My Secret Acupuncture Experiment

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

4 Facts to Know

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

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

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

3) Sympathetic Activity EXTENDS our body

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

• Puts us in a High Threshold Strategy

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

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

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

My Experiment

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

References

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

February Hits (2015)

Clinical

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

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

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

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

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

Pain

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

Training

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

Research

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

Other

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

Top 5 Tweets of the Month

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

Gif of the Month

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

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Andreo Spina's Functional Range Release

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

Andreo Spina

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

Bringing it Back to Histology

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

What Are We Really Feeling?

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

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

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

Assessment / Approach

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

• Articular DOF = Nervous System DOF = Movement DOF

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

Don’t Hang Up

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

Isometrics

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

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

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

Guiding Soft Tissue Remoulding/Healing

Does not intend on expanding range

Low level, frequent contractions

PAILs II (Expand Range of Motion)

2 minute passive, direction specific stretch

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

PAILs III & RAILs (Expand ROM & Training Stimulus)

2 minute passive, direciton specific stretch

Ramped isometric contraction with 100% effort (longer duration)

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

Followed by another deep, passive stretch (and repeat)

Anatomy Pearls

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

• Levator Scapula is medial on the neck

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

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

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

• The subscapularis tendon becomes transverse humeral ligament

• The long head of the triceps becomes the inferior labrum

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

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

Randoms

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

• Muscle responds to NS quickly

• Connective Tissue responds to longer force inputs

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

• Load > Capacity = Injury

• Load < Capacity = Rehab

• Capacity >> Load = Prevention

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

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

• Joints maintain their health with movement

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

• OA occurs from lack of motion

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

• Opening is normal, tissues have to adapt

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

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

• “Changing posture is about habitual cueing”

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

Bottom Line

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

Dig Deeper

Cellular/Histological/Bioflow

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

Motor Control/Dynamic Systems

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

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

Fascia/Tensegrity

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

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

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January Hits (2015)

1) If you are a manual therapist, please understand the current concepts of manual therapy.  One of these concepts is that we cannot cause an immediate and permanent plastic deformation of tissues.  So painfully digging into tissues to "release" them is really just another form of torture.  Here are 3 Pain Free Manual Techniques from Erson - Pec Minor, Psoas, QL.2) “Based on animal studies, it has been proposed that central sensitization associated to nociception (maladaptive plasticity) and plasticity related to the sensorimotor learning (adaptive plasticity) share similar neural mechanisms and compete with each other.”3) Seth Oberst has a great read on hyperinflation and what to do about it (Part 1, Part 2).4) The FIFA 11+ seems like a good program to reduce injuries.5) Here's some advice for getting stronger.  I particularly like the Russian Skill-Strength methodology of the “everyday maximum”.6) We’re lucky Charlie Weingroff does brain unloading like this.  Tons of great stuff.  “Treat tissues compressing an artery if there is pain.  If it works, it was claudication, not mechanical or neuromuscular. - “So if we have a very low lactic threshold by being terribly unfit and more activity or sooner during any given activity throws us to the lactic energy systems, we are more apt to developing to resting muscle tension and if continued chronic TrP. - “Research is history.” - “Passive stretching without developing tension throughout the range is a mistake. - ”Stress can only do 4 things: Change pain, Change mobility, Change Motor Performance, Change Fitness"7) Attrition substitution is a type of availability heuristic that occurs often in this field.  Make sure you're aware of it so that you don't make this common clinical mistake.8) “Ankle sprain is associated with altered global motor strategy as well as localized joint impairment”-Jordana Bieze Foster (@biezefoster)9) Good vibrations - Make your stressed out, over sympathetic patients hum.  Humming stimulates the vagus nerve.10) The environment I create to stop low kettlebell swings.11) “Much like life, movement is a balance of moderation, modulation and modification.” -Michael Mullins has a great post on knee pain12) Another Chubbs study - “Early rapid strength production of the hip extensor muscles may be a sensitive and effective measure for discriminating between elderly females of different fall histories.”13) Anatomy geeks should love this.14) Another great functional anatomy post from Kathy Dooley - The Psoas - “If the hips are tight from a forward pelvic tilt, psoas is not the one to stretch. Imagine putting nerve tension on all those structures passing through psoas!  Stabilize the spine and move through the hip.  Free up the ribcage so the diaphragm can properly move.  Lay off psoas and focus on adjacent anatomy.”15) Once again, medical imaging may be leading us to the wrong conclusions.  “The 95% reference intervals of morphometric measurements of FAI in asymptomatic hips were beyond the abnormal thresholds, which was especially true for cam-type FAI.” 16) Gait Guys always have good stuff.  Here's a good read on why metatarsalgia happens.  Here's a foot waving exercise for metatarsal plantarflexion and intrinsic dissociation (Part 1, Part 2). 17) The Nominalist is on a tear this month.  Here's a bunch of great articles with a solid perspective on clinical intervention.

Don’t forget about the rotational component of ankle dorsiflexion

"Watch for the unilateral side-benders, they’re everywhere.”

The Myth of the Hinging Knee

Eclectic approach to hip mobility

Foot-to-Hip, PRI, Toe Spaces, Avoiding the Forefoot, and CKC Hamstring

”Shoulders are rarely shoulders, and even if they are shoulders, they’re also necks, and rib cages and cores. “

18) “The goal is to optimize the efficiency of the body so that the environment you create causes appropriate adaptation with minimal compensation.” -Gray Cook discusses Russian/Hardstyle/Strongfirst Swing vs. American/Overhead/Crossfit Swing19) Adriaan Louw thinks there are two main questions we should ask patients to understand their beliefs:

1. “What do you think is going on with your _______ (fill in the painful area)?”

2. "What do you think should be done for your _______ (fill in the body part/issue)?"

“Nothing is as powerful as changing someone’s beliefs.”

