The Art of Recovery (Part 1 of 2)

One of the most difficult questions to answer in rehab is: "when will I get better?"Coming out of grad school my response was usually mumbling some ridiculous time period with a deer in the headlights look on my face.  I had no idea.  I knew the tissue healing timetable...and that was about it.  I had little experience with specific injuries and didn't yet understand the complex, multi-faceted factors that influence recovery.Now I'm a little better at hiding that deer in the headlights look, I have more clinical experience, and I know more about the art of recovery.

Stress

Before diving into recovery, you have to understand a little more about the stressors that cause recovery and adaptation.There are two types of stress: Internal Physiological Stress and External Environmental Stress.The Internal Stress is an on-going battle to keep our physiological homeostasis.  We have to adapt to these cellular stressors to make sure we can continue to keep all of our systems functioning together.  This type of stress is perpetual as long as you're alive.The External Stress is what happens when we interact with our environment.  It's how we adapt to function and survive in our surrounding habitat.  This can be physical and/or mental stress.

• Physical Stress includes any external force/load that is applied on the body (e.i., getting out of bed, walking, sitting in a chair, carrying groceries, bring a beer to your lips, etc.).  Even gravity counts as a physical stress.  But don't use that as an excuse to skip your next workout.

• Mental Stress includes all the sensory input and complex psychological processing.  This is an extremely complicated system and cannot be overlooked.  Even listening to music elicits a certain amount of mental stress, let alone listening while texting your friend, checking your email, and trying to avoid walking into people on the sidewalk.

Unfortunately, there is no way to completely avoid stress.  Trust me, with Netflix binge watching I have given it a good shot.  Nevertheless, if you are alive, and you live in an environment, you will have to deal with these internal and external stressors.  And this is a good thing (to a certain extent).

• Stress Must Occur for Adaptation to Occur

All of these different types of stressors are compounded on the body.  In other words, it's cummulative.  The external stressors are added to the internal stressors, and it forces your body to adapt (both physically and mentally).  If your body can't adapt, if it can't recover from the stress...bad things will start to happen.

The Art of Recovery

I know, it sounds like a book you'd see in the self-help section of Barnes and Nobles.  But I've come to realize how important recovery is when you look at the big picture.We all want our magical hands, brilliant exercises, and genius programming to cause specific advantageous adaptations that give our patients super-human like powers.  But the sad truth is, even if we put a magic spell on a patient, they will only get better if they can adapt from it.

• Adaptations Occur During Recovery

Simply put, your patient won't be able to adapt to physical stress without a proper recovery.  The gains will be diminished, non-existent, or even reversed.  And if this short term lack of recovery continues over time, it can lead to a very damaging effect.This applies to everyone; from rehab to strength and conditioning.  Whether it's a post-op ACL or a PR deadlift session, recovery drives the adaptation.Stress can either cause an adaptation or push them further down the biological stress path.

Tissues Heal

Tissues will naturally heal.  Our bodies have a great capacity to repair themselves.Tons of people injure themselves everyday and don't need any rehab or exercises to recover.  Their tissues heal with time (providing they don't do anything stupid).  They just ride the natural progression towards recovery.Understanding this simple concept is a big part of recovery.Since the tissues are going to naturally heal themselves, you better make sure you and your patient don't do anything to disrupt this process.  This comes down to educating your patient on the factors that influence their recovery.  If all you do is control these factors of recovery, the patient will physiologically get better (not talking about pain and/or movement patterns).After you have the preventative/augmentative aspect of recovery covered, you can start to try to create the right environment for the patient to heal in.  This comes down to controlling the specific stressors (seed) you apply to the patient (soil) in the clinic.

Factors That Influence Recovery

The Art of Recovery is an individualized process that depends on who your patient is and what injury they have.  Everyone is different and requires a different recovery process.You can't apply a cookie cutter approach to recovery.  It won't work.  There are too many patient variables to consider: coping style, lifestyle, social factors, occupation, expectations, education level, learning styles, previous injuries, expectations, economic status, goals, cultural background, etc.It needs to be tailored for the human being you are working with.So where do you start?Start by understanding all the factors that can influence recovery.  Specifically, the external environmental factors, since these are the ones both you and your patient have the most control over.  And these external environmental factors can be used to influence the internal physiological factors.Our species will respond in a similar manner to all these factors.  Regardless of who you are, a bad diet, lack of sleep, high level of stress, and lack of exercise will adversely affect your recovery.  However, the degree to which everyone is affected by these factors will differ.Once you understand this complex concept and some of the variables involved, you can then start to assess and individualize these factors to the person's specific needs.It's important to realize that many of these factors can either positively or negatively influence recovery.

