Coaching & Cueing (Part 4 - Internal Verbal Cues)

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

Benefits of Internal Cues

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

3 Topics in This Article

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

Disclaimer

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

Why Internal Cueing is Important

It’s Not Always About Motor Learning or Performance

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

Why is Body Awareness Important

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

Semantics - Body Awareness

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

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

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

Body Awareness Concepts

Attention for Wiring

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

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

Homunculizing

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

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

Mindfulness

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

Benefits of Internal Cueing

Internal Cues Provide the Map

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

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

Changes Focus / Distraction from Pain

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

It Worked for Arnold and the Brosephs

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

Ways to Influence the Internal Map

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

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

Summary

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

Coaching & Cueing

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

References

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

July Hits (2015)

Clinical

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

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

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

Intrinsic Motivation

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

You Have to Understand Breathing to Understand Movement

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

Tendinopathies

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

Pain & Neuroscience

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

Memory

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

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

Training

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

Research

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

Other

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

Top Tweets of the Month

• Charlie Weingroff‏ @CWagon75 - I've said this before. The more one reads about physiology, the more it appears aerobic fitness solves rehab problems before they happen.
• Rod Henderson,PT,ScD‏@HeadStrongMove - I love when providers say they "treat the whole person." Like the rest of us have a bunch of disembodied elbows running around the clinic.
• Navin Hettiarachchi‏@NAVIN_H - We restore and reposition in the sagittal plane, retrain for stability in the frontal, integrate to get reciprocal in the transverse. JLB
• James Anderson‏@J_Anderson_PRC - "REACH" is a state of Exhalation word. "PULL" is a state of Inhalation word. Use your words. Or your words will Use you. #PRI @postrestinst
• Aaron Swanson‏@ASwansonPT - It's just as important to back up your manual therapy with the right words as it is the right exercises. #Expectations #ConfirmationBias

Gif of the Month

               [subscribe2]--The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

 [subscribe2]

Coaching & Cueing (Part 3 - External Verbal Cues)

The type of cue one chooses should be based on the environment, individual, and task.This article should help you understand when to best choose an external cue.External Cue: focuses on how the body’s output affects the environment (outcomes, objects, etc.) 

Science of External Cueing

External verbal cues (VC) have been the most commonly discussed type of cueing in the past decade. There’s a good reason: the latest research has provided some clear results that can have a major impact on coaching.

• “External focus allows the motor system to “self-organize”; efficiently coordinating and directing forces needed for accurate, maximal and sustained force production.” -David C. Marchant

Research shows:

External VC Are Better Than Internal VC for:

• Performance
• Skill Acquisition
• Complex Motor Tasks
• Multi-Segmental Motion
• Force Generation (summative, accuracy, endurance)

8 Benefits of External Cueing

1. Allows the Motor System to “Self-Organize”
2. Keeps Movement Reflexive and Automatic
3. Frees the Brain From an Extra Task - Constrained Action Hypothesis
4. Decreases Aberrant Muscle Activity = Less EMG Activity = Conservation of Energy
5. Less Co-Contraction
6. Increases Speed
7. Better Retention and Carryover
8. Produce Greater Force, Increased Accuracy of Target Forces, and Increased Duration of Force Production

How to Use External Cues

The most important aspect of external cueing is incorporating part of the existing environment.  Simply chose something that is NOT part of the individual (i.e. don’t reference muscles, kinematics, etc.).  It can be anything from a belt buckle to a location in the room.To achieve a more specific outcome, Nick Winkelman uses a 3-D approach to cueing.  He states that we need to cue Distance (close, far, etc.), Direction (away, towards, etc.), and a Description (push, snap, drive, etc.).Cue selection depends on a variety of factors including: environment, task, desired outcome, biomechanical movement, participants experience, readiness, etc.  Different cues will elicit different results.  “Drive the ground away” will be different than “punch the ground away”.  There are many external cueing choices for each movement. Which one you choose is where the “art” of coaching comes into play.

Analogies

Analogies also fall into the external cueing category.“Analogies allow us to convey technical complexity through the lens of relatable stories/experiences that are easy to understand.”-Nick WinkelmanFor example, during a single leg deadlift you can tell the patient to keep their belt/waistband level like an airplane (then add the visual cue of tilting your hand which way their pelvis needs to move in the transverse plane).

Choking

An interesting finding during my research was that one of the major causes of choking in sports performance comes from self-focused attention.  When the athlete is under a high stress situation, an internally focused point of view leads to decreased performance (choking).This is obvious when Tiger hits it into the rough after focusing on his glutes.  But it is less obvious when your frustrated medicare patient is losing balance while walking after trying too hard and focusing internally.  An external cue would help in both situations.

Deadlift Example

Lets go back to the deadlift example.  If you’re trying to increase the weight or speed of the movement, then you need an external cue - “push the ground away”.  This would allow the motor system to simply focus on providing the optimal output to accomplish the task based on the current variables.Internally cueing someone to contract their glutes would only clog up the brain and make the movement less efficient.  While this internal cue may not be bad during the learning phase for chunking purposes, it could be dangerous when the person is at the limits of his/her capacity (i.e. 1RM or in a fatigued state).

Summary

External cues are far superior to internal cues for various outcome results (performance, complex motor task, skill acquisition, force generation, etc.).  If you’re learning or performing a complex motor task, don’t clog up the processing with internal cues. Instead, use external cues to free the motor system to choose the most efficient and effective motor patterns.And don't overcomplicate things with too many words.

• “Say the most with the absolute least” -Nick Winkelman

Dig Deeper

Most of the research has been led by Gabriele Wulf.  She provides detailed explanations of the concepts associated with external cueing.  However, if you want to skip going through the research yourself, but want a deeper understanding, you should look to Nick Winkelman.  He has done a great amount of work to bring the message of the research on cueing to the Strength & Conditioning field.

Coaching & Cueing

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

References

Marchant, David C. "Attentional Focusing Instructions and Force Production." Frontiers in Psychology. Frontiers Research Foundation, n.d. (2015)Wulf, Gabriele. "Attentional Focus and Motor Learning: A Review of 15 Years." International Review of Sport and Exercise Psychology 6.1 (2013): 77-104Wulf, Gabriele, and Wolfgang Prinz. "Directing Attention to Movement Effects Enhances Learning: A Review." Psychonomic Bulletin & Review8.4 (2001): 648-60.Wulf, Gabriele, Nancy Mcnevin, and Charles H. Shea. "The Automaticity of Complex Motor Skill Learning as a Function of Attentional Focus." The Quarterly Journal of Experimental Psychology A 54.4 (2001)Rochester, Lynn, et al. "The effect of external rhythmic cues (auditory and visual) on walking during a functional task in homes of people with Parkinson’s disease." Archives of physical medicine and rehabilitation 86.5 (2005): 999-1006. [subscribe2]

June Hits (2015)

Clinical

1) Sure, it’s a dynamic system and the nervous system has a huge influence.  But you can’t dissociate the physicality of our world from the human body.  Simple biomechanics can have a profound effect on your patient’s movement.  Here’s an example of how the first class lever works to Increase Glute Med Activity.2) Don’t forget about the frontal plane aspect of the bunion deformity - “the degree of first metatarsal pronation is linearly related to the amount of medial deviation of the first metatarsal”3) Kathy Dooley goes over the Obturator Externus - “When this muscle is locked long, it will contribute to hip compression. Since the muscle travels from the anterior outer pelvis posteriorly to the greater trochanter’s inner fossa, it works as a sling with obturator internus to keep that femur jammed into the acetabulum. “4) “Short-term practice of LNB (left nostril breathing) improves vagal tone, increases HRV, and promotes cardiovascular health of medical students.”5) Here are the first two posts to my Coaching & Cueing Series

Intro

The Categories

6) If you ever treat cervical patients you need to read this.  Erson shares 5 Ways to Modulate Acute Cervical Pain (PNF/Isometrics, Traction, Functional Mobilization, IASTM with Movement, Education).  Great share of useful clinical information.7) Perry Nickelston goes over a hypothetical piriformis syndrome case (assess bilaterally!)8) Tom Myers has a great post on Foam Rollers

“In epithelial and muscle tissues, the water is squeezed out of the tissues, and then is sucked back in when the pressure moves on or is taken away. Like squeezing a sponge over the sink and then letting it fill again while doing the pots and pans, this is generally a good idea.”