20) Dean Summerset goes over 5 Mobility tips - 1) Use Breathing 2) Add Stability 3) Get the Feet Right/Bottom-Up Approach 4) Get the Head Right/Top-Down Approach 5) Distal Fascial Lines 21) Erson - 5 Mistakes you might be making22) Research is confirming what many of us already know - Core Stability Training and the ACL .  "Conclusion: Better H/Q strength ratio was seen in core stabilization group. Core stabilization exercises improved postural stability more than classic rehabilitation."23) “High heeled shoe research model suggests increasing height by 13 cm shortens gastroc by 5%, leads to sarcomere loss.”-Jordana Bieze Foster (@biezefoster)24) Charlie Weingroff shares 8 Reasons Why The Knee Buckles (at the bottom of the post)25) A review of Erson’s Eclectic Approach Course26) “Protect before correct” -Gray Cook27) We already know this clinically, but it’s nice to have some research to back it up.  “These findings suggest that alignment of the lower extremity up to the pelvic girdle, can be altered, due to forces acting on the foot.”  28) Zac Cupples makes you think about wisdom teeth and depth perception.  "My wisdom teeth essentially alter pterygoid position and reduce my mandible’s capacity to move."29) Two great things in one post - beer and periodization.  A great read that simplifies the periodization process.

2014 In Review (Best of Posts)

• Dead Summerset
• Eric Cressey (Articles, Guest Articles, Baseball, Videos)
• Bret Contreras
• Todd Hargrove
• Zac Cupples
• The Gait Guys Podcast
• Seth Oberst
• Danny Matta
• Erson
• Sports Medicine Research
• The Nominalist
• NOI Jam

 Top 3 Tweets of the Month

1. Michael J Mullin‏ - @mjmatc - If you're not asking "Where do you feel that?" regularly during your day, u should. You might be surprised at what the response is at times
2. Dr. Andreo Spina‏ - @DrAndreoSpina - Chronic internet contrarians rarely, if ever, contribute anything of value to the collective knowledge
3. Jon Herting‏ - @JonHerting - You shouldn't have to choose between breathing and spinal stabilization. #breathstrong #proximalstability #moveeffeciently #painfreefunction

Chasing Pain...

The Best of 2014

One of the best things about the information age is the amount of great content out there.  There are so many smart, generous individuals sharing information that can improve your skills and increase your quality of care.  These blogs are accessible, straight forward, and clinically applicable.  Here is my year end summary of some of my favorite stuff from this past year.I came out of the stone-age and started using Google Analytics, which allowed me to see which of my articles were most popular, and which ones were only read by my girlfriend.  It wasn't what I expected.Keep in mind that these lists are in no particular order.  And also, this is just a small amount of the great articles out there.  It's just the ones I enjoyed the most from a years worth of Hits.  If your favorites weren't listed here, please feel free to leave a comment with your Top Reads.

Top 5 Theoretical Reads

1. Zac Cupples - The End of Pain
2. Placebos - Nicholas Humprhy, Todd Hargrove, DPPT
3. Todd Hargrove - A Systems Perspective on Chronic Pain
4. Andreo Spina - Functional Exercise
5. Our Kids, Our Species - Eric Cressey, Seth Oberst, Angela Hanscom

Top 6 Clinical Reads

1. Morphology - The Gait Guys (1, 2, 3a, 3b, 4), Dean Summerset, Paul Grilley
2. Jaw Position & The Tongue - Seth Oberst, Zac Cupples, Kathy Dooley
3. Erson - Redefining the Smudge
4. Loading Tendons - Michael Kjaer, Jill Cook
5. Gray Cook - Coaching vs. Correcting
6. Bret Contreras - Hip Extension Forces with the Deadlift, Squat, & Hip Hinge

Top 6 Research Reads

1. The millions of articles on the importance of sleep (see references in this article - constantly updated)
2. The importance of muscle mass in mortality
3. Whether the RTC repair is intact or not doesn't matter
4. Ice possibly delays healing
5. See a PT and save $2 Million
6. Erson - Top 5 Articles That Changed His Practice

Top 5 Exercises

1. Bret Contreras's Hip Thruster
2. Mark Cheng's Sphinx Progression
3. Foot Wave
4. FMS/Strongfirst ASLR Kettlebell Correction
5. Crawl Progressions

Top Course

•  PRI Pelvis Restoration with Jen Poulin

I don't know if it's the learning curve, the culmination of the information, chunking, or Jen Poulin.  But this really pulled together the PRI concepts for me.  I was able to use PRI much more efficiently and able to apply the concepts more often in the clinic.I will say that if you are interested in PRI you have to go to a live course.  The home study courses are good, but they don't compare to the live events.

2014 AaronSwansonPT.com

What I Thought Were My Most Important Articles

• Everything is Moving Proximally
• 4 Mistakes People Make with the FMS System
• The Art of Recovery (Part 1 & Part 2)

What Were My Most Popular Articles

• An Open Letter to Crossfit: The 2 Mistakes (Part 1 & Part 2)
• The Deep Squat
• Mark Cheng Prehab-Rehab 101 Review

Self Clinical Review

4 Clinical Mistakes I Learned From

1. Letting the patient off the hook (for not listening, not exercising, not living a healthy lifestyle, not taking responsibility, dogmatic beliefs, not trying)
2. Not following up with discharged patients to ensure 100% recovery
3. Using pain science as an excuse
4. Overloading patients with assessment results and information

9 Clinical Epiphanies

1. Forefoot pathomechanics, assessment, and treatment implications
2. Importance of morphology (osseous structures)
3. One way or another, everything comes back to the core
4. How to build true scapula stability
5. Importance of direct communication and laying it all out on the table for your patients
6. And then LISTENING to what they think about it
7. Neck patients are rarely just mechanical/kinesiological patients
8. I finally understand what Sahrmann and Kinetic Control is really about
9. The Vestibular System might be the best way to progress static stability exercises 

December Hits (2014)