Assessing the Patient

Recovery can be viewed from the lens of the nervous system (Autonomic NS).  The nervous system oversees and affects all of the other systems, especially when dealing with stress.Everyone will be on a continuum of sympathetic and parasympathetic dominance.  Where they lie on this continuum depends on many components, but global perspective can help to assess how much stress a person has.If there is a lot of stress (internal & external), the body will be in more of a fight or flight mode (sympathetic) trying to recover from this stress.  If your body is adapted and not as stressed, it will be more relaxed (parasympathetic) and closer to homeostasis.You can generally tell what system is more dominant by spending some time with the patient.  You can just globally look at their symptoms, interactions, affect, demeanor, and body language.  Or you can get a little more objective using the cardiovascular system (heart rate variability).Either way, you need to determine where your patient stands.  Are they too far on the parasympathetic side and need some added stress to initiate positive adaptation?  Or are they too far on the sympathetic side and need to reduce some of the cumulative stress to allow for recovery?In general, your body recovers better on the parasympathetic side.  Especially in today's over stimulated world, everyone could probably benefit from getting a little more parasympathetic.  Just realize that some people will need more work to get there.  And the goal is to get to a state of neutral, not to push your patient into a coma for recovery.

Influencing Recovery

How to influence these factors is a whole other animal.  Because of the complexity of patient variables, it is impossible to have a protocol for influencing recovery.  Developing this approach is much like pain education, it really needs to be specific to the patient.There are 2 things you should take into consideration:

1. People respond differently to different methods of recovery
2. People may not be able to change certain factors

Instead of dogmatically forcing certain methods or certain factors, listen to your patient and work with them on what they can do.For example, the new father with a busy work schedule may not be able to get 7 hours of quality sleep every night.  It's just not in the cards.  So instead of beating a dead horse on sleep, you should educate and promote one of the other factors.  He can probably improve his diet/hydration, exercise for 20 minutes, find 5 minute to meditate, or reduce his technology use at home.And this doesn't need to be a 10 minute lecture or a big intervention.  It is just an open discussion with the goal of educating the patient and helping them improve their recovery.How you educate them is up to you, but if they don't know, they can't change it.  And if they can't change it, that perfect exercise won't "grow" to be the adaptation you were hoping for.

A Role in Promoting Health

All you can do is educate and try to sell the patient on recovery.  In the end, their recovery is in their own hands.But also consider that you are doing more than just advocating recovery.A side benefit of focusing on factors that influence recovery, is that you are also promoting a healthier lifestyle.  Not only will they recover more efficiently, but their overall health can dramatically improve with small changes.  This could make a big impact on their quality of life.And think about the effect this could have on our healthcare system.Someone that sleeps 4 hours a night, doesn't exercise, eats bad food, is stressed with work, and sits in a chair for 80 hours a week will cost the healthcare system A LOT of money.  If this person could change at least one of those factors they would be in much better health and put less strain on the healthcare system (if 25% of the population were more fit, it would save over $58 Billion per year).

Bottom Line

Many times we become so worried about applying the perfect stress that we forget about the importance of the patient adapting to it.We can get so caught up with movement patterns, mechanics, pain education, and manual techniques that we sometimes overlook some of the easy ways to help a patient recovery quicker.  Educating and attempting to control the factors that influence recovery is not only a part of their current rehabilitation, but it's also a big part of their overall health.So the next time your patient inquires about "when they will get better", take the opportunity to discuss some of the factors that influence their recovery (and their health).

