February Hits (2016)

The Hits

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

Clinical

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

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

Challenge a Concept

Provide an Alternative Concept

Provide Evidence for a New Concept

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

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

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

Biomechanical vs. Anatomical Breathing

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

Pain & Neuroscience

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

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

Training

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

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

Exercise of the Month

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

Research

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

Clinical Question

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

Other Good Stuff

Psychology and Communication

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

Diet

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

Sleep

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

Reading

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

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

Other Useful Stuff

73) Great read on how to improve creativity (get new experience, go for walks, take a shower, get some me time, outsiders mindset, keep trying) - “It’s important to encounter new and unusual experiences. It really helps with your cognitive flexibility. Any exposure to things that take you out of your normal way of viewing the world really increases cognitive flexibility, and is a core part of creativity.”74) Powerful 1 minute read - The Story of the Taoist Farmer75) “When there is negation of all those things that thought has brought about psychologically, only then is there love, which is compassion and intelligence.” -Krishnamurti76) “You have more willpower in the morning so push yourself to do that thing you’ll regret not having done. Afterwards, you’ll feel good about yourself. And the rest of the day will look comparatively easy.”-Eric Barker on 7 morning ritual habits77) Put it away you addict!  “Replication study confirms: Mere presence of your smartphone harms your conversations”--The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.

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Guest Post: Biomechanical vs. Anatomical Breathing

Guest Post: Biomechanical vs. Anatomical Breathing

By Cameron Yuen

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

Diaphragmatic Breathing

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

Biomechanical Breathing

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

Anatomical Breathing

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

Summary

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

About Cameron Yuen

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

The Best of 2015

News

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

Top Hits of the Hits

During the process of going through all the previous Hits, it was interesting to see how one small blog article can change my practice and help me develop a greater understanding over time.  These were some of the ones that had a lasting impact on my practice.  Small waves eventually change coastlines.1) “Based on animal studies, it has been proposed that central sensitization associated to nociception (maladaptive plasticity) and plasticity related to the sensorimotor learning (adaptive plasticity) share similar neural mechanisms and compete with each other.” 2) Here’s a great 3 minute video that goes over both the cause and treatment of tendinopathies.3) “The nervous system depends on consistent patterning in a non-threatening environment in order to best learn and perform. Patterns create security (though these patterns may not always be ideal). Security allows for one to pay attention and integrate sensory cues with minimal internal noise or distraction.” -Seth Oberst with another solid post on stress/threat (including some great clinical advice)4) Tom Purvis goes over squat biomechanics and body proportions.5) Zac Cupples teaches you about Salience, inputs, processing, and pain.6) Are your patients using their Short Head Biceps Femoris to compensate for a lack of hip extension in closed chain movement patterns?  Kathy Dooley thinks so and discusses more clinical pearls in this phenomenal anatomy post.7) Erson’s 5 Rules for Resets: 1) It has to be Novel 2) Hit the End-Range 3) Frequent Reinforcement 4) No Pain 5) Education8) The Cynefin Framework9) Top 10 Bodyweight Exercises From GMB – Squat, Frogger, Monkey, Cartwheel, Pull-Up, Bear, Push-Up, Hollow Body Hold, Scales, L-Sit, and Handstand.10) 12 Ways to Make Better Exercise Choices by Eric Cressey11) Dan Pope literally bridged the gap - exercise progressions.  Scapula - Part 1 – Closed Chain & Part 2 – Open Chain |:| Jump/Plyometric Double Leg Jump Progression - Single Leg Jump Progressions - Advanced Double Leg Jumps - Advanced Single Leg Jumps12) ““Toes up” technique involves consciously firing the anterior compartment muscles, particularly the extensor digitorum longus. It fires more into the extensor pool and assists in firing ALL your extensors through spatial and temporal summation and also helps to shut down flexor tone through reciprocal inhibition. It will also help you to rocker through your stance phase and get more into your hip extensors.” -Gait Guys13) If you’ve been following this blog, then you know isometrics have been gaining popularity with respect to decrease tendon pain while providing safe mechanotransduction (#29, #3, #47, #20, #9,  #13, #3, Jill Cook, Andreo Spina Review).  More research (Heavy Slow Resistance, Reduced Cortical Inhibition) and blog posts (Body in Mind, Leon Chaitow – Mechanism) are now surfacing that will hopefully change the medical mainstreams bias of eccentric exercises for all tendinopathies.  Tom Goom has some of the best tendinopathy posts here (stages, treatment 1, treatment 2).  Probably the best resources to share with your peers that may not know about tendinopathies.14) Dave Tilly on Movement Variability - “It also has been suggested that there is an optimal amount of variability for skills. Too little variability in their skill, and the person is stuck with an inflexible system that has very limited adaptability. Too much variability (especially coordinative) in their skill and the person may be all over the place unable to narrow in on the important performance components that lead to skill success.”15) Here’s a great post from Tom Goom on the importance of load capacity, the envelope of function, kinetic chain load, and the non-tissue issues.  This might be the most important concept in rehab.16) “When I think aerobic training, I think recovery, energy development, and fatigue buffer.” -Lance Goyke17) The stress section in the October Hits18) Great write up on pain and diet/microbiome from Andrew Rothschild – “an imbalance between bacteria in our guts can interact with our immune system causing the release of inflammatory chemicals and stress hormones, kicking off our body’s natural stress response, even when we are not truly in a stressful situation.”19) “When you change your beliefs about a situation, your brain changes the emotions you feel.”  And remember...pain is an emotion.20) “Overextension refers to not just a position of one or more joints, but also a state of mind.” -Michael Mullin21) “What if, instead, you approached lifting like it was your job and you got paid to not only make the lifts, but to also to look good and be entertaining while you are doing it? How often would you attempt to set a new record lift 1 rep maximum? How ambitious would that attempt be?”22) “Lubricin is a protein that mixes with hyaluronic acid and other molecules to form a nearly frictionless environment.” “Words and phrases to power up the nugget include “lubricin is cytoprotective and chondroprotective”, “you can build up a lubricin reservoir in your joints with healthy movement” and “marvel how your eyelids slide on your eye – that’s lubricin“.”23) “The nerve plays a role in a vast range of the body’s functions. It controls heart rate and blood pressure as well as digestion, inflammation and immunity. It’s even responsible for sweating and the gag reflex. “The vagus is a huge communicator between the brain and the rest of the body,” says cardiologist Brian Olshansky of the University of Iowa in Iowa City. “There really isn’t any other nerve like that.””24) “Muscular power, especially in the legs — which are the largest muscles in the body — is widely accepted as a marker of healthy aging. Older people with relatively powerful leg muscles get around better than those with weak legs. They also tend to have sharper minds, studies show.”