“More time won’t help; more accuracy of placement will.”

9) For more on Foam Rollers check out #11, this quick literature review write up, and this layman friendly article on foam rolling tone with Doug Kechijian10) Here’s a very good article on crawling - “The increased “little brain” activity during cross-crawl, on top of the stimulation to the high-order thinking function of the frontal cortex, contributes to better balance and coordination, which becomes particularly important when kiddo starts to walk and develops an interest in sports.”11) One of the things I learned from Qi Gong was the Teacup exercise.  Here’s a unilateral version shared by Erson.  It’s pretty much good for everything from your hand to your spine.12) Eric Cressey shares a nice quick postural assessment story in #4.13) Inside the Mind of Charlie Weingroff - June Edition.  These have a lot of good stuff in them.  Example - “T=R Principle: If you are a good enough coach to train around an injury, then the most important part of human performance is fitness.  Because it’s resiliency to stress (aka fitness) that led to your injury in the first place. The only reason we need rehab is because we didn’t have training.”14) APTA shares some great information on Dry Needling15) Do you know your foot pathomechanics?  Forefoot varus can be a big problem - it can lead to hyperpronation and excessive internal rotation of the kinetic chain.16) I thought our profession was starting to understand the latest research on tissue deformation.  Then I had an eval last week who left her old PT because he left bruises on her back from trying to “break up knots and scar tissue”.  Don’t be that guy.  Read this and remember that it takes a ton of force (literally >2000lbs) to deform tissue 1%.  And share this with your peers!17) 5 things you should ask your patients from Erson18) “Considered another way, from the top down this time, if at the moment of heel contact the gmedius is delayed (as suggested in the study below from achilles pain), the pelvis is likely to drift laterally and this could cause a reactive inversion strategy of the rearfoot, and maybe even forefoot as well, as an instinctive measure to try and draw support beneath the laterally drifting body mass center of gravity. (This in essence sets up the “cross over gait” deployment strategy we have talked about here for years now).”-Gait Guys19) Kinetic Control goes over our 6th sense (proprioception) and why it’s so important for movement.20) I’ve been doing this Bridge Walkout Exercise with one of my proximal hamstring tendinopathy patients.  It offers solid mechanotransduction without compressing the tendon (hip flexion).  If done correctly it also works core stability.21) “low level activity in the rectus abdominis and external oblique throughout the gait cycle, more concentrated activity of the internal oblique at initial contact/loading response (heel strike).”-The Gait Guys22) Learn how to go from Gary Busey to Denzel Washington in Zac Cupples review of PRI Cervical Revolution - "The neck is the top priority because its mobility maximizes cranial sensory activity".23) The Postural Restoration Institute (PRI) approach can be quite confusing.  Especially to those who have not attended a live courses.  There’s a lot of complexity and there isn’t a very thorough explanation easily accessible.  For those that want to dive deeper into the rabbit hole and learn more I would suggests these three sites:

Heather Carr (1, 2, 3, 4, 5)

Integrative Human Performance (1, 2)

Zac Cupples

Pain & Neuroscience

24) “Tone seems to be dictated by our perceptions of threat and the ability to cope with external demands.” -Another great read on the autonomic nervous system and threat/stress perception by Seth Oberst25) Zac Cupples goes over some gems from the BSMPG Conference including stress response, every neuroscience fan’s favorite animal (Zebras), thoraxes, decision making, and the Cynefin Framework.26) Stairs look steeper for patients with ankle pain?  Interesting read on how pain changes the perception of one’s environment.27) Great piece on Spondylolisthesis and other threatening diagnoses.  “The purpose of dethreatening any diagnosis is not to ignore, belittle or dismiss it, but rather to bring it into the light of a modern understanding of pain – under the ever-increasing power of this spotlight, many diagnostic DIMs [Danger In Me] can be dramatically deflated.”28) “researchers at the University of Virginia School of Medicine have determined that the brain is directly connected to the immune system by vessels previously thought not to exist”29) “Some of these brain changes will remain long after the injury, with epigenetic changes in a number of brain areas evident 6 months after peripheral nerve injury (Tajerian et al 2013) and glial cells remaining ‘experienced’ and on alert for years (Banati et al 2001).”30) The Placebo Effect should be used with more of an warm/empathetic style rather than technical (up to 82% better).  But is it really a placebo?  Or is it a change in the brain that we have not yet identified?31) Random Opinion - it seems that all successful pain science clinicians have one thing in common - HUMOR

Training

32) Hip Thrusters are a great and easy exercise that can easily increase glute strength and improve lumbopelvic function.  However, I’ve noticed many people tend to perform this with terrible form.

Here’s Ben Bruno going over neck position

I wrote an article on why it’s good in the rehab setting

And this video displays the correct and incorrect form

Don’t sacrifice form for more weight - you’ll pay for it later

33) I've been doing a lot of this stuff lately.  Top 10 Bodyweight Exercises From GMB - Squat, Frogger, Monkey, Cartwheel, Pull-Up, Bear, Push-Up, Hollow Body Hold, Scales, L-Sit, and Handstand.34) Don’t let the click baiting “butt wink” title fool you, this is some serious stuff.  Dean Somerset writes a great series on hip morphology and how it affects range of motion (Part 1, Part 2, Part 3).

“those with more acetabular anteversion (forward placement on the pelvis) had greater flexion range of motion and less extension, lateral placement of 45-55 degrees gave the best overall mobility, but a lateral angle of less than 45 degrees gave more flexion range of motion and more than 45 degrees gave less rotation capability. He even showed that if the femoral neck was thicken by 2 mm in diameter it significantly reduced the range of motion in all directions, irrespective of placement.”

“The recipe for deep squatting seems to be slight femoral anteversion combined with acetabular anteversion, lateral placement of less than 45 degrees, and a thin femoral neck.”

“If someone has a very high degree of mobility, the likelihood of their having a thin femoral neck and a shallow socket is pretty high. If they have all the mobility of a clam, they likely have a deeper socket and thicker femoral neck. This combination, regardless of orientation of the acetabulum, will limit the overall diameter of the conical range of motion of the hip due to earlier contact with the acetabulum compared to a thinner neck and shallower socket.”

35) Very informative read on blood flow restriction training from James McCarron - “Setting initial pressures of around 50 mm Hg, a target pressure of 150 mm Hg and using loads of 20-30% 1RM would appear to be best practice from the what data is showing us.”36) Eric Cressey goes over ways to increase your training density37) Dan Pope displays some great hanging scapula exercises.38) Dean Somerset has a nice logical article on unstable surface training.  Make sure to read Eric Cressey’s article on this topic as well.  Unstable surface training has a place in training, just make sure you find it and don’t force it.39) Gray Cook discusses the Squat vs. the Deadlift - I like the “coil the spring” concept.  For more information, check out this article.40) I still like Mike Robertson’s easy exercise introduction format:

Name the Exercise

Describe Why They’re Doing It

Demonstrate the Exercise

Coach the Exercise

41) “Potential productivity is a complex process which depends on integration and interaction of different systems and organs on different levels of organization: from biochemical to genetic to social.”  PP is determined by a host of physiological and psychological factors: genetics, gender, body mass, age, the state of health, energy systems’ power, capacity, and efficiency, the state of the neuromuscular apparatus, the psychological state, motivation, the climate, the season, work conditions, etc.’ -Pavel on work capacity42) It’s good that more people are starting to understand the importance of recovery.  Lance Goyke writes a piece with some advice on how to recover the other 23 Hours of the day that you’re not in the gym.43) Regretting winter decisions?  Me too.  Here’s Eric Cressey’s 15 tips for leaning out for the summer - “Avoiding liquid calories is the still, in my opinion, the biggest dietary game-changer most folks in the general population can implement.”44) 12 Ways to Make Better Exercise Choices by Eric Cressey.  #12 is one that is often overlooked and not discussed on social media.