Dig Deeper

References will be provided in Part II.Signs & Symptoms of Overtraining  --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 (2014)

1) One of the best things about PRI is their interdisciplinary approach.  They've done a great job at providing holistic care.  Specifically, PRI Vision is putting out some great stuff.  PT's have been stuck advising the same ergonomics with the same reasoning for the past 30 years.  Heidi Wise goes over a more methodical way to address your patient's ergonomics (Part 1 & Part 2).2) Kevin Carr goes over some great Row Progressions.  Use these for your patient.  Use these for yourself in the gym.3) The language you use with your patient has a huge impact.  Be positive and optimistic.  Don't talk over their heads.  Don't scare them with patho-anatomy and diagnoses.4) Mike Boyle clears up some things on ACL "prevention".  "The bottom line is that a good strength and conditioning program is also the best ACL prevention program.".  This article is a must read for anyone that works with ACL patients.  Like Charlie always says, Rehab=Training.5) Gray Cook & Stuart McGill got together for a discussion on their different approaches to movement.  Jeff Cubos puts all the reviews in one place here.6) The Gait Guys have a nice quick review of gait analysis.  Knowledge of potential foot pathomechanics helps assessment.7) Anything that the body does can be chased back to neuroscience.  Here's a Top 10 Neuroscience TED Talks list.8) "Why you would want to turn your lat on to reach overhead is a puzzle to me, as it limits shoulder flexion and scapular upward rotation, draws the humerus into internal rotation (closes down the subacromial space), and pulls the spine into an extended position (excessive arching).  What folks really should be doing is a subtly posterior tilting the scapula to free up space at the front of the shoulder, and facilitate upward rotation." - Eric Cressey9) More evidence for the importance of scapula upward rotation.10) Sleep is an important variable of recovery.  Read about it in this series.11) Developmental Stability is a big part of what I do.  It's natures perfect self-limiting exercise.  It's the hominin's first SAID principle.  It's something every patient can benefit from.12) Neuroplasticity is a gift.  This is a long read, but well worth it.  "Neuroplasticity is an intrinsic property of the human brain and represents evolution’s invention to enable the nervous system to escape the restrictions of its own genome and thus adapt to environmental pressures, physiological changes, and experiences.” -Dr. Alvaro Pascual-Leone13) A nice quick review of Andreo Spina's course - Functional Range Conditioning.14) The importance of breathing is often understated.  If your patients can't breath right, they're going to have a bad time.  Seth Oberst goes over breathing in his 4 part series (I, II, III, & IV).15) Here's a nice EMG chart summarizing the glute med activity with specific exercises.  The side-plank wins.  But keep in mind, EMG studies should be taken with a grain of salt:

1) Do you want a stabilizing muscle firing near a full maximal contraction (strength vs stability, timing vs. force, efficiency, task purpose)?

2) Too many variables to consider with the subjects (exercise history, potentially influencing impairments, past injuries, motivation, etc.).  Keep it individualized; not everyone will elicit 74% MVIC of their glute med during the side plank.

3) The reductionistic isolated muscle approach can cause a blunder by overlooking the complexity of movement patterns and biomechanics.

16) "Don't believe that the neck is connected to the core?  Try lifting your head up in supine without activating your core.  It's impossible."-What I tell patients that don't buy into the proximal influence17) "Diffuse noxious inhibitory control (DNIC) is one of several varieties of “descending modulation”, by which the brain alters the amount of nociception (pain) signal coming in."18) Gray Cook wrote a great piece about the new Standord University strength and conditioning approach.  Here's 2 articles (1, 2) on their approach and how they've reduced injuries by 87%.19) Top 3 Tweets of the Month

• Emily Soiney - The key to the Frontal door is in the Sagittal lockbox. #PRI
• Seth Oberst - Hip impingement not just structural issue. We can unimpinge many athletes with mobility and spinal control. Don't just rush to surgery.
• Craig Liebenson - "FMS is not a biomechanical or mechanism of injury screen. It evaluates sensory input."

20) When you can't run outside, you have to find a way to make the treadmill interesting.           [subscribe2]

Everything is Moving Proximally

In the past 10-20 years there has been a trend towards stabilizing the proximal joint.  Everything seems to be going more and more proximally.  And this is a good thing!  It is providing us with better outcomes and quicker pain free rehabilitation.If you look at the knee joint you can see the progress.  We've gone from isolated patella mobs and VMO strengthening to hip strengthening.  And now we are going even further up the chain and looking at lumbo-pelvic complex.The same thing is happening with the shoulder.  We've gone from isolated thera band ER/IR to scapula stabiliztion.  And now we are going even further and looking at the thoracic spine and ribs.And if we go just 1 step further at both joints we end up where it all began in the first place...the core.

