the fibers of the UT attach to the posterior boarder of the distal third of the clavicle (Johnson et al, 1994).  This would mean the fiber orientation would actually cause medial rotation of the clavicle, compress the sternoclaviculalr joint, posteriorly tilt of the scapula, elevate the lateral clavicle, and increase upward rotation.

So have we been completely wrong all along?

Yes and no.Yes, there can be an excessive elevation during the initial stages of shoulder flexion.  So there is a movement dysfunction.But no, the UT isn't capable of elevation with the arm at the side.  The UT works synergistically with the LT and SA after the shoulder has started to flex/abduct.  The excessive elevation is from the levator scapula (the main scapula elevator with the arm at the side).To make matters worse, when the upper trap is weak the levator scapulae will jump in and try to make up for this weakness.  Unfortunately the LS doesn't upward rotate, so it just pulls on the cervical spine, jacks up the scapula, and throws off all force couples.

Bottom Line

The down and back traditional treatment of shoulders may not be the best approach for all patients.  Not to mention there is a great deal of benefit from training in full scapular upward rotation (i.e. increased subacromial space, UT/SA/LT strengthening, downward rotator lengthening, t-spine extension, anterior core stability, etc.).After reading this article you will have the necessary understanding to better assess and treat the overhead shoulder (part II).

Dig Deeper

Eric CresseyWarren Hammer - Dynamic ChiropracticAdam Meakins - Upper Trapezius James Speck - UT Doesn't Fire IndependentlyLudewig PM, Cook TM. Alterations in shoulder kinematics anda ssociated muscle activity in people with symptoms of shoulder impingement. Phys Ther 2000;80:276-91Johnson G, Bogduk N, Nowitke A.  Anatomy and actions of the trapezius muscles.  Clinical Biomechanics.  1994;9:44-50. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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September Hits

1) Kettlebells are becoming more and more common in fitness and rehab.  If you don't use them, you should.  Here's this months article on my expirience at the premier kettlebell workshop.2) Erson goes over 5 things to look for in runners.  "Running is one sport that arguable needs more symmetry than most. I tell my runners it's because you're doing the same thing over and over for 1000s of steps until you stop!"3) Habits are regularly tendencies that become automated by the brain.  James Speck goes over how to form good habits.  This is something we need to teach all of our patients.  Some great points: habits take 60 days to develop, tap into subconscious willpower by visualizing & planning goals, reward yourself, start small, be consistent, and make it measurable.4) Mike Robertson has a great article on life long lifting.  This is a must read, because unless your a vampire, we all get older everyday.5) Yoga or Doga?6) Eric Cressey gives you a solid base for a medicine ball workout.  These provide a great functional workout.  Great gem here: "When performed correctly, medicine ball exercises serve as an outstanding way to "ingrain" the mobility you've established with a dynamic warm-up prior to training."7) Andreo Spina describes the important difference between mechanical tightness vs. neurological tightness.  Chasing neurological tightness with interventions such as static stretching, joint mobs, or ART are unlikely to yield good results.  Instead you should try PNF, slow fascial release (for parasympathetic response), and breathing techniques.  Another important consideration is pain.  Pain changes everything.  Often neurological tightness is a protective mechanism to avoid pain.8) Having trouble teaching the squat?  The Goblet Squat is the best way to start.  Progression: Goblet Squat, Front Squat, Back Squat.9) Here's an interesting perspective on the psychological benefits of yoga.  "I came to realize that yoga works not because the poses are relaxing, but because they are stressful.  It is your attempts to remain calm during this stress that create yoga's greatest neurobiological benefit."  Make sure your patients don't forget that there's supposed to be a mind attached to the body they workout.10) The elbow is a more complicated joint than most people realize.  Eric Cressey has a great series on elbow pain (Part 1, 2, 3, 4, 5, 6).  He also has an article on 13 ways to take care of your elbows.[subscribe2]

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