1) Two great articles on placebos.  The evolutionary history of placebos from Nicholas Humphrey - “when people are cured by placebo medicine, they are in reality curing themselves” - “The placebo effect is a particular kind of priming effect.”  And how placebo helps pain from Todd Hargrove - "In other words, the placebo effect does not involve anything magical. It is one of many ways that our cognition affect our physiology." - "The research of Benedetti and others has identified three different patterns of mental processes that create the placebo effect: (1) expectations of benefit; (2) reduction of anxiety; and (3) learning through association."2) Customised foot orthoses are no more effective than sham foot orthoses for reducing symptoms and improving function in people with mid-portion Achilles tendinopathy undergoing an eccentric calf muscle exercise programme.  And apparently heel lifts for Achilles patients are not very effective according to the latest evidence.3) This Cupples quote helps display the complexity of the PRI system -”The goal is to flex the sphenoid, which closes the foramen magnum and produces appropriate OA extension. This position keeps the brainstem happy.”  And that’s the simple way to say it.4) It might not be the ITB that’s flicking over the lateral femoral condyle…5) This might be the best glute max exercise you are not doing.6) “Both cognitive and somatic relaxation strategies reduce perceived stress and physiological markers of stress.”7) If you have any interest in handstands, you need to read this.  “when it comes to improving your overall strength, body control, and spatial awareness, it’s hard to beat handstand training.”8) Another very thorough and intelligent series from the Gait Guys.  This time they cover the different aspects of stretching.  Links - Why it Feels Good, Thoughts, Reciprocal Inhibition, Autogenic Inhibition, Symmetrical Tonic Neck Reflex, Asymmetrical Tonic Neck Reflex9) The radial nerve is often involved in elbow pain.  A new study finds “A single session of 3 neural mobilization resulted in a decrease of pain in computer users with lateral elbow pain. A long-term randomized trial is necessary to determine the effects sustained over-time.”  This was their prescription in the study - "The radial nerve was mobilized using a series of 8 oscillations and repeated 3 times with a one minute rest in between."10) “If your muscles are tight no matter how much you stretch, you may need strength to support the stretch.”-Kathy Dooley with a great concise post on the 4 knots11) Foam Rolling

"If there’s too much compression it can cause the muscle to contract harder, but enough compression to cause some overload can help stimulate and then fatigue the receptor, which helps to “release” the muscle or sarcomeres affected so there’s less tension."-Dean Summerset

“Roller massage was painful and induced muscle activity, but it increased knee-joint ROM and neuromuscular efficiency during a lunge.”-Duane C. Button

“The possible effects of foam rolling on serum cortisol, combined with other findings regarding its effects on arterial stiffness, arterial function and vascular endothelial function, are intriguing. While the research is not extensive enough for us to make recommendations, it will be fascinating to see whether future work confirms these findings, which indicate that foam rolling may have some sort of modulatory effect on the autonomic nervous system.” -Chris Beardsley

I think it also has a role in cortical mapping to improve body awareness.

12) “They found that the knee OA patients had significantly less coronal plane range of motion at the midfoot and significantly less sagittal plane range of motion at the hallux compared with the controls.”13) Technology is having quite an effect on our species; both physically and mentally.  We need to make sure we educate patients on efficient mechanics, adverse postures, good movement, and healthy lifestyles.  Otherwise this might be our future.  This text-neck article became popular this past month.  It has some great points, just make sure you don’t give your patients any thought viruses when educating on posture/mechanics.14) Andreo Spina shares a common pull-up mistake.15) Why muscle stiffness is important for elastic recoil during running.16) Eric Cressey goes over 3 coaching cues - 1) Follow your hand with your eyes 2) Drive hamstring tension before pulling the bar 3) Let the scapula go where the humerus goes17) Here’s a nice evidence based article on the high plank exercise.18) “Work capacity is the integrity of postures and patterns against fatigue across time. “-Gray Cook19) It’s not the mind that makes a great clinician, it’s the mindset.20) Physical therapy would be so much easier if everyone just listened to everything I said.  Unfortunately, convincing people to move and changing beliefs are a very important part of the job.  Here’s a great article on how to get people to do what you want them to do.21) An interesting read on endogenous analgesia.  “Our nervous system has the capability to reduce pain by activation of specific pathways that exert inhibitory effects on the messages entering the central nervous system during or after threat or damage to the body.”22) Getting bored with early post ops? Not sure what to add in this slow stage?  Zac Cupples gives some great ideas in this article.23) More on placebos, “compared to control, the injected placebo improved 3 km race time by 1.2%.”24) Erson Friday 5’s

5 TMD Tips - 1) The Nod 2) Diet 3) Mandible Protrusion 4) How They Eat 5) Self Masseter Massage

5 Press-Up Advancements - 1) Full UE Extension 2) Make it Passive 3) Cervical Extension 4) Sag 5) Start in Quadruped and Drop In

25) This is my favorite new foot exercise.  You'll be amazed at how many of your patients can't do it.25) “pain during training had an impact on the retention of motor memories” - “These results suggest that the same motor rehabilitation intervention could be less effective if administered in the presence of pain.” (via @RyanDavisDC)26) Pavel’s input on cervical positioning during the swing - cervical extension drives posterior chain activation.27) Exposure Therapy “is an experiential treatment approach: people must expose themselves to the things they fear so that they learn, in person, that their fear is not founded upon genuine threat.” -Tory Madden28) Eric Cressey goes over some great cues during the landmine press.29) “Presently, the full explanation for development of tendinopathy remains elusive with two suggestions being currently proposed. One theory posits that tendinopathy reflects a misbalance between overloading of the tissue resulting in both a cell reaction towards apoptosis and increased proteolytic activity. An alternate theory suggests a local unloading of tendon cells due to micro-ruptures of collagen fibres as an initial step in pathological changes seen in tendon injuries. In this scenario, it would be the absence of tensile stimuli that would trigger catabolic alterations of tendon tissue.” #LoadTheTendons30) There are no bad exercises, just bad clinicians/trainers.  We need to stop making black and white statements about specific exercises.  It confuses patients and can discredit our profession.  Don’t agree?  Read these two articles: Bret Contreras - Scotty Butcher31) Eric Cressey shares 5 things he’s learned about mobility - 1) Soft Tissue Importance 2) Breathing 3) Don’t Conform to One Approach 4) Don’t Mistake Laxity for Mobility 5) Deposits > Withdrawals32) People You Should Know - Brian Mulligan is a renowned physical therapist from New Zealand.  Our profession owes him a great deal for his contribution to manual therapy.  He discovered and developed the Mobilizations With Movement (MWM) technique.  This manual approach restores function and decreases pain through non-painful, manual joint “repositioning”.  In other words, his techniques provide an external input to centrate joints and improve human movement.  The Mulligan Technique has become a standard in the physical therapy field as a great tool for manually improving movement.  Here’s his story of how he came up with the technique:

“A young patient (in her 20s) came to see me with a painful immobile swollen interphalangeal  joint.  She injured it playing basketball.  I tractioned the joint to no avail, then applied anterior glides to see if I could get it to move.  No success. I then remember applying a medial glide which caused pain. I then applied a lateral glide and the patient said that it did  not hurt.  While sustaining the lateral glide I by chance asked her if she could move it. To my astonishment she flexed the joint with no pain. I  asked her while I maintained the glide to do some repetitions.  The  result? Virtually full range of pain free movement.  She returned two days later, the finger was fine and no further treatment was necessary.