Top 5 Research Reads

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

Top Exercises

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

Top 2 Courses

1) Ron Hruska’s Cervical Revolution

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

2) Gait Guy’s Advanced Biomechanics Course

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

Top Books

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

My Articles

What I Thought Were The Most Important Articles

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

What Actually Were…

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

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

Writing Around the Internet

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

Clinical Self Review

4 Mistakes I Have Learned From

• 1) Pain Language  

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

• 2) Are They Ready?

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

• 3) Tough Love

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

• 4) Complete Rehab Takes Time

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

8 Clinical Epiphanies

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

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

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December Hits (2015)

News

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

Clinical

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

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

Protrusion puts COM anteriorly, down regulating the posterior chain

Retrusion puts COM posteriorly, down regulating the anterior chain

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

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

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

Bill Hartman

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

Posture Matters

Complexity of knee position, movement variability, and individualism

Head Position and Stability

Breathing Affects Movement - Concept

Breathing Affects Movement - Example

Why Necks Are Stiff

Running

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

Pain & Neuroscience

• “Focus is the new IQ.” -Cal Newport

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

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

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

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

Exercise of the Month

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

Michael Mullin

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

Tweets of the Month

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

Training

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

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

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

Research

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

Other Good Stuff

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

Psychology and Communication

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

Sleep

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

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

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

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

Diet

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

Coffee

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

Instagram

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

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

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

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

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

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

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

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Coaching & Cueing (Part 7 - Phases & Summary)

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

So where do you start?

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

Four Ways to Manage Coaching & Cueing

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

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

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

3) Phases of Learning

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

Transtheoretical Model

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

Fitts & Posner 3 Stages of Motor Learning Model

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

Movement Compensation

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

4) Practice

• Skill = Knowledge + Experience

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

Four Questions Before the Movement

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

After You Answer These Questions

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

Two Questions After the Movement

1) Did it look good?  

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

2) Where did they feel it?