Research

45) Watch this.  Then make your peers watch it.  Great talk on Evidence Based Medicine and why it can be “rubbish” - Trish Greenhalgh #PatientBasedEvidence46) Study on the kinetic chain influence on Serratus Anterior anterior - the best activation involved the anterior spiral line (serratus-external oblique-internal oblique-hip flexors/adductors).  This is pretty much gait.47)Craig Payne shares some gems from ACSM48) “Tendon microcirculation increases after ultrasound and vibration massage intervention concentrated on the Achilles tendon.” [Gasp] ultrasound can be useful?  Hipster PT’s won’t like that.49) Sometimes research is just good to help spread the word - “This study showed that a single bout of isometric training reduced PT pain immediately and for at least 45 minutes following. An insight into the mechanism was provided by the concurrent increase in cortical inhibition.”

For more on Isometrics for Pain Relief look at #1 here.

50) “Previously injured athletes demonstrated significantly reduced biceps femoris muscle activation ratios with respect to ipsilateral gluteus maximus, ipsilateral erector spinae, ipsilateral external oblique, and contralateral rectus femoris in the late swing phase. We also detected sagittal asymmetry in hip flexion, pelvic tilt, and medial rotation of the knee effectively putting the hamstrings in a lengthened position just before heel strike.”51) It’s sad that this may be news for some people in our profession - “Both hip as well as core strength were significantly correlated to frontal plane alignment during the single leg squat, especially hip abductor strength was an important predictor of the frontal plane kinematics.”52) Interesting article on plantar flexion static-stretching (SS)

“Hence the SS-induced impairments prior to 10-20 minutes post-warm-up may not impact competition performance.”

“The effects of prolonged and intense SS on the joint receptors might lead to inhibitory effects on motoneurons, such as autogenic inhibition and Type III (mechanoreceptor) and IV (nociceptor) afferents and Golgi tendon organ discharge, and their greatest effects can remain for 5-10 minutes (Behm and Kibele, 2007).”

‘In conclusion, the SS protocol effectively increased passive ankle ROM of the stretched limb. The increased ROM appears to decrease the muscle peak force and pre-activation; however these finding were only a temporary effect (less than 10 minutes after the SS protocol was applied). The decrease of jump height and impulse for the non-stretched limb suggests a central nervous system inhibitory mechanism from SS.’

53) “The bit of the brain that maps muscle change, changes when muscles change, and can be measured by muscle changes.” -Roger Kerry’s one line summary of this article54) Strength wins again!  Here’s a new study showing the importance of shoulder/neck strength in patients with tension headaches.  As Dr. Andreo Spina has says - “you can’t rub someone strong.” #Context55) “The rate of spontaneous regression was found to be 96% for disc sequestration, 70% for disc extrusion, 41% for disc protrusion, and 13% for disc bulging. The rate of complete resolution of disc herniation was 43% for sequestrated discs and 15% for extruded discs.”  This doesn't make sense to me.  Is it along the lines of if it's really bad it can only get better?  Does anyone know the time for disc regression?

Other

56) 23 Alternative Ways to Reduce Pain & Joint Inflammation.  Patients seem to always ask about these things.57) Zebra and Reptile lovers will enjoy this article - “"Traffic noise may influence metabolic and cardiovascular functions through sleep disturbances and chronic stress," lead study author Dr. Andrei Pyko told Australian Associated Press. "Sleep disturbances may affect immune functions, influence the central control of appetite and energy expenditure as well as increase circulating levels of the stress hormone cortisol."58) “The loss of prefrontal function only occurs when we feel out of control.” -Amy Arnsten in Eric Barker’s article on how to control Fear59) Maybe we’re fat because of the artificial light?  “Excess artificial light is a circadian disruptor: same diet & exercise will have a very different impact on someone with circadian misalignment.”60) I’m a big fan of Louie C.K.  I think he’s as smart as he is funny.  He summarizes dysfunctional human communication in this skit.61) Aaron LaBauer shares some great business advice for Cash-Based PT Practices.62) I patient recently introduce me to Mandalas.  It’s a form of art therapy, meditation/mindfulness, and has great psychological implications.

 Top Tweets of the Month

• Robert Butler PT PhD‏@rjbutler_dptphd - There is a stark difference between "doing corrective exercises" and normalizing a movement pattern. The goal is to keep the goal the goal.
• Scott Johnson, PT‏@PTnomad - If you're a PT and only do exercise with pt's, aren't you just an over qualified personal trainer? #manualtherapy
• Sarah Haag‏@SarahHaagPT - We don't assume 'head injury' when we have a headache... Why do we assume 'back pain' = 'back injury'? #Bronnie2015
• Michael J Mullin‏@mjmatc - Don't automatically attach strength principles to rehab. In rehab, less is often more...
• Aaron Swanson‏@ASwansonPT - Mindless exercise will soon become painful exercise. #BePresent #Feel

Gif of the Month

                [subscribe2]   --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

Coaching & Cueing (Part 2 - The Categories)

We need to first clarify an important concept before we go into coaching and cueing:

• NOT ALL MOVEMENT REQUIRES COACHING

To Coach or Not to Coach

If someone is performing a movement/exercise correctly, all you have to do is shut your mouth and smile.If someone is performing a movement/exercise incorrectly, you should ask yourself two questions:

1. Do they need a different environment via a sensory change/coaching and cueing?
2. Is this a professional error?  Is this the right exercise for this patient at this time?

So if someone can’t perform the deadlift correctly, they either need some coaching and cueing (a sensory change) or they need a different exercise.

3 Types of Coaching

I break down coaching into 3 different categories:

• 1) Verbal - External & Internal
• 2) Visual - External & Internal
• 3) Proprioceptive

Each of these categories are a change of the inputs from the environment.  Each section has a specific attentional sensory focus.  Below is a brief introduction to each type of cue.  For a more in depth look at specific cueing types, stayed tuned for Parts III-IV in this article series.

1) Verbal

Verbal cues are by far the most common and one of the most researched coaching cues.

External Cue

Focuses on how the body’s output affects the environment (outcomes, objects, etc.)

Internal Cue

Focuses on the body processes and internal systems (muscles, kinematics, pressure, etc.)

2) Visual

Visual cues are rarely discussed in the coaching realm.  However, there are some interesting concepts in this category that can have a huge impact on your clients’ movement.

External

Influences movement through visual input (visual field, objects, orientation, demonstrations, eyewear, etc.)

Internal / Motor Imagery

“Motor Imagery is defined as an internal rehearsal or reenactment of movements from a first person perspective without any overt physical movement. From another perspective, MI, also known as kinesthetic imagery, is an active cognitive process during which the representation of a specific action is internally reproduced in working memory without any overt motor output” -Carl Gabbard and Ashley Fox

3) Proprioceptive

Proprioceptive cues are very common in both rehab and training (whether the practitioner knows it or not).  It’s a common sense type of approach that can have more profound effects than any other sensory change.  These proprioceptive cues can be divided into MANY different sub-categories.

• Postures
• Load
• Speed
• External Stimulation (tactile, tape, surface, footwear, etc.)
• Regressions
• Progressions
• Lateralizations
• Modifications
• Modulations
• [Insert Latest Terminology]

 

Summary

Which type of cue the patient needs depends on many factors.  A greater understanding of each of these types of sensory changes will help one determine which one to use.  Keep the overall goal in mind and match your desired outcome to they type of cueing.And remember, if someone isn’t performing a movement correctly despite your coaching/cueing, you either need a different sensory change or a different exercise.

Coaching & Cueing

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

Coaching & Cueing (Part 1 - Intro)

My co-worker was on vacation recently and I was seeing one of his chronic pain patients (years of pain).  She was doing very well and was becoming independent in a full exercise routine.  I did a quick evaluation and noticed one thing that she could improve on from a movement perspective.  I didn’t use any dangerous pathoanatomical language.  I just simply pointed out that she could be stronger if she kept her rib cage down when she performed certain exercises.  We went over this cue a bit more with some basic proprioceptive exercises before she started her exercise program.About 20 minutes into her routine, she stopped and approached me.  I was worried she was going to complain of pain or be confused about the “ribs down” cue.  But instead she said with a smile, “you know, it’s nice to think about something other than my pain for once when I exercise”.As a physical therapist who works with people who have pain with simple movements, this was quite profound.I have been hearing from many professionals that external cues are far superior to internal cues.  Some people even go as far as saying you should never use internal cues.  However, this all or none approach doesn’t seem to be the case in the clinic. With this specific client, internal cues were beneficial on a few different levels.  So I wanted to dig in a little deeper and look at cueing from a different perspective.  I did some research and will summarize my findings in this series.