Why was the treatment so successful?  Louis Pasteur said that  in the field of discovery chance only favours a prepared mind.  I sure had a prepared mind. Why had  the regular manual therapy treatment I was teaching failed? What did I do that was different? After much thinking the only explanation I could come up with was that there had to be a minute positional fault which inhibited joint movement and caused the pain.  With this explanation in mind I began experimenting with all painful joint restrictions and Wow It changed my life.”

33) 4 Top Tweets of the MonthFollow John Kiely.  He consistently puts out useful content.

• Perry Nickelston @stopchasingpain - 'The slower you go, the more your brain teaches your body.'-Thomas Hanna
• Dr. Michael Chivers‏ @drmchivers - Joints need full mobility to give the CNS a good "picture" of what is going on. This way appropriate motor synergies can be chosen.
• Charlie Weingroff‏ @CWagon75 - Figuring out how to skip steps without missing anything starts with tediously honoring a systematic approach so you don't miss anything.
• Robert Butler PT PhD‏ @rjbutler_dptphd - Kettlebell swing should be like a series of standing long jumps where the center of mass doesn't go anywhere @Fakedanjohn

34) Happy Holidays               

November Hits (2014)

1) Stress is stress.  And there are many outputs that can occur in response to stress.  Too often we get stuck obsessing over just one of the outputs - PAIN.  As movement professionals we should focus on the output that we’re the most proficient at - MOVEMENT.  If you disagree, Zac Cupples will convince you in this phenomenal article.  “Assessing movement may be the simplest way to assess an individual’s stress status.”2) Decreased hamstring strength increases ACL loading during sidestep cutting.3) “If your tongue is on the roof of your mouth, you are connecting palate, pharynx, hyoid, jaw, and skull.  You are stabilizing your airway, so you can breathe, while anchoring your TMJ so it doesn’t deviate. Now, your body is more balanced and can better ambulate.” -Kathy Dooley4) Your butt can stop you from peeing?5) Aleks Salkin has some great advice on how to pass your SFG Snatch test.6) “Football players who had greater cervical stiffness and an ability to decrease the displacement of their head following perturbation were less likely to sustain a moderate and severe head impacts.“7) Some good advice for cross-training when injured.8) “Sure posture does not matter when studied, but it's the introduction of variability that resets the nervous system, not always something as simple or mechanical as postural correction.” -Erson Religioso9) Regarding exercise regressions and progressions - “a continuum is an environment that we create.” - Gray Cook10) “Rather than friction causing irritation of the ITB, it is now thought that compression of the associated fat layer may be the culprit.”  The best ITB article I've read in a long time, by John Foster.11) When you bash other approaches it not only confirms your insecurity as a clinician, but it also...12) “Acupuncture points have a higher density of micro-vessels and contain a large amount of involuted microvascular structures. The non-acupuncture points did not exhibit these properties.”13) A great 5 minute TED-Ed video to help explain pain to your patients (via @ShinePTyoga)14) Here’s a nice review of sensory processing in the brain.15) Erson’s Friday Fives

5 Ways to Increase Ankle DF Without the Talocrual Joint - 1) Calcaneus 2) Great Toe 3) Tibial IR 4) Sidegliding in Standing 5) IASTM to Anterior Calcaneus

5 Ways to Ensure Patient Compliance - 1) Use the Edge of Ability 2) Make it Pain Free 3) Simplify the HEP 4) Encourage Communications 5) Connect with Your Patient

5 More Articles That Have Influenced My Practice

16) The squat is a very complex movement.  There are many variables that can affect the movement pattern.  A common mistake is to blame a complex output on a single input.  The butt wink (posterior pelvic tilt/lumbar flexion at the bottom of a squat) has many possible causes.  Some have blamed it on hamstring length, osseous morphology, ankle dorsiflexion limitations, anterior tibialis weakness, hip flexor weakness, eccentric quad strength, decreased anterior core, glute weakness, lumbar extensor weakness, decreased thoracic mobility, limited hip internal rotation, local motor control dysfunction, or a poor global motor program.  Julie Wiebe adds another variable to this list - Pelvic Floor Dysfunction.  “Squeezing one part of the system does not create a balance.”  The more you know, the better you can assess.17) This is my go to exercise for shoulder patients who have progressed past supine KB holds and quadruped progressions.18) “Generally speaking, slow stretch activates the Ia afferent loop which causes a physiological contraction of the muscle (this is one of the reasons you do not want to do slow, steady stretch on a muscle in spasm).” -Gait Guys19) “Our results show that an increase in the amplitude of force produced by one hand corresponded with a decrease in pain perception in the other hand.”20) Here's an article on shoulder flexion/extension muscle patterns.  “During extension subscapularis and latissimus dorsi were activated at higher levels than during flexion; during flexion, supraspinatus, infraspinatus, deltoid, trapezius, and serratus anterior were more highly activated than during extension. In addition, the pattern of activity in each muscle did not vary with load.”21) Here are a ton of great interviews from CinemaSays.22) Dysregulated Supersystems, Cognition, Phase Shifts, Attractors, Feedback Loops, and more.  This is the best article you’ll read on chronic pain from Todd Hargrove.23) Want your patients to cooperate?  Try telling a story - "character-driven stories do consistently cause oxytocin synthesis".  “Oxytocin is produced when we are trusted or shown a kindness, and it motivates cooperation with others. “24) Here's my opinion on Crossfit and the 2 Mistakes that can prevent injuries.25) David Butler shares an example of how to treat “shin splints” with neurodynamics and pain education.26) Patrick Ward tells you what kind of manual therapy you should choose.27) An interesting read on muscle spindles.28) Bret Contreras sums up everything you want to know about EMG studies in this article.29) “Flexion allows for movement variability, which is desirable in the human system. Variable movement reduces threat perception.  However, system flexion leads to increased instability and the risk of falling forward. To combat this risk, impingement may occur by compensatory extension.” -Zac Cupples30) Loss of anterior core control is an epidemic.  We see it in all different patient populations.  Eric Cressey goes over 6 reasons why you need to focus on the anterior core.31) If you’re doing box squats for performance training, make sure you don’t sit on the box.32) “In fact, MRI findings will increase the fear of their condition, which in turn increases their awareness of their pain”33) “What "master" clinicians often have is not necessarily better hands, or psychomotor competence, but recognition of Clinical Practice Patterns.”-Erson34) Get to know the influence of the one, the only, the Great Toe.  “What happens is that toe stays flexed, the first met head collapses, the arch falls and forces the foot into early pronation which locks up dorsiflexion.”35) It’s not just physical movement that determines return to sport.  “Psychological readiness to return to sport and recreation was the factor most strongly associated with returning to the preinjury activity.”36) Here’s another gait assessment rabbit hole from the Gait Guys.37) Manual therapy is really brain therapy.38) Corey Hart was right.  You should wear your sunglasses (blue blocker) at night if you're using blue light devices.  It’ll improve your health via your Circadian cycle.39) People You Should Know - Robin McKenzie was a pioneer who helped change physical therapy from a passive modality directed by MD’s to an autonomous profession that utilizes active assessment and intervention.  The story behind the origin approach, Mechanical Diagnosis and Therapy (MDT), is worth a listen.  He was one of the first physical therapists to abandon the pathoanatomical biased model in preference for a movement based system.  His approach has changed the way medical professionals address back pain.  It provides physical therapists an avenue with which they can empower patients to treat their own pain.40) Top 3 Tweets of the Month