The Greats Love Proximal Stability

This is no where close to being a new concept.  Many of our professions greatest clinicians have been emphasizing the influence of proximal stability on the distal extremities for years.Shirly Sahrman always discussed relative flexibility/adjacent stiffness, PRI's focus is achieving a Zone of Apposition (ZOA), PNF (Kabat & Knott) has always advocated Proximal Stability before Distal Mobility, Gray Cook prioritizes Symmetrical Core Stability, Stuart McGill discusses Super Stiffness, DNS (Kolar) starts with a Centrated Spine for a Punctum Fixum, Kelly Starrett talks about Midline Stabilization, and Janda's Upper/Lower Crossed could be argued to be the result of poor core stability.Anyone that uses these approaches knows of the benefits of core stability for extremity function.It's becoming more and more common in clinics, training rooms, and gyms.  But it goes beyond empirical cases; the research on the influence of the core on the extremities seems to be increasing as well.I would bet that in several years, core training and integration for extremity dysfunction will be as common as hip strengthening for dynamic valgus.

The Core

We could sit here for days and argue over semantics on the definition of the core.  We can then spend another couple hours arguing about how it can be separated: inner core, outer core, local muscles, global muscles, anterior, posterior, lateral, etc.This is great and can provide for some interesting discussion, but these semantics don't change how the core works.I try to keep it simple and define the core is the center of the body.  It's your axial skeleton and all the muscles that connect to it.Regardless of your definition, the focus should be on how the core works, how to assess it, and how to train it for each individual patient.

The Developmental Perspective

Looking at movement through the neuro-developmental lens gives us an unbiased perspective of how we ALL started to move.  Every generation has developed motor functions through the same neuro-developmental kinesiology.  It's a pre-written genetic code with more than 6 million years of evolution.  We are all born with full mobility; and then we struggle our way from rolling, to sitting, to crawling, to walking.We develop our first movement patterns with minimal influence of external factors.  It's the purest form of movement that we have in this world.It's before shoes deprive our sensory input and lock up our ankles.  It's before we're forced into chairs and give away all sorts of proximal mobility.  It's before someone tries to coach or teach us how to move.  It's before we can be influenced by a certain model of movement (yoga, pilates, martial arts, powerlifting, sports, etc.).The developmental perspective shows us how humans move before the detrimental influence of their culture.Needless to say, it's a good standard to measure against.

How the Core Works

Developmentally, all movement starts at our core.  We start to control our head, we start to gain sagittal spinal stability, and then we start moving our extremities.  This combination of spinal stability in concert with extremity movement then drives the rest of the movement development.   Once we have this extremity motion integrated, we start rotating and rolling, then we sit up, then we go from creeping to crawling to cruising to walking.This is all basically a core motor control and strengthening progression.  The core stability demands increase with the each progression of the developmental milestones (least=supine/prone, most=standing/walking).  It's the first SAID principle our bodies have to deal with.If the core doesn't fire efficiently, the baby won't be able to perform the task and the baby will fall down.  Without an integrated core, the baby won't be able to use their extremities for manipulation and movement.In this manner, developmental kinesiology prevents humans from progressing to the next milestone without mastering the previous one.  It's natures perfect self-limiting exercise.Babies don't perform planks, do 3 sets of 10 crunches, or isolate their transverse abdominis.  Thats not how the core works.  The core works to create efficient proximal stability for the production, control, and transfer of force.  The core works to create a stable base for goal oriented movement.  It's a complex, integrated system of feed-forward and feed-back strategy.  And it is developed through the use of the extremities.It's important to note that this "efficiency" is not a measure of strength.  It's an assessment of the neuromuscular patterns.Core efficiency involves the complex coordination, timing, and motor control of ALL the muscles involved in the specific task.  From the big toe on the ground to the opposite shoulder, all muscles must be fire in concert with the core.  It's not just "pre-activating" your inner core.So what happens if your core isn't stable?  If you're not able to transfer force and stabilize your center of gravity?  If you're not able to centrate your center?