Disclaimer

Keep in mind this is from a physical therapist’s point of view.  The world of sports performance is always a hot topic.  The exciting things people are doing with professional athletes are always interesting and fun to integrate into rehab.  But what works for the NBA’s Lebron doesn’t always work for the AARP’s Betty.  Not everyone lives their life to improve their sports performance.  So keep in mind:

• Performance Training is a Luxury.  Movement Training is a Necessity.

Chronic Pain

Yes, this patient has been educated on pain science thoroughly, she has read books, watched videos, and has seen a psychologist for her chronic pain.  This post series will be focused on coaching and cues used for improving movement.  For more information regarding pain, I highly recommend starting with Adriaan Louw’s work and ISPI.

May Hits (2015)

Clinical

1) I often have athletes come into the clinic that have been aggressively stretching their hips or shoulders.  They keep getting tight, keep stretching, and keep getting injured.  I have found that the culprit for these injuries is usually not a mobility problem.  Instead, it is often the result of a poorly tied knot.2) Mike Cantrell teaches you about rib cage dynamics in these 2 videos (1, 2).  Great stuff for anyone that enjoys learning about anatomy, biomechanics, and movement.3) Great summary video on prescribing running shoes.4) Are your patients using their Short Head Biceps Femoris to compensate for a lack of hip extension in closed chain movement patterns?  Kathy Dooley thinks so and discusses more clinical pearls in this phenomenal anatomy post.5) Zac Cupples cleans out his nose and moves better - another first-person perspective on the PRI rabbit hole.6) Lance Goyke goes over the non-popular functions of the Serratus Anterior: Rib Cage Retraction, ER Lower Ribs, IR Upper Ribs, Contralateral Translation of the Thorax, Contralateral Thoracic Rotation.7) NOI goes over the importance of the Sural Nerve.  I actually just had a patient this week who thought she had a sprained ankle, but it turned out to be a sural nerve pathology.  Her symptoms were resolved after 1 week.  I created a chart with all the neurodynamic tensioners in this article.8) Great TMD pearl from Erson “They are using their capital extensors, instead of gravity and diagastrics to help open their mouth. We should not have to use capital extensors to promote end range mandible depression. This also leads to overuse of cervical protracted posture, which may place stress on the mandible elevators and TM joint.”9) Michael Mullins shared an interesting story on the teeth-ACL correlation.  Then he provided this article for more information - Teeth as Sensory Organs.  Very interesting stuff - “In this paradigm, tooth contacts are understood to initiate streams of mechanosensory information that shape oromotor behavior.”10) Sometimes tibial IR mobilizations can be too provocative.  Shante Cofield goes over a smart alternative tibial IR mobilization that unloads the joint and gives some indications of which patients will likely benefit from this mob.11) Erson’s 5 Rules for Resets: 1) It has to be Novel 2) Hit the End-Range 3) Frequent Reinforcement 4) No Pain 5) Education

“graded exposure to end range reduces threat associated with movement, also bombards the CNS with novel and non threatening proprioceptive information”

"the nervous system is easily tricked, but not easily convinced"

"education is empowerment"

12) The Nordic Hamstring Exercise for preventing hamstring strains is something you should know about.13) Zac Cupples reviews Interdisciplinary Integration with some great information on the over-achievers, vision, and even the auditory system..14) “Strength training is one of many options to buffer stress.” -Charlie Weingroff with another great share including some gems on fascia15) Andreo Spina goes over 5 Ways to Promote a Healthy Musculoskeletal System in Children: 1) Don’t Rush Walking 2) No Shoes/Socks 3) Pick Stuff Up With Your Feet 4) No Hands When Standing 5) Physical Play16) We’ve been using this approximation and positional release technique in our clinic with some success.  For one patient, the approximation aspect provided >50% improvement in ROM.17) “There is no lymphatic system in the brain, so the brain uses cerebral spinal fluid to clear the toxins that build up in the brain during the day, and yep you guessed it, this process only happens during sleep.” -Paul Lagerman goes over the correlation of Pain and Sleep.  For more articles on sleep, check out the references from this article.18) The Gait Guys, providing some of the best stuff out there:

“What ischial-femoral impingement might look like as aberrant shoe wear.”

Short Foot or the Toe Spread Out Exercise?  Here’s one of the answers.

""The electrical signal that drives a given movement is therefore an amalgam — a summation — of the rhythms of all the motor neurons firing at a given moment.” This is of course monitored (and modified) by one of our best friends, the cerebellum."

Why you shouldn't just be simply activating weak muscles for a movement solution.  "You may be over riding the central pattern generators, reflex responses and complex cortical loops arthrogenic responses, which could be neuro-protectively calculated."

3 categories of muscle weakness "Local causes include muscle injury and muscle pathologies, like muscular dystrophy and neuromuscular endplate disorders like myasthenia gravis. Segmental causes are largely due to reflexes which occur at the spinal cord level. Long loop and cortical causes are due to an increased inhibition or lack of drive from higher centers, such as the motor cortex and cerebellum."

"Remember the foot intrinsics fire from midstance to pre swing, further stabilizing the foot “core”."

Pain & Neuroscience

19) “And without the ability to regulate our basic needs, engagement with the environment thru sensorimotor processing is limited. This is why peripheral vision is decreased during stress (they literally have tunnel vision) and it's probably why movement suffers because if you can't perceive sensations accurately you don't make good motor plans.” -Seth Oberst writes a great piece reviewing the Polyvagal Theory and correlating it with Maslow’s Hierarchy of Needs.  Read it.20) This article covers a ton of neuroscience - top-down & bottom-up influence, expectations, biases, attention, and perception.  Very applicable to what we do in the clinic.  Expectations influence perception.21) Good read from Lorimer Moseley - No Brain, No Pain.  “any credible evidence of danger to your body will make pain worse and any credible evidence of safety to your body will make it better”22) “Animal studies provide convincing evidence that the sympathetic nervous system is involved in certain forms of chronic pain.” -Peter Drummond23) Todd Hargrove goes over Greg Lehman’s course on pain science.  I agree, clinicians should be able to dissociate chronic pain from biomechanics - especially when it comes to communication and education.  But I also want my patients to biomechanically be able to dissociate their hips from their spine.  #Bathwater24) Movement variability has been getting a lot of attention these days.  “If someone does not have a system capable of varying its movement then finding alternative strategies may be problematic and thus possibly lead to chronicity.”

Don’t forget that mobility (degrees of freedom) dictates the amount of available patterns.  This is one of the reasons why 9 year olds have more variability than 70 year olds.

Training

25) I always enjoy feeling awkward when I move.  It’s good for your body and your mind.  Here’s a couple ways to feel awkward in a “Primal Warm-Up” from Andrew Reed.  Give it a try and be the weird guy in the gym.26) GMB teach you how to do a Muscle Up27) YLMSportsScience shares a quick infographic on the Science of Post Activation Potential28) The unstable ones can’t slow down.  “This is also where the pain science and movement science worlds don’t realize they’re often saying the same thing. Asking someone to move differently is training the musculoskeletal and the nervous systems. Changing how you say, move your arm, changing that habit, is training the brain.”-Brian Reddy29) Dean Somerset goes over anterior hip anatomy, Sahrmann’s anterior femoral glide syndrome, and provides a few isolated hip exercises.30) Eric Cressey with solid training advice as always: incorporating single leg pauses, rotational low rows, RTC exercises after overhead work, and different strength qualities.31) “In intermediate and fast fibers mitochondria are developed by pushing the fibers into light acidity (slight local fatigue), then backing off and recovering aerobically over and over.” -An interesting read from Pavel on long rests for capacity, the effects of acidity, and why we should focus on the mitochondria rather than the energy systems.32) Lance Goyke goes over some neuroscience, habits, willpower, diet, and exercise.  A good post to give to your clients to read - How Exercise Helps You Stop Eating Dessert33) CrossFit is always a fun discussion topic on social media (for better or worse).