• Tom Myers‏ @myers_info - Genes are the canvas ; environment is the paint
• Scott Belsky ‏@scottbelsky - Thinking: One of the most important things experience gives you is the confidence to make decisions without certainty.
• Nick Winkelman‏ @NickWinkelman - "Ask your clients how many pillows they need to sleep. If it is more than one they have a mobility problem." -Dan John #AZNSCA #Simple

41) Another way to treat your own back               

An Open Letter to Crossfit: The 2 Mistakes (Part II)

Be sure to check out Part I for my thoughts on Crossfit and Mistake #1.

Mistake #2 = Not Training Unilaterally

Our bodies are inherently asymmetrical.  Don’t believe me?  Here are a couple examples of this natural asymmetry: we have a liver on the right, a heart on the left, 3 lung lobes on the left, 2 on the right, the stomach is tilted, one kidney is higher, the right diaphragm has a better zone of apposition, each brain hemisphere is lateralized for different tasks, and our left-otolitic dominance makes our motor system prefer the right side of our bodies.  On top of this, there are many other possible asymmetries and different morphologies due to genetics/ontogenetics.Not only are our bodies asymmetrical, but we live in a very asymmetrical world.  Everyday activities are asymmetrical; you push the car pedals with your right foot, grab your wallet out of the same pocket, open doors with your right hand, use the computer mouse on the same side.  Sporting activities are asymmetrical; you shoot with your right hand, kick with your right leg, swing a golf club to the same direction everytime.  And then there is just plain handedness.These asymmetries are normal and usually not a problem.  However, sometimes these asymmetries become too significant.  The imbalances become too much for the body to handle.This asymmetrical problem is taken to the next level when you add a symmetrical load to the system.  Symmetrically loading an asymmetrical system is the formula for injuries.  And this is one of the biggest mistakes Crossfitters make.While this applies to the entire body, it is critical in shoulders.  There are two reasons why:

1) You have a much more prominent handedness than footedness

2) Your legs benefit from some unilateral weight bearing activities everyday (walking, stairs)

Therefore, your upper extremity asymmetry is accelerated much faster compared to the lower extremity.  In other words, a right handed person can pretty much go all day without using their left arm at all.Fast forward to this person going from not using their non-dominant arm for most of their life (or past few years) and then throw a barbell at them.  It’s not going to go well.  The symmetrical external load (barbell) won’t be met with a symmetrical internal force (muscles).  Bringing a symmetrical exercise to an asymmetry is a recipe for disaster.Look at your car for an analogy.  If you car alignment is off, it’s going to cause some big problems.  Not only is most of the load going to be dumped onto one side, but it will also prevent a smooth straight path.  With the alignment off, the car will naturally want to veer from straight.  But it is being driven in a straight path, so the car has to pull (compensate) to maintain the desired direction.The same thing happens at your shoulders with barbell exercises.  One shoulder will get too much of the load, the other has to compensate to keep it straight, and it becomes an internal tug-of-war to keep the all important straight bar path.  Therefore, if you have a shoulder asymmetry, then the whole time you are cleaning, pressing, or snatching your shoulders will be compensating against each other.As mentioned in Part I, over time compensations lead to decreased performance and injuries.So what do you do about this?  Start brushing your teeth with your non-dominant arm?  Do barbell cleans with one arm?  Walk on your hands?

A Suggestion

The best thing you can do is incorporate some single arm (unilateral) strengthening into your weekly workouts.  This will not only prevent injuries, but it can also be used as an assessment.  If you can strict press 70# with your right arm, but only 50# with your left, then what do you think is happening when you strict press with a barbell?There are many different ways to work on unilateral strengthening, but in my opinion kettlebells are the best equipment to accomplish this.  They allow for the same metabolic burn, similar technique work, multi-joint strengthening, and most importantly - unilateral strengthening.  Pavel said it best "Your body has to adapt to the barbell while the kettlebell works with your body."Here’s a list of some unilateral shoulder exercises that can be done with just a kettlebell and some space:

Armbars, Bear Crawls, Quadruped T's, TGU, Single Arm Push Ups, Half/Tall-Kneeling/Standing KB Strict Press, Farmers Walks (overhead, rack, suitcase), Single Arm KB: Swing, Squat, Clean, Clean & Squat, Clean & Strict Press, Clean & Push Press, Snatch, Unilateral Suitcase Deadlift, Plank KB Pull Through

There are plenty of great coaches that can probably come up with some amazing unilateral upper extremity WODs.  There’s not just one right way to do it.  As long as you are training unilaterally and exposing weakness you will be decreasing your risk of injury and improving performance.For clinicians there is this Clinical Pearl

• If someone comes in with dominant side shoulder pain from bilateral/symmetrical training, the fix may be to strengthen the non-dominant side

Bottom Line

Like anything that becomes popular or trendy, there quickly becomes a group of people that jump on the bandwagon and a group of people that protest against it.  But this isn’t EDM, this isn’t Instagram, this isn’t the new iPhone.  This is simply another opportunity to help people stay active and exercise.  It’s not for everyone, but it’s not for no one.Medical professionals need to focus on ways to reduce injury and improve the activity rather than just pointing out what we don’t like.  Crossfit coaches need to focus on what’s best for the athletes health rather than what will give them the best workout.  And the Crossfit athletes need to be educated on the risk of lifting with poor technique and/or with a significant asymmetry.