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

Avoid Over Coaching

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

Summary

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

Coaching & Cueing

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

November Hits (2015)

Clinical

• "Knowing how to think empowers you far beyond those who know only what to think." -Neil deGrasse Tyson

1) Great stuff from David Butler.  He goes over tennis elbow and shares several manual and exercise treatments.  A very generous post.2) “Overextension refers to not just a position of one or more joints, but also a state of mind." -Michael Mullin3) Great post by Sian on patella tendinopathy.  This article seems to cover all the current concepts with a clinical perspective.4) The tongue is more important than you think.  “When the teethers restricted movements of the tip of the tongue, the infants were unable to distinguish between the two “d” sounds. But when their tongues were free to move, the babies were able to make the distinction.”5) “The key factors in the onset of tendinopathy appear to be repetitive energy storage and release, and excessive compression. The key word here is compression, not tearing in the collagen.”6) Great article summarizing exercises benefits on the brain "The fact that physical activity benefits both gray and white matter is the primary reason that exercise is the No. 1 way to keep your brain young"  #ExerciseIsMedicine7) Todd Hargrove always puts out good stuff.  Here's his latest tactful article on "tightness" - "So tension is not a threat, but the absence of adequate rest or blood flow is a threat, which could cause metabolic stress and activate chemical nociceptors. So the problem that a feeling of tightness is trying to warn us about is not the existence of tension, but the frequency of tension or the lack of blood flow (especially to nerves, which are very blood thirsty.)"8) It's complex. Erson gives a brief example on the ecosystem of patients. For a more in-depth understanding check out these two articles. #Variables9) “Tall-kneeling hits ‘save’ on the document of thoracic spine mobility and hip extension. Half kneeling hits ‘save’ on the document of the 3-D hip and the ankle. Both add integrity to the lumbar spine. Half kneeling adds integrity to the knee by keeping that knee tracking over the foot and training that in your warm-up so that you don’t have to think about it when you’re doing lunges or split-stance work.”10) A simple and concise post on returning to athletic activities (running) by Chris Johnson.  Take 2 minutes and read this one.11) This is an interesting neurological (Arthorkinetic Reflex) trick from Z-Health: compress a joint to inhibit, distract a joint to facilitate.

Here are some examples (neck, back/pelvis, cervical/thoracic, hip, shoulder, elbow, ankle, weird stuff)

Seems similar to Andreo Spina’s CARs, but with a different intention

As with any neurological change, the questions are: how long does it last? how do you make it last longer?

12) Zac shares some info from the Omegawave course including some training recommendations13) More great stuff from Charlie Weingroff. It's great that he shares his thoughts to make everyone better. "Sleep is when motor skill acquisition goes from adjustment to adaptation. If you can’t control sleep, I don’t know that motor skill acquisition is a great idea that day. Instead getting after a fitness or pain quality passively is better suited to that day."14) Charlie mentioned Bosch exercises.  I had no idea what they were.  Looked it up to find out more (here & here).  Seems like it’s based on dynamic systems theory, specificity of training, stiffness, and adequate muscle isometric to take advantage of elastic properties of tendons (no muscle slack).15) "Almost any amount and type of physical activity may slow aging deep within our cells, a new study finds. And middle age may be a critical time to get the process rolling, at least by one common measure of cell aging." #ExerciseIsMedicine16) Share this easy read on the importance of strength with your patients. "In other words, the greater your muscle mass, the lower your risk of death," concluded Dr. Karlamangla"

Pain & Neuroscience

• "Everytime we choose safety we reinforce fear"

17) Here’s a great interactive lesson on exposure therapy, pain connections, conditioning, and neuroscience.  It’s presented in a way that can help people understand why they have pain in certain situations.18) "the nervous system subconsciously monitors energy use and continuously re-optimizes movement patterns in a constant quest to move as cheaply as possible"19) "This study is the first to show that mindfulness meditation is mechanistically distinct and produces pain relief above and beyond the analgesic effects seen with either placebo cream or sham meditation"20) "The current study supports a bidirectional temporal association between depression and fibromyalgia such that each disease occurring first may increase the risk of the other subsequently." You mean it's not just myofascial trigger points and peripheral hypersensitivity?  #Variables21) "When you change your beliefs about a situation, your brain changes the emotions you feel."22) A good argument for why healthcare providers should learn a Cognitive Behavioral Therapy - "I think health professionals who see people are probably exerting greater influence over thoughts, beliefs and emotions than many of us acknowledge. And given that’s the case, I think it’s only ethical to learn to craft that influence in ways that are positive rather than inadvertently doing harm because of ignorance."

Attention Focus & Awareness

23) "And that's what we're doing in treatment and training - restoring and reinforcing a robust sense of self thru awareness and behavior modification." -Seth Oberst24) “Attention’s place in this architecture is to help us structure our internal world so that the thoughts, emotions, or motivations that are most relevant to our goals will get preferential processing through the brain”25) "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."26) No one knows how many hours it takes to become an expert. There are way too many variables involved.  But we do know two things that are necessary: attention focus and feedback.