Stuart McGill had some interesting things to say in this interview - “Olympic lifting must find the lifter. Not the other way around given the special anatomical gifts needed to lift with efficiency and injury resiliency.”

These are two of my more popular articles.  This one elaborates on what McGill discusses in the above article.  This one discusses a common CrossFit mistake that most people miss.

7 Rules for Preventing CrossFit Injuries

34) 4 Unconventional Fat Loss Methods from Mike Robertson: Low Intensity, New HIIT, Focus on Recovery, Front Load Energy System Work.  I like the pyramid in this article.35) “Begin with the end in mind” Mike Reinold goes over periodization.  I first heard about the Undulating Model from Cal Dietz a couple years ago - very interesting stuff.36) Eric Cressey has the best Baseball stuff out there.  If you or your clients have any interest in this sport, read this quick post here.  And here’s another one on some things that should change in the Baseball Culture.37) John O’Neil goes over Motivation, 3 important factors, and makes it clinically applicable:

“Autonomy in the training process is a client’s ownership of their program, understanding that while they are provided structure and coaching, they are the one executing the movements and looking to improve upon their given goals.

Mastery is the ability to perform the process of the given program to the point where variables – movement type, loading scheme, structure – need to be altered periodically to maintain both psychological interest and physiological adaptations.

Purpose is a client’s awareness that movements they are given have reasons in progression towards their goals and the client feeling the need to continue the process to optimize performance.”

38) I recently had a patient that introduced me to Jeff Galloway and his run-walk-run program.  It’s not just for beginners.  It’s for performance.  Very interesting.

Research

39) "A significant association was found between lumbar disc degeneration and tibiotalar joint arthritis (P < .01)."40) “These results provide experimental support for the importance of action exploration, a key idea from reinforcement learning theory, showing that motor variability facilitates motor learning in humans and that our nervous systems actively regulate it to improve learning.”41) “When compared to a matched comparison group, there were impairments of scapular musculature strength and endurance in patients with LE (lateral epicondylitis), suggesting that the scapular musculature should be assessed and potentially treated in this population.”42) “beyond the amplitude of the neural drive, muscle force depends on several biomechanical factors (eg, specific tension and physiological cross-sectional area). Therefore, the VL/VM activation ratio does not provide information about the VL/VM force ratio, which is ultimately the most important information from a clinical perspective.”43) “A program focused on eccentric hamstring strengthening may prevent hamstring injuries.” -SMR’s review of the Nordic Hamstring Exercise44) Chris Beardsley goes over all the Kettlebell Research.  The conclusion is that Kettlebells are awesome and you should use them.45) “Fiber bundle length decreased significantly as a result of a concentric training program, whereas the eccentric strength training did not result in a decreased fiber bundle length. Pennation angle, muscle thickness and muscle strength increased similarly in both groups. Applying eccentric training may lead to preservation of fiber bundle length, allowing the muscle to sustain force over a greater ROM.”46) I’ve always liked this study - “The results indicate that the master cyclists have a significant asymmetry (30 ± 8 to 23 ± 13 %) during the pedaling exercise at all power output level tested in this study (100, 150, 200 and 250 W).”47) “a nostril will drive air to the ipsilateral lung” -Zac Cupples shares this article48) MRI Knuckle Cracking (shared by Jon Herting). Here’s the cavitation article on pubmed.49) “‘The Placebome’; the impact of genetics to the placebo response.  There is evidence for several genetic variations in neurotransmitters and neurological pathways mediating the placebo response, which could possibly explain the variations in clinical outcomes.”50) “The purpose of this review is not to suggest a whole-scale rejection of periodization theories but to promote a refined awareness of their various strengths and weaknesses.” -Important article from John Kiely on Periodization51) Strength wins again!  “Individualised PRT (progressive resistance training) intervention targeting the key muscles of lower limbs is more effective than TBE (therapeutic balance exercise) in improving forward limits of stability among elderly people, aged ≥65 years who are not frail.”52) Difference between genders and ITB “females with ITBS exhibited significantly greater hip external rotation (ER) angles during swing phase (52-54% of gait cycle) when compared to male runners. Male runners with ITBS showed decreased hip adduction angles throughout swing phase as well as greater ankle internal rotation.”53) “The closed chain condition elicited significantly higher infraspinatus activation levels than the open chain condition. The posterior deltoid activation levels on the other hand were significantly decreased when the exercises were performed in a closed chain. Moreover, the infraspinatus:posterior deltoid activation ratio was significantly higher in the closed kinetic chain condition.”54) “Tennis players above 16 years of age had less scapular upward rotation than the younger age groups. “55) Still fascinated by this stuff - Catherine Kerr on the somatosensory attention56) “Study suggests that unloaded movement facilitation is more effective than "no exercise" for chronic lower back pain” (shared by TPI)57) Research and evidence is very important.  But don’t become a Research Snob.

“Another important consideration is the fact that there a significant number of incredibly brilliant minds in the industry, and while there are a lot of them in academia, there are a significant number who are not.” =Mike Mullins

Practice-Based Evidence

The Truth About Randomized Controlled Studies

Other

58) Communication may be the most important part of our jobs.  Here are 10 Tips to improve it.59) 5 Ways to Make a Good First Impression 1) Assume They Already Like You 2) Drug Them 3) Solid Handshake 4) Spin a Positive Self 5) Don’t Play Cool

Top Tweets of the Month

• Ben Peterson PhD  ‏@Ben_J_Peterson - Research papers are not answers. They are clues which you must think about in greater depth to find truth. #alwaysquestion #Think
• Dr. Mark Cheng‏@DrMarkCheng - Errors in proprioception, coordination, and/or even socialization are due to a disconnect between self-perception & reality. #truth
• Doug Kechijian‏@greenfeetPT - That neurology drives biomechanics doesn't diminish the latter's importance
• Seth Oberst‏@SethOberstDPT - Until we take into account and measure how our inputs affect the brain, we will likely have incomplete answers on mechanisms of change
• Zac Cupples‏@ZCupples - Just because humans are adaptable doesn't mean the adaptations will be beneficial for that individual's well being.
• Christopher Johnson‏@chrisjohnsonPT - Trying to make performance gains in the context of injury is a recipe for disaster. #rehab2traintrain2competecompete2defineyourlimits
• Aaron Swanson‏@ASwansonPT - Effective communication skills are a pre-requisite to effectively teaching patients about pain.

Gif of the Month

               [subscribe2]--The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

April Hits (2015)

Clinical

1) Lately, I’ve been interested in the connection between vision and the cervical spine.  Here’s two interesting articles I found this month.

“The direction of eye movements was horizontal when the sternocleidomastoidmuscle on one side of the neck and the splenius on the other side were activated, and downward when both splenii muscles were vibrated.”

"During neck rotation SCM and MF EMG was less when the eyes were maintained with a constant intra-orbit position that was opposite to the direction of rotation compared to trials in which the eyes were maintained in the same direction as the head movement."

I put people in challenging developmental positions and have them use their vision to either increase motion or to dissociate their vision from their cervical spine (changing muscle activation patterns).

2) Still don’t think vision and the cervical spine are related?  Check out this research article on vision, cervical rotation, and pain “When vision overstated the amount of rotation, self reported pain occurred at 7% less rotation than under conditions of accurate visual feedback, and when vision understated rotation, pain occurred at 6% greater rotation than under conditions of accurate visual feedback.”3) The sign of a great educator is someone that takes complex ideas and makes them seem simple.  Here’s the Great Cantrell teaching the importance of hamstring flexibility (must watch video - share with your peers)4) I like Kelly Starrett’s concept of the shoulder shelf.5) Here's best 20 second explanation of the ankle as a torque convertor.6) You’ve never head a physical therapist talk about wisdom teeth like this - “the maxillary (top side) wisdom teeth limit the excursion of my lateral pterygoids for lateral trusive movements” -Zac Cupples7) Erson goes over End-Range Loading and 4 reasons why it works.8) Seth O’Neil shares a great article on the soleus and it’s implications on achilles tendonosis.  Some gems:

“The actual forces it produces are around 8 times body weight.(5) In comparison the Gastrocnemius produces forces around 3 times body weight.”