References

Strength is a Good Thing1) Preethi Srikanthan, Arun S. Karlamangla. “Muscle Mass Index as a Predictor of Longevity in Older-Adults.” The American Journal of Medicine (2014) 2) Lauersen JB, Bertelsen DM, Andersen LB.  The effectiveness of exercise interventions to prevent sports injuries: a systematic reviewand meta-analysis of randomised controlled trials.  Br J Sports Med. (2014) Jun;48(11):871-7.3) Harridge, Stephen D.r., Ann Kryger, and Anders Stensgaard. "Knee Extensor Strength, Activation, and Size in Very Elderly People following Strength Training." Muscle & Nerve 22.7 (1999): 831-39.4) Suetta, C., S. P. Magnusson, N. Beyer, and M. Kjaer. "Effect of Strength Training on Muscle Function in Elderly Hospitalized Patients."Scandinavian Journal of Medicine & Science in Sports 17.5 (2007)5) Askling, C., J. Karlsson, and A. Thorstensson. "Hamstring Injury Occurrence in Elite Soccer Players after Preseason Strength Training with Eccentric Overload." Scandinavian Journal of Medicine and Science in Sports 13.4 (2003): 244-506) Nadler, Scott F., Gerard A. Malanga, Melissa Deprince, Todd P. Stitik, and Joseph H. Feinberg. "The Relationship Between Lower Extremity Injury, Low Back Pain, and Hip Muscle Strength in Male and Female Collegiate Athletes." Clinical Journal of Sport Medicine 10.2 (2000): 89-97.7) Peate, Wf, Gerry Bates, Karen Lunda, Smitha Francis, and Kristen Bellamy. "Core Strength: A New Model for Injury Prediction and Prevention."Journal of Occupational Medicine and Toxicology 2.1 (2007)8) Orchard, J., J. Marsden, S. Lord, and D. Garlick. "Preseason Hamstring Muscle Weakness Associated with Hamstring Muscle Injury in Australian Footballers." The American Journal of Sports Medicine25.1 (1997): 81-859) Jankowski, C.m. "The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial."Yearbook of Sports Medicine 2012 (2012): 65-66.10) Willson JD, Dougherty CP, Ireland ML, et al. “Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg. (2005) Sep;13(5):316-25.11) Hewett TE, Lindenfeld TN, Riccobene JV, et al. “The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.” Am J Sports Med. (1999) Nov-Dec;27(6):699-706.Movement Based Exercise vs. Isolated Exercise12) Gentil, Paulo, Saulo Rodrigo Sampaio Soares, Maria Claúdia Pereira, et al. "Effect of Adding Single-joint Exercises to a Multi-joint Exercise Resistance-training Program on Strength and Hypertrophy in Untrained Subjects." Applied Physiology, Nutrition, and Metabolism 38.3 (2013): 341-4413) Gottschall, Jinger S., Jackie Mills, and Bryce Hastings. "Integration Core Exercises Elicit Greater Muscle Activation Than Isolation Exercises."Journal of Strength and Conditioning Research 27.3 (2013): 590-96Exercising in Fatigued State14) Cortes, Nelson, Eric Greska, Roger Kollock, Jatin Ambegaonkar, and James A. Onate. "Changes in Lower Extremity Biomechanics Due to a Short-Term Fatigue Protocol." Journal of Athletic Training 48.3 (2013): 306-13.15) Santamaria, Luke J., and Kate E. Webster. "The Effect of Fatigue on Lower-Limb Biomechanics During Single-Limb Landings: A Systematic Review." Journal of Orthopaedic & Sports Physical Therapy 40.8 (2010): 464-73.16) Barnett S Frank, Christine M Gilsdorf, Benjamin M Goerger, et al.  “Neuromuscular fatigue alters postural control and sagittal plane hip biomechanics in active females with anterior cruciate ligament reconstruction.” Sports Health (2014) Jul;6(4):301-817) Quammen D, Cortes N, Van Lunen BL, et al. “Two different fatigue protocols and lower extremity motion patterns during a stop-jump task.” J Athl Train. (2012) Jan-Feb;47(1):32-41.18) Pau M, Ibba G, Attene G. “Fatigue-induced balance impairment in young soccer players.” J Athl Train. (2014) Jul-Aug;49(4):454-61.Imbalances Are Bad19) Knapik, J. J., C. L. Bauman, B. H. Jones, J. Mca. Harris, and L. Vaughan. "Preseason Strength and Flexibility Imbalances Associated with Athletic Injuries in Female Collegiate Athletes." The American Journal of Sports Medicine 19.1 (1991): 76-8120) Baumhauer, J. F., D. M. Alosa, P. A. F. H. Renstrom, S. Trevino, and B. Beynnon. "A Prospective Study of Ankle Injury Risk Factors." The American Journal of Sports Medicine 23.5 (1995): 564-70.21) Common Sense & Conventional Wisdom (>6 million years BC)Motor Learning22) Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.23) Schmidt, Richard A., and Craig A. Wrisberg. Motor Learning and Performance: A Problem-based Learning Approach. Champaign,IL: Human Kinetics, 2004.24) Williams, L. R., McEwan, E. A., Watkins, C. D., Gillespie, L., & Boyd, H. (1979). Motor learning and performance and physical fatigue and the specificity principle. Canadian Journal of Applied Sport Sciences, 4, 302-308.