What Happens When the Core Doesn't Stabilize

What happens is that the next joint down has to do extra work to stabilize.  The next joint down can't transfer (unload) force to the proximal core.  The next joint down ends up taking on a lot more force.  The next joint down overworks to make up for the lack of efficient proximal stability.  The next joint down gets locks down in attempt to "stabilize" and becomes "tight".  The next joint down becomes inefficient.This is an example of how not having proximal stability leads to decreased distal mobility.So that hip might be restricted and feel tight because it can't transfer (unload) forces proximally because of a lack of core stability.  And those ankles might always be locked up because they might be constantly active as a postural balance strategy because of a lack of core stability (unstable center of mass=instability=terminal segment compensation).That's not to say it can't swing the other way.  With a lack of proximal stability, the distal segment will not be as efficient at producing force/torque.So that overhead shoulder might feel weak because it can't receive valuable proximal force production from the core.  And those achilles might be overworked because they're trying to make up for the lack of proximal stability from the hips and core.

Assessment & Intervention

Assessment

I assess the core using a developmental postural stability progression.  This progression is essentially going from lying on the ground to standing.  From a stable base to a narrow base.  From minimal degrees of freedom to maximal degrees of freedom (joints available).

Postural Assessment

Each posture is progressed from wide base of support to a narrow base of support.

• Supine/prone is assessed with either rolling patterns or foam roll marching (depending on client and space).
• Quadruped is assessed with Alternate UE & LE ("bird-dog").
• Tall & Half Kneeling is assessed with half kneeling to ensure that there are no asymmetries.
• Single leg stance is assessed with eyes open and eyes closed.

I usually assess people for 10-20 seconds in each posture.  I look for the movement quality, common pattern dysfunction, and compensatory strategies.  The goal is for the patient to stabilize the closed chain extremities through their core.  I don't get too caught up in the positioning of the open chain extremities.

Intervention

My intervention follows the developmental postural stability progression in a static to dynamic fashion (low threshold to high threshold).After I have their core movement assessed, I use these positions at their "Edge of their Ability" to develop reflexive static stability and core efficiency.  I usually tell my patients to "find the point where they struggle, but don't fail".http://www.youtube.com/watch?v=b06-S2F3qm0Once they can demonstrate the most difficult level of static stability (narrow base), I add either upper extremity or lower extremity dynamic movements in these postures.  From here, the possibilities are limited by your creativity.Some Examples:

• Upper Extremity: Wall Slides in Tall Kneeling, Plank with Reach, Quadruped T's, UE PNF Patterns in Developmental Postures

• Lower Extremity: Side-Plank with Hip Abd/Flex, Bridges with Marching, Plank with Hip Extension

• Both: Chops & Lifts, Single Leg Asymmetrical Deadlift, Resisted Quadruped Alt UE/LE, Turkish Get-Up, Quadruped Rocking, Crawling/BearCrawling

Bottom Line

• "Any purposeful movement first requires spinal stabilization" -Pavel Kolar

I try to add some core integration for all of my patients.  It's easy to do, there are tons of benefits, and the patients usually like it.  Plus, it taps into the hard-wired CNS developmental patterns.You can incorporate this tomorrow.  Just keep doing what you've been doing with your patient, but throw them at the edge of stability in one of the developmental postures.  They'll get more sensory input, and therefore a better motor output.  Their core gets integrated, and you have a new trick up your sleeve.  Everyone wins.Even if you don't buy into this whole proximal stability thing, you should at least consider it when that ankle dorsiflexion hasn't improved in 6 weeks.

Dig Deeper

Gray Cook:

Motor Control, Stability, and Prime Movers

Sequence of Core Firing

Edge of Ability  

Kelly Starrett - Midline Stabilization, Example of Midline Stabilization FaultSeth Oberst - Motor Control Priority Steve Smith - DNSLieberman, Daniel. The Story of the Human Body: Evolution, Health, and Disease. New York: Pantheon, 2013. PrintWalter, Chip. Last Ape Standing: The Seven-million Year Story of How and Why We Survived. New York: Walker &, 2013. Print.Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.Liebenson, Craig. Rehabilitation of the Spine: A Practitioner's Manual. Philadelphia: Lippincott Williams & Wilkins, 2007. Print.Studies:Moreside JM, et al.  Hip joint range of motion improvements using three different interventions.  J Strength Cond Res. 2012 May;26(5):1265-73.Leetun DT, et al.  Core stability measures as risk factors for lower extremity injury in athletes.  Med Sci Sports Exerc. 2004 Jun;36(6):926-34.Kibler WB, Press J, Sciascia A.  The role of core stability in athletic function.  Sports Med. 2006;36(3):189-98.Wilson JD, et al.  Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg.  2005; Sept13(5):316-325Shinkle J, et al.  Effect of core strength on the measure of power in the extremities.  J Strength Cond Res. 2012 Feb;26(2):373-80Granacher U, et al.  The importance of trunk muscle strength for balance, functional performance, and fall prevention in seniors: a systematic review.  Sports Med. 2013 Jul;43(7):627-41.Gottschall JS, Mills J, Hastings B.  Integration core exercises elicit greater muscle activation than isolation exercises.  J Strength Cond Res. 2013 Mar;27(3):590-6. --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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January Hits (2014)