“Gastrocnemius functions largely isometrically whilst the Soleus tends to function eccentrically”

“91% of symptomatic tendons have pathology in the medial part of the tendon- the part relating to Soleus.”

“Most runners with AT will need to use body weight + up to an additional 50-75%. Without this they will not be working at a high enough threshold to rehab to an eccentric strength of around 200% body weight (as shown to be the average for healthy runners).”

9) Here's some PRI magic using occlusion for hip flexor flexibility.  I would love to know what the treatment plan is with this guy.10) “One of the best ways to keep people motivated in activity is to find something that gets them into or close to their flow state where they are engaged.” -Gray Cook on his latest checklist and the Skill:Challenge Ratio11) Only Zac Cupples can make you think about where to sit during the evaluation - “Being to someone’s left could build a better emotional connection.”12) Erson goes over 5 More PT Myths.13) Mike Reinold shows you a simple accessory respiratory muscle assessment (inhale in cervical rotation).14) “Here we show that contrary to predictions from optimal control theory, habitual muscle activation patterns are surprisingly robust to changes in limb biomechanics.”15) Perry Nichelston teaches you some baby moves - unilateral crawl16) “Perhaps we need to think of extension as system closure; a system closing problem. Flexion will be the solution to open the system.” -Zac Cupples17) "Peripheral nerves require extraordinary mobility in relation to surrounding tissues, sometimes sliding up to 2 centimetres as we move." -David Butler18) Mike Reinold goes over some overhead shoulder mobility concepts.  I’ve written detailed articles on two of these concepts (scapula upward rotation & lumbopelvic/core).19) Allan Phillips has a great DNS Review -

“3month position is the “starting line.”  Lift legs off table and secure torso w/o deviation.  Starts with position at ribcage and pelvis.  If not optimal, load shifts to extremities”

“Main time to influence joint morphology is in first year of life”

“Deep neck flexors require stability of abdominal wall”

“Breathing is an expression of the nervous system”

“Abdominal wall contraction can prevent diaphragm from descending”

20) Erson collects advice from Mike Reinold, Barton Bishop, Chris Johnson, Chris Nentarz, and Charlie Weingroff.  Some great gems in there including: “In reality there are flaws in all of the different models of physical therapy. Don't get locked into one thought process or you'll spend more time defending your belief than allowing yourself to grow.”-Reinold |:| “You are only as good as your last injury and the extent to which you rehabbed it”-Johnson |:| “Anything can work for anybody, and nothing works for everybody.”-Weingroff21) Michael Mullins teaches you about Dennison Laterality Repatterning (here & here)22) Navin Hettiarachchi introduced me to this interesting toy for improving foot/ankle function - Cobblestone Mats.23) Kathy Dooley is one of my favorite anatomy teachers.  The “subclavius assists the scapular protraction executed by pectoralis minor and serratus anterior”.  It also has a close proximity to the subclavian vein and artery thus making it relevant for all distal structures via circulation/blood supply.24) Hamstrings

Mike Robertson goes over some injury prevention strategies here.

Harold Gibbons keeps it simple and effective here.

25) In PT school, I remember learning how to teach neck patients to stretch their “levator scapulae”.  In the clinic, I remember these patients coming back feeling much worse without resolving any of their dysfunction.  Cranking and pulling on the cervical spine isn’t a good idea.  A few may get a temporary relief, but this does not provide any permanent change in the tissues.  It doesn’t lengthen the "tight" muscles.  It just places a ton of stress on the delicate cervical spine.  Here is an alternative exercise for neck "tightness" that provides relief without excessive stress.

Clinical Question

26) Two of my clinical mentors are asking a good question regarding post-op knees.  Do femoral nerve blocks affect the patients ability to regain their quad strength after surgery?  Should they only be doing saphenous nerve blocks?  What are the risks and rewards?  If it's just for pain, is it really worth the risk?  Anyone that has any answers or opinions please leave a comment at the bottom of this post.

Pain & Neuroscience

27) Emotions control the volume of pain.  Here’s an article you can share with your patients.28) Radiolab Podcast has a great Placebo Episode.  It's an easy place to start for those that want to learn more about placebo effects and the processing component of the human body.29) Erson’s 5 Pain Science Rants30) Zac Cupples says Salient 21 times and discusses pain - “A salient input is necessary for an altered output.”31) I’ve been studying attention focus recently.  It’s pretty fascinating stuff.  Apparently other people think so too.

Here are 5 questions to ask yourself about attention that can have a profound affect on your happiness.

“Improving one's awareness of the blind spots can improve attentional focus and potentially optimize motor output without inducing a maladaptive response - such as pain, anxiety, excess muscular tension. Because the brain has already "been there" and explored the region, the sensory input (whatever the mode) is likely much less threatening to the system. “ -Seth Oberst with a great read on attentional focus

Chronic pain patients have difficulty switching their attention focus off of their painful body part.  Here's a great TED talk on attention and mindfulness from Catherine Kerr.

Training

32) Here’s a nice collection of some higher level foot stability exercises - I like the kettlebell swap idea.33) I like this idea of the Landmine Squat.  I found it helpful to pre-activate the anterior core.  Give it a try and see what you think for yourself.34) Dean Somerset goes over 5 Squatting Concepts 1) Pause Squats are Underrated 2) Most Squat Restrictions Are Not Muscular 3) Valgus Collapse is Less About Technique & More About Reaction 4) Long Torsos Are Better Than Long Femurs 5) Breathing Patterns Change with Load and Fatigue35) Some interesting PRI Golf exercises - I like the sidelying 45 degree leg lifts.36) Pavel’s 5 Ab Training Mistakes 1) Chasing the Burn 2) Not Focusing on the Contraction 3) Not Using Enough Resistance 4) Exclusively Isometric Training 5) Not Making Every Exercise an Abdominal Exercise37) Feel awkward with GMB.  Here’s their thorough tutorial on How to Planche.38) 5 Miguel Aragoncillo Tips 1) Use Discovery Learning 2) Reduce the Amount of Corrective Exercises 3) Know the Difference Between Blocked & Random Practice 4) Oatmeal 5) Band Love (including this great core engaged hip flexor mob)39) Pavel discusses rest intervals (ordinary, stress, stimulation) - “ if you are only practicing incomplete recovery between your sets of strength exercises, you will never achieve your potential”40) Dean Somerset shares a great modification to the side plank for those with shoulder problems.41) Loaded Carries may be the best abdominal exercise you’re not doing.42) Harold Gibbons shares some breathing based core exercises43) We all benefit when Eric Cressey writes articles to promote a product.  Tons of good stuff from him this month:

He take post-activation potential (PAP) and creates a system (Stage System) to improve your lifting performance.

The Split-Stance Anti-Rotational Ball Scoop Toss exercise.

“The lower the motivation of the exercising individual, the greater the need for randomness to keep exercise engaging. This is working out.  The higher the motivation of the exercising individual, the greater the need for repetition to deliver a specific physiological effect. This is training.” -Eric Cressey on Repetition vs Randomness

Build Multi-Directional Strength & Power.  Tons of exercise examples.

Solid Deadlifting advice.