“The body does not have the capacity to learn movement patterns when highly stressed/fatigued. This factor is not related to the specificity of training principle associated with overload adaptation in energy systems. The specificity principle of physiological adaptation does not apply to motor learning. To learn skilled movement patterns that are to be executed under fatigued conditions, that learning has to occur in non-fatigued states” — Williams 1979

 --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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An Open Letter to Crossfit: The 2 Mistakes (Part I)

As many physical therapists have probably noticed, there is an increase in the amount of Crossfit athletes showing up in our clinics.  This isn’t because it injures everyone.  It’s because it’s becoming very popular and people love it.We see the same thing happen during ski season and marathon season.  It’s not necessarily the activity, it’s the increase in participation.However, that’s not to say that it’s only an increase in participation that leads to a higher incidence of injuries.  There are many other variables involved.  Some of which can be improved upon to decrease the risk of injury.I’ve noticed a few trends in my experience with Crossfit athletes.  The crossfitters that tend to get hurt are the ones that seem to make the same 2 Mistakes:

1) Constantly Training to (and Past) Failure

2) Not Training Unilaterally Enough.

I think if Crossfit could improve on these 2 mistakes they would see a lot less people getting injured.

A Disclaimer

I have nothing against crossfit and don’t think it is ruining our species like some of my peers.  In fact, I think Crossfit is great.  Some of you might agree and some of you might be angry just by reading the word crossfit.  But let me explain why I think it’s good.Crossfit changes peoples lives.  This is often an exact quote from many of my crossfit patients.  I’ve had many patients who have lost tons of weight and become motivated to stay active because of Crossfit.  This leads to changes in other parts of their lifestyle and improves their overall quality of life .  Where personal trainers, spin classes, running, and traditional weightlifting have failed, Crossfit has succeeded.  In a time where obesity and sedentary lifestyles are an epidemic, anything that gets people moving should be viewed favorably.  I’d much rather have our population suffer with the occasional sore shoulder rather than die early from heart disease.Crossfit has popularized strength training.  Too many people go on crazy diets, perform too much aerobic activity, or follow DVD fads to lose weight and get a metabolic burn.  Crossfit has helped shift the emphasis to being strong.  And strength is one of the best modalities for improving function, decreasing injuries, reducing morbidity, and decreases mortality (1-11).Crossfit focuses on movements.  Isolated muscle strengthening and machine based workouts are better than nothing, but they are vastly inferior when compared to multi-joint based movements.  Crossfit has brought functional global movement exercises such as power lifts, olympic lifts, and kettlebells back to the mainstream (12-13, 22).One last disclaimer is that I know not all “Boxes” are the same.  Not all coaches are the same.  And not all athletes are the same.  Like every other activity or profession, there is a continuum of competence among crossfit gyms and coaches. I know there are a ton of very knowledgeable and talented Crossfit coaches out there already doing all the right things.  Also, these mistakes are not just made by Crossfit coaches.  There are many trainers, strength & conditioning coaches, physical therapists, and chiro’s making the same mistakes.  The goal of this article is simply to bring awareness and offer solutions for 2 common mistakes that seem to happen often (not to attack crossfit as a whole).

Mistake #1 = Constantly Training to (and Past) Failure

I understand it’s important to test your limits every once in a while.  And I know that when you’re in a competition or going for a PR many of the rules go out the window.  But that doesn’t mean you should train like this every time.As fatigue sets in, good biomechanics, technique, and form start to fail.  Everyone that has worked out to failure knows this and has felt this.  Even if you haven’t experienced a fatigued state, there is more than just empirical evidence to support this hypothesis.  Research has shown that mechanics and proper form go out the window in a fatigued state (14-18).This is not only bad for performance, but more importantly, it is bad for your health.  The more you continue to train in a fatigued state, the greater your risk for injury.  This injury can either be an acute one or a chronic one.Acute injuries are fairly easy to comprehend.  Acute injuries occur instantaneously when the external load is greater than the tissues accepting it.  It’s a cause and effect event.Some examples of the acute injuries:  A tired and sloppy deadlift with a rounded back on the 10th rep could damage your lumbar spine.  A tired and sloppy snatch with forward shoulders and poor T-spine extension could lead to a labral tear.  A tired and sloppy box jump with a knee caved in could lead to an ACL tear.  In other words, it puts you at risk for an accident that occurs in a split second, but takes months to recover from.Chronic injuries are a little more complicated and have to do with compensations and movement patterns.Movement patterns are the stored neurological “program” that resides in the brain.  This “program” is what your nervous system fires out to make the right muscles fire at the right time to achieve the desired result.  Performing exercises with poor form and inefficient muscle activation can teach your brain poor movement patterns.  In other words, it can set in bad habits.A long winded example might help.  Lets take my favorite exercise done to failure - deadlifting.  When you finish out those last 5 deadlifts with a rounded back because you were too tired to use the right muscles, your brain stores a new motor pattern.  Now your brain has a new easier way to deadlift.  Why lift with muscles when you can just lean on passive tissues like ligaments, joint capsules, and lumbar disks?  In other words, your brain decides it’s better to save energy and rely on tissues that don’t require energy to get the job done (passive tissues).  It decides lifting with a rounded back is a good idea.  Stupid brain.  You might be able to lift more weight (temporarily), but it will be at a cost to your spine.  Overtime, this stress to your back accumulates and can lead to a slew of injuries (paraspinal strain, disk herniation, neurodynamic problems, SIJ strain, etc.).So is it really worth it to sacrifice your movement to push it to the limit at every workout?  Do you really need to do over 40 reps of every exercise on each set?  What if you did more sets instead of more reps? Wouldn’t it be better to stop the set once technique starts to waver?  What if you let people “ladder” down throughout the WOD instead of compensating through?  Why not perform AMPRAP (As Many Perfect Reps As Possible) instead of just AMRAP?

A Suggestion

Better programming and an emphasis on improving technique as well as strength is something that many Crossfitters could benefit from.Crossfit coaches can improve in this realm by emphasizing technique over numbers or metabolic expenditure.  Assessing for poor technique and over-fatigue significantly decreases the risk of injury and will improve performance in the long run (you can’t make gains if you keep having to take time off because you’re injured).  Coaches need to help athletes become aware of when their form goes bad and stop them from grooving bad movement patterns with compensatory muscle activity.  And the WODs they develop can be programmed to avoid unnecessary fatigue and sloppy form on complex movements.However, it’s important to understand that assessing for over-fatigue and poor technique is not just the coaches responsibility.  The athletes need to be EDUCATED that when they can’t maintain form they are at a greater risk for injury and they need to stop.  I think this is one of the biggest mistakes most crossfitters make.  Many of them don’t understand this concept; they don’t understand the dangerous effects of not listening to your body and training with poor technique.  Others are simply not aware of their poor form.  Either way, this mistake needs to be addressed to decrease the risk of injury.A warrior mentality often exists with Crossfitters.  However, this mentality should adopt the idiom - live to fight another day.