Exercise of the Month

Can you pronate and supinate your hip?  If not, your foot, knee, or back will likely do it instead.I use this exercise to help cortically map the transverse plane in patients that can't perform a single leg deadlift correctly (open chain hip rotates towards ceiling during downward phase).https://www.youtube.com/watch?v=t7NcR2inqN0

Training

27) Chris Johnson shares a great advanced hip exercise for athletes - Barbell Lateral Taps28) Dean Somerset shares some interesting information on lifting with a flexed versus and neutral spine.  I like the study he provided on disc shape.29) There’s also a lot of research out there that shows that torque is the major problem with spine injuries.  And think about this, if you have an asymmetry and you perform a symmetrical lift, then you just created torque.30) "Our goal as a coach is to help them commit to a challenge that emotionally drives them and stretches their abilities."31) GMB share an easy and modifiable body weight circuit that everyone can do.32) I completely agree with this article. Everyone that exercises should understand this concept. "What if, instead, you approached lifting like it was your job and you got paid to not only make the lifts, but to also to look good and be entertaining while you are doing it? How often would you attempt to set a new record lift 1 rep maximum? How ambitious would that attempt be?"33) I owe GMB a ton for improving my movement. Working on their stuff has really cleaned things up and given me much more true, connected, strength. Try their progression on the L-Sit.

Research

• "Everything that irritates us about others can lead us to an understanding about ourselves." - Carl Jung

34) Many times in rehab, education has the most profound change. Here's one to instantly decrease PFPS stress:

"Step rate significantly affected peak contact force magnitudes. Increased step rate induced a 16.6% lower patellofemoral force. The effects of an increased step rate also changed the medial component of the patellofemoral force. Step rate modification is an attractive option given that is easily trainable via auditory cues and can induce notable changes in loading patterns. An increasing step rate (i.e. shortening step length) can effectively decrease cartilage contact area and the peak and average cartilage contact pressures that arise in mid-stance. It can also reduce knee energy absorbtion, with the latter effect primaraliy due to running with a more extended limb. The vastus medialis strength did not affect pressure magnitudes, but did shift the location of contact pressure medially on the patella."

35) Research that everyone loves: "Research conducted by the University of Alberta in Canada has found that health benefits in resveratrol, a compound found in red wine, are similar to those we get from exercise."36) "Decreased range of internal femoral rotation results in greater ACL strain and may therefore increase the susceptibility to ACL rupture with athletic cutting and pivoting activities."37) Exercise improves sleep which decreases anxiety. #ExerciseIsMedicine38) “To maximize tensor fasciae latae stretching, patients should be positioned with their hip adducted and extended and with more than 90º of knee flexion.”39) Stress & Recovery 

Diet, Nutrition, & the Microbiome

40) My good friend, Jesse Cullen-DuPont, is one of the smartest guys I know.  He has a passion for diet/nutrition and has dug deeper on this subject than anyone I know.  I asked him to send me some of his favorite links, here’s what he gave me:

Dr. John Cryan Podcast

Microbial Endocrinology

Chris Kresser Podcasts (American Gut Project, Leaky Gut, Altered Intestinal Microbial Balance)

41) This is why I always take diet advice with a grain of salt (no pun intended) - “Different diets work for different people, and now new research reveals that it may be possible to predict how people will react to different diets, based on the composition of the microbes in their gut.”  Unless you’re a dietician, please don’t prescribe specific diets to people.  #OutOfYourScope #Microbiome42) This is one of my favorite reads by Andrew Rothschild on the holistic nature of the gut microbiome and how it affects pain.43) “A growing body of data, mostly from animals raised in sterile, germ-free conditions, shows that microbes in the gut influence behaviour and can alter brain physiology and neurochemistry.”   #BellyNeurotransmitters #LessDrugsBetterFood “44) "No Sugar" Foods with Maltodextrin Mess with Your Gut Microbiome - Effects are Significant and Could Explain Rise in IBD, Crohn's, Ulcerative Colitis & Co” #EatLessProcessedFood45) Great article on our nation's diet problems - too much fear of fats, too little understanding of glycemic index/load. "glycemic index influences human physiology, clearly demonstrating its importance to preventing and treating obesity, diabetes and cardiovascular disease"46) Here’s a list of 100 common food’s glycemic index and load.47) “Irregular eating patterns, including not having consistent meal times or eating late into the night, can affect health, metabolism and circadian rhythm.”

Other Good Stuff

• "You don’t get frustrated because of events, you get frustrated because of your beliefs." -Albert Ellis

48