15 Random Thoughts on S&C Programs

Slowing down the concentric - “taking 3-5 seconds to externally rotate the humerus during cuff work can prevent the deltoid or lat from taking over” -Eric Cressey

Research

44) This is a dead horse that can’t get beat enough.  “Asymptomatic shoulder abnormalities were found in 96% of the subjects”  Medical imaging is NOT the gold standard for movement, health, or function.45) The latest research in fascia “supports the multiple functions of the connective tissue matrix, combining strength and elasticity – biotensegrity – a word that describes ways in which the architecture of connective tissue cells – such as fibroblasts – respond to different degrees and forms of mechanical load leading to rapid modification of chemical behavior and physiological adaptation – including gene expression and inflammatory responses.”46) Found this entertaining.  Now you can tell your RTC tear patients that it happened because they’re fat!  But really, it has to do with hypovascular zones and cardiorespiratory efficiency.47) The Top 6 Recent Tendinopathy Papers (share with your peers - most people in medicine don’t know this stuff)48) “The infraspinatus muscle was found to be composed of three partitions: a superior, middle and inferior part were present in all muscles. In 62.5% of the muscles, full compartmentalization was established (i.e. a separate nerve branch entered all three partitions). It can be speculated that the different neuromuscular partitions correspond to different biomechanical functions of the infraspinatus.”49) Runners need Achilles Viagra #Stiffness50) Cuing for more knee flexion and less impact on single leg landing led to: increased knee flexion, decreased peak vertical ground reaction forces, and decreased co-contraction (quad & HS).  #ACL51) Chris Beardsley provides a thorough evidence-based review52) Chris Beardsley also has an equally thorough evidence-based review of the Glute Max53) “The study found that twelve weeks of sitting Tai Chi training could improve the dynamic sitting balance and handgrip strength, but not QOL, of the SCI survivors.”54) I heard Gray Cook talking about this years ago - if he was a hipster, he’d be saying he did it before it was researched.  “A simple beam-walking task and an easily collected measure of distance traveled detected differences in walking balance proficiency across sensorimotor abilities.”  #ResearchLagsClinicalExcellence55) “Surgical decompression yielded similar effects to a PT regimen among patients with LSS (lumbar spine stenosis) who were surgical candidates.”  Why choose PT?  One of the side effects of surgery could be death or paralyzation.

Other

56) An interesting way to use a Ladder by Kathy Bowman.57) The Obstetrical Dilemma - “The results show that pelvic width does not predict hip abductor mechanics or locomotor cost in either women or men”58) I’ve been learning some Traditional Chinese Medicine from our acupuncturist.  The Meridians can offer an interesting perspective.

 Top Tweets of the Month

• Seth Oberst‏ @SethOberstDPT - The meaning of sensory information to the brain is much more important than the volume of the inputs
• Charlie Weingroff‏ @CWagon75 - Long term health and maximal performance in a strength sport are fairly exclusive. You can't have both.
• FMS‏ @FunctionalMvmt - We want trainers and rehab professionals to approach their work like Pandora does music: listen to the patterns and refine the information.
• Robert Butler PT PhD‏ @rjbutler_dptphd - FMS is not a treatment model. SFMA is proper treatment model that fits w PRI, DNS, astym, etc
• Sam Yang‏ @allouteffort - Health is first and foremost a mental and attitudinal change.
• Zac Cupples‏ @ZCupples - Claiming to ever have similar baseline characteristics among groups or individuals in research is a myth. #everythingmatters #alwaysnof1
• Aaron Swanson‏ @ASwansonPT - If they can't feel it, they can't control it.

 Gif of the Month

                [subscribe2]--The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

March Hits (2015)

Clinical

1) There’s a weird campaign by some Hipster PTs who are arguing that posture isn’t important.  Maybe they’re doing it for social media popularity.  Maybe what they’re really trying to say is that we shouldn’t create thought viruses.  Maybe what they’re saying is that we shouldn’t blame all of our patients' problems on a static postural assessment.  Maybe they don’t understand that posture is a biobehavioral pattern.  Regardless of their underlying point, dogmatically saying posture doesn’t matter is like saying physics and physiology doesn’t matter.2) “From a sensory perspective, moving fast has a lot of sensory noise - it's loud…By lowering the magnitude of the sensory stimuli, we can better perceive excessive muscular rigidity and help to regulate it.” - Seth Oberst3) “The 90-90 hip lift says that the pelvis is too far forward, especially on the left and we would like to put it back to a neutral position and we are going to use a couple muscles to keep it there” -The Nominalist4) Here’s a list of some DNS based exercises.5) A Therapeutic Alliance as "a trusting connection and rapport established between therapist and client through collaboration, communication, therapist empathy and mutual understanding and respect."  |:| “Quite a bit of literature links a trusting therapeutic relationship to superior patient outcomes”6) The squat is a very trendy social media topic.  Which leads to a ton of people discussing it with a black and white approach.  And someone always has the newest way to squat better or the real reason you can’t squat well.  Tom Purvis goes over the gray of squat biomechanics and body proportions.  One of the best explanations out there.  7) Here's some easy to read pain science analogies and the weighted sleeper exercise for shoulder internal rotation by The Nominalist8) “In most cases, the perception of tightness is just that, only a perception.” -Erson9) “Every exercise is an assessment. Each time your clients and athletes move, they're providing you with information. The more you pay attention, the better you'll be able to individualize their programs and coaching cues moving forward.’ -Eric Cressey goes over 10 assessment tips10) Pelvic floor, breath holding, and crossfit.  “Lifting with a belt also increases the IAP by bracing the back, sides and front of the abdomen…but what about the top (diaphragm) and bottom (pelvic floor) of the abdominal canister? What often happens is that the very strong diaphragm can hold its own and so the pressure gets directed downwards into the pelvic floor.”11) Mike Robertson shares his 3 Safe Shoulder Exercises12) Inside the Mind of Charlie Weingroff (Random Thoughts #2)

• "Screening generally with unlearned movements first will allow for a more organic appraisal of joint position, which is all any movement screen should be judged against."

• "Testing with another series of movements very different from your training but requiring the same “bucket” of movement qualities is likely far more indicative of general motor skill acquisition."

• "One of the summary interpretations that I have made is that for balanced joint position with ideal co-contraction to be achieved, we require full non-threatened joint motion in all planes and vectors."

• "Develop motor skills and fitness simultaneously with carry over to terminal athletic goals"

• "Can you have any kind of legitimate grip without a particular centration of the scapula and t-spine?"

13) “The craniocervical region is incredibly mobile for a reason. That reason is to create precision for our sensors: vision, audition, olfaction, respiration, and vestibular sensation. This precision occurs reflexively, whereas other appendages act proprioceptively.  These sensors drive the neck. Losing the ability to sense is what can increase the need for a neck to become stable. And when you can’t move a stable neck, teeth may be one thing you try to use.” -Zac Cupples with a great article on the cervical spine, occlusion, and the girl he wants to marry14) "When a patient cannot move properly without pain, paraesthesia, or perception of stretch, and a manual technique is performed, we are really modulating that perception." -Erson Religioso15) The Foot Core System - a great read on foot function, evolutionary adaptation, and intrinsic foot assessment & treatment.  An important read for anyone that works with people that have feet.16) Erson shares 2 studies on the importance of vision with cervical patients.17) Louis Gifford’s Mature Organism Model really laid down the blueprint for how I view my patients (inputs, processing, outputs).  Zac Cupples shares his interpretation of this model, jokes about your mom, and lays out a way to influence this system.  A great read that everyone can relate to.18) “When we’re going to move, it’s very biologically important to be engaged in our movement.  If we look at the natural environment around us, animals are 100% engaged in the moment and in their current activity.  When we have two electronic devices on our hip just so we can run—one so we can text and the other so we can listen to music—I’m not sure that many of the lessons that running in the environment could teach us are even accessible.” -Gray Cook19) “What’s the point of asking an athlete to commit an hour a day to more efficient movement if you're not going to address the four hours per day they are reinforcing an unhealthy movement?” -Lee Burton on texting posture20) Erson reviews SFMA 2.  “you can ride a bike after not doing it for 10 years, but can you still do calculus?”21) 7 Reasons to Goblet Squat from the Nominalist 1) Comfortable Hips Below Knees 2) Opens Up Areas that Stretching May Not 3) Increases Hip Capsule ROM 4) Exposes Foot/Ankle Weakness 5) Pelvic Floor Alignment 6) Easy to Reproduce Independently 7) Helps to Isolate the Shoulder22) Shameless Self Promotion - I agree with John, it’s a lot easier to put people in positions where they can’t compensate instead of using 17 different verbal cues.  Sometimes I use the same concept for overhead movements - the deep squat locks out the lumbar spine and prevents a compensatory rib flare.23) It’s important to remember that the human body is an adaptation machine.  If you play basketball 3 times a week, it will adapt to handle those loads (assuming graded exposure).  However, if you only play basketball every several months, the body will not be adapted to handle those loads.  Injury risk and pain are potential outcomes.  Brian Reddy discusses this concept in this article - “Soreness is a sign of working your body in a way it’s not used to.”  Educate your patients.24) Another great post from Zac Cupples.  You might have a different view of the Thomas Test after reading this one.25) Ron Hruska describes my NYC patient population.26) I was having some difficulty determining the driving force of the pes cavus foot type.  Specifically I wasn't confident whether it was a plantarflexex forefoot or a rearfoot varus.  Dr. Suzanne Fuchs pointed me towards the Coleman’s test (5 min into this video).27) Loukia Lili is getting treatment from the cueing master, Mike Cantrell.  Here are 4 videos using PRI and some solid coaching to ensure proper muscle activation (1, 2, 3, 4).28) Dennis Treubig shares 5 things he wishes he would have learned in PT school 1) Treatments aren’t very specific 2) A movement assessment system is important 3) Modern Pain Science 4) How to pick CEU courses 5) Medical imaging is clinically irrelevant 29) One thing I wish we would have learned more about in PT school is psychology.  It’s such an important component that was not covered well in school.30) "attempting to achieve sufficient dorsiflexion through the combined ‘foot pronation-ankle dorsiflexion’ mechanism, as opposed to just dorsiflexion from the ankle mortise joint alone, may change the dynamics of the entire limb…. in this case, hip flexion range observation. Is this because when dorsiflexion is cheated via foot pronation, instead of just ankle dorsiflexion, there is more internal tibia/femoral spin than would normally occur from just sagittal ankle hinging which can in turn impair terminal hip flexion range via impingement type action ? I think so. It would be cool to see what would have happened in the study had the pronating clients been shown my foot tripod restoration exercise.”   -Dr. Allen