Click Here for Part II

References

Strength is a Good Thing1) Preethi Srikanthan, Arun S. Karlamangla. “Muscle Mass Index as a Predictor of Longevity in Older-Adults.” The American Journal of Medicine (2014) 2) Lauersen JB, Bertelsen DM, Andersen LB.  The effectiveness of exercise interventions to prevent sports injuries: a systematic reviewand meta-analysis of randomised controlled trials.  Br J Sports Med. (2014) Jun;48(11):871-7.3) Harridge, Stephen D.r., Ann Kryger, and Anders Stensgaard. "Knee Extensor Strength, Activation, and Size in Very Elderly People following Strength Training." Muscle & Nerve 22.7 (1999): 831-39.4) Suetta, C., S. P. Magnusson, N. Beyer, and M. Kjaer. "Effect of Strength Training on Muscle Function in Elderly Hospitalized Patients."Scandinavian Journal of Medicine & Science in Sports 17.5 (2007)5) Askling, C., J. Karlsson, and A. Thorstensson. "Hamstring Injury Occurrence in Elite Soccer Players after Preseason Strength Training with Eccentric Overload." Scandinavian Journal of Medicine and Science in Sports 13.4 (2003): 244-506) Nadler, Scott F., Gerard A. Malanga, Melissa Deprince, Todd P. Stitik, and Joseph H. Feinberg. "The Relationship Between Lower Extremity Injury, Low Back Pain, and Hip Muscle Strength in Male and Female Collegiate Athletes." Clinical Journal of Sport Medicine 10.2 (2000): 89-97.7) Peate, Wf, Gerry Bates, Karen Lunda, Smitha Francis, and Kristen Bellamy. "Core Strength: A New Model for Injury Prediction and Prevention."Journal of Occupational Medicine and Toxicology 2.1 (2007)8) Orchard, J., J. Marsden, S. Lord, and D. Garlick. "Preseason Hamstring Muscle Weakness Associated with Hamstring Muscle Injury in Australian Footballers." The American Journal of Sports Medicine25.1 (1997): 81-859) Jankowski, C.m. "The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip Strength in Females With Patellofemoral Pain: A Randomized Controlled Trial."Yearbook of Sports Medicine 2012 (2012): 65-66.10) Willson JD, Dougherty CP, Ireland ML, et al. “Core stability and its relationship to lower extremity function and injury.  J Am Acad Orthop Surg. (2005) Sep;13(5):316-25.11) Hewett TE, Lindenfeld TN, Riccobene JV, et al. “The effect of neuromuscular training on the incidence of knee injury in female athletes. A prospective study.” Am J Sports Med. (1999) Nov-Dec;27(6):699-706.Movement Based Exercise vs. Isolated Exercise12) Gentil, Paulo, Saulo Rodrigo Sampaio Soares, Maria Claúdia Pereira, et al. "Effect of Adding Single-joint Exercises to a Multi-joint Exercise Resistance-training Program on Strength and Hypertrophy in Untrained Subjects." Applied Physiology, Nutrition, and Metabolism 38.3 (2013): 341-4413) Gottschall, Jinger S., Jackie Mills, and Bryce Hastings. "Integration Core Exercises Elicit Greater Muscle Activation Than Isolation Exercises."Journal of Strength and Conditioning Research 27.3 (2013): 590-96Exercising in Fatigued State14) Cortes, Nelson, Eric Greska, Roger Kollock, Jatin Ambegaonkar, and James A. Onate. "Changes in Lower Extremity Biomechanics Due to a Short-Term Fatigue Protocol." Journal of Athletic Training 48.3 (2013): 306-13.15) Santamaria, Luke J., and Kate E. Webster. "The Effect of Fatigue on Lower-Limb Biomechanics During Single-Limb Landings: A Systematic Review." Journal of Orthopaedic & Sports Physical Therapy 40.8 (2010): 464-73.16) Barnett S Frank, Christine M Gilsdorf, Benjamin M Goerger, et al.  “Neuromuscular fatigue alters postural control and sagittal plane hip biomechanics in active females with anterior cruciate ligament reconstruction.” Sports Health (2014) Jul;6(4):301-817) Quammen D, Cortes N, Van Lunen BL, et al. “Two different fatigue protocols and lower extremity motion patterns during a stop-jump task.” J Athl Train. (2012) Jan-Feb;47(1):32-41.18) Pau M, Ibba G, Attene G. “Fatigue-induced balance impairment in young soccer players.” J Athl Train. (2014) Jul-Aug;49(4):454-61.Imbalances Are Bad19) Knapik, J. J., C. L. Bauman, B. H. Jones, J. Mca. Harris, and L. Vaughan. "Preseason Strength and Flexibility Imbalances Associated with Athletic Injuries in Female Collegiate Athletes." The American Journal of Sports Medicine 19.1 (1991): 76-8120) Baumhauer, J. F., D. M. Alosa, P. A. F. H. Renstrom, S. Trevino, and B. Beynnon. "A Prospective Study of Ankle Injury Risk Factors." The American Journal of Sports Medicine 23.5 (1995): 564-70.21) Common Sense & Conventional Wisdom (>6 million years BC)Motor Learning22) Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.23) Schmidt, Richard A., and Craig A. Wrisberg. Motor Learning and Performance: A Problem-based Learning Approach. Champaign,IL: Human Kinetics, 2004.24) Williams, L. R., McEwan, E. A., Watkins, C. D., Gillespie, L., & Boyd, H. (1979). Motor learning and performance and physical fatigue and the specificity principle. Canadian Journal of Applied Sport Sciences, 4, 302-308.

“The body does not have the capacity to learn movement patterns when highly stressed/fatigued. This factor is not related to the specificity of training principle associated with overload adaptation in energy systems. The specificity principle of physiological adaptation does not apply to motor learning. To learn skilled movement patterns that are to be executed under fatigued conditions, that learning has to occur in non-fatigued states” — Williams 1979

 --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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