1) Pain and Central Sensitization is a growing topic in our field.  And for a good reason, pain is the #1 reason people come to see us.  Plus, chronic pain is becoming more and more common.  It's great having so much information available to learn about these topics, however, there isn't a lot of information on the specific clinical application.  I sought out pain expert, Adriaan Louw, to answer some clinical questions on pain science in this months post.2) Charlie Weingroff goes over some theory on why ankle mobility is important for glute activation.  He also has a great article on how different body types tend to move and perform.3) Neurological Warm up from XLAthlete.  There's at least one thing from here that you can use on your patients tomorrow.4) The "Knees Out" cue is great to prevent dynamic valgus.  However, sometimes it forces patients into a severe varus positin at the knees or a severe inversion moment at the ankle.  I've also seen a lot of patients struggle to keep their big toe down when trying to keep their knees out.   Derrick Blanton uses the cue "drive the lateral heels" to help avoid these mistakes.  The more cues you have, the more patients you can help.5) Hebb's Law - "Neurons that fire together, wire together"6) So we need to stop icing?  "Now a study from the Cleveland Clinic shows that one of these recommendations, applying ice to reduce swelling, actually delays healing by preventing the body from releasing IGF-1 (Insulin-like Growth Factor-1), a hormone that helps heal damaged tissue (Federation of American Societies for Experimental Biology, November 2010)."7) Zac Cupples PRI Advanced Integration Day 1, Day 2, Day 3 & Day 4.  The PRI approach seems like a bottomless rabbit hole.  These reviews will help get you deeper.  "When I have the ability to flex, I have greater variability to change. In extension, movement blocks more likely occur. If you think about the human body, how many joint’s closed packed positions involve extension? "8) Nutrition is a lot like politics.  Everyone has an opinion, trends and buzzwords are all you hear about, and no one knows what is really going on.  Luckily for us, Kris Gunnars creates a great post on the science and research behind nutrition recommendations.9) I'm a big fan of the SFMA and global-neuro-movement-approaches.  This is a great post on some of the SFMA principles.10) If everyone did this everytime they looked at their phone, neck pain would decrease by 723%.11) I remember learning about the importance of intensity in my exercise physiology classes.  Of all the variables (load, duration, frequency, etc.), intensity may be the most important.  And the fitness industry is now taking advantage of this important variable.12) The Gait Guys go over some of the potential dangers of activating an inhibited muscle.13) Some great conversation on the latest tendinopathy research with Peter Malliaras.  Download the podcast onto your phone and give it a listen.14) Eric Cressey went over his top articles for the year.  I remember this one on 15 Static Stretching Mistakes was extremely useful.  I think anyone that works with movement should be forced to read it.15) Seth Oberst has a great post on the cervico-mandibular relationship.  "Anatomically,  a forward head changes the line of pull of several muscles (the infrahyoids) running from the mandible (lower jaw bone) to the sternum and even the scapula. This new alignment causes an altered pull on the jaw jamming up the delicate, sensitive disk within the TMJ."16) MDT Clinical Pearls for the flared up patient from Erson.17) 3 Great Quotes from this Article on Setting Goals

• "When helping patients set goals, it is imperative to understand the Contrasting Effect, which refers to beginning the goal setting process with the ideal future, then contrasting it to the current condition.  This creates motivation, optimism, and positivity."

• "It is key to remember to start with a picture of the patient’s ideal future, and then work backwards for greater chances of success."

• "We are not ultimately the one setting the goals for our patients. It is our work to extract the goals that are most important to them and then use our expertise to support them in succeeding."

 18) The deadlift is a great shoulder exercise.  The distraction force causes reflexive stabilization.              [subscribe2]

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 extension

18) 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 outcomes

23) 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 integration McKenzie 

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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