Pain

31) “when I can’t find something physically stopping you from doing something, I have to help you get back to normal by using graded exposure (CBT techniques) and explaining pain to you” -Antony Lo31) Kento Kamiyama discusses the lion-pain metaphor.  “The adrenaline rush is a normal response and once the lion goes away, everything returns back to normal.   However, when it is prolonged the body starts using cortisol instead of adrenaline.  Cortisol is a more potent and longer lasting chemical to deal with longer lasting threats.“32) What your adrenal glands really looks like.33) Sometimes new terms are created for self-promotional reasons or for the sake of argument.  Many times I find this trivial - we often waste too much time on semantics.  However, when new terms are created for educational purposes it can be powerful.  NOI recently released a new book to help patients understand pain.  They created the terms DIMs & SIMs (Danger In Me & Safety In Me) - “This is a reminder of the power of context.”34) “Social context matters. It can affect our learning processes, and does so also in the context of pain. While we can only speculate about the underlying mechanisms at this point, it seems plausible that a threatening environment (be it social or not) could facilitate the rapid distinction between threat and safety”-Kai Karos

Training

35) Pavel teaches you why and how to build your slow fibers (1, 2, 3, 4)36) Eric Cressey goes over 7 Thoughts on Speed, Agility, & Quickness Training.  “Understanding what "normal" looks like is important, but don't think "abnormal" is necessarily always inappropriate.”37) Mike Reinold shows you how to prep for throwing - Part 1 & Part 238) 4 Reasons Why You Should Bear Crawl 1) Anit-Extension 2) Reaching 3) Breathing 4) Dynamic Exercise39) Bret Contreras lays out specific plan to build stronger glutes and goes over specific approaches for different populations (powerlifters, bodybuilders, crossfit, beginners, etc.).40) Cressey Coaching Cues 1) Create a Gap 2) Don’t Let the Plate Fall 3) Don’t Break the Glass41) Shante Cofield shows you how to instantly improve mobility - Shoulder Flexion, Functional Internal Rotation, Elbow Flexion, Hip Flexion41) Eric Cressey shares some tips on long-term development for young athletes.42) 5 Reasons Why Your Squat is Difficult 1) Too Much Knees 2) Poor Anterior Core 3) Hyperextension 4) Wrong Squat Type 5) Not Taking Advantage of Irradiation

Research

43) Why kinesiotaping works? Neuromodulation.  A fancy term that just means we're changing sensory input in attempt to change the way the brain processes information.44) John Snyder goes over scapula strengthening exercises through a EMG lens (Part 1 & Part 2)45) “hyaluronic acid (HA) – the key lubricant in the sliding function of fascial layers – lies at the heart of the problem” - Leon Chaitow 46) If you breathe bad, you’ll move bad.  A good read on the FMS and breathing.  “These results demonstrate the importance of diaphragmatic breathing on functional movement. Inefficient breathing could result in muscular imbalance, motor control alterations, and physiological adaptations that are capable of modifying movement.”47) There’s a lot of great work being done on tendinopathies.  Please share this study with your peers - too many people in the medical field are only using eccentrics.  “There is little clinical or mechanistic evidence for isolating the eccentric component”48) If you only practice evidence-based medicine, you are almost 2 decades behind!  “Studies have shown that it takes an average of about 17 years for new knowledge generated by randomized trials to be incorporated into practice.”49) If you’re into injury prevention, you should also be into fatigue prevention “Following a fatiguing exercise protocol, participants showed increased anterior tibial translation, compressive force, and knee flexion range of motion during the transition from non-weight-bearing to weight-bearing. This illustrates an inability of the lower extremity muscles to stabilize the knee joint.”50) A sensorimotor approach to Chronic Ankle Instability - “The STARS interventions include ankle joint mobilization, plantar massage, and triceps surae strengthening.”51) A great read on proprioception and body awareness.  Tons of great references throughout.52) You can explain this with basic biomechanics, physiology, breathing, DNS or PRI philosophies, or just common sense - standing with excessive lumbar lordosis isn't the best posture for your back.

Other

53) “When individuals speak slowly and clearly, they tend to sound more credible than those who speak quickly.”54) Phrenology is interesting. 55) Todd Hargrove’s post on what we can learn from robotics.  “A big part of motor intelligence lives in the “design” of the passive elements of the motor control system – the bones, fascia, tendons, connective tissue, etc. When the passive structures are optimally designed (by natural selection) for a certain task, the muscular and neural systems don’t have to work very hard to produce optimal movement patterns.“56) Stress, Homeostasis, Allostasis and the Bank Account analogy by James Cerbie57) Some nice example dialogues to help change patient behavior from Erson58) “Titin, however, seems to be an essential missing link in how muscles actually work.” -Jules Mitchell59) A Solid Read on Tensegrity by Donald E. Ingber

• “There my studies of cell biology and also of sculpture led me to realize that the question of how living things form has less to do with chemical composition than with architecture.  The molecules and cells that form our tissues are continually removed and replaced; it is the maintenance of pattern and architecture, I reasoned, that we call life.”

• “changing cytoskeletal geometry and mechanics could affect biochemical reactions and even alter the genes that are activated and thus the proteins that are made.”

• “At the Johns Hopkins School of Medicine, Donald S. Coffey and Kenneth J. Pienta found that tensegrity structures function as coupled harmonic oscillators. DNA, nuclei, cytoskeletal filaments, membrane ion channels and entire living cells and tissues exhibit characteristic resonant frequencies of vibration. Very simply, transmission of tension through a tensegrity array provides a means to distribute forces to all interconnected elements and, at the same time, to couple, or "tune," the whole system mechanically as one.”

Top 8 Tweets of the Month

• Charlie Weingroff‏ @CWagon75 - To suggest SMCD, TED, and JMD are the same is awful. The CNS put them there, but it will be wildly different approaches to get them removed.
• Doug Kechijian‏ @greenfeetPT - "Tricking" the nervous system is ok provided you exploit that neurological window of opportunity by applying the right stressors afterwards
• What The Foot‏ @AnatomyMotion - If it extends, flex it, and if it flexes, extend it! #WhatTheFoot
• Anthony Donskov‏ @Donskovsc - "The less you know, the more opinionated you are." -Buddy Morris
• Mark Reid, MD‏ @medicalaxioms - A little extra diagnosis or treatment can get you into a lot of trouble.
• Seth Oberst‏ @SethOberstDPT - It’s all about pattern recognition - the human brain is really adept at it provided we’re aware and present in the moment
• Michael J Mullin‏ @mjmatc - Conscious awareness before subconscious competency = You have to learn it before you can own it
• Aaron Swanson ‏@ASwansonPT - The answer to a question should be followed by another question. #ThereIsNoFinalAnswer #DigDeeper

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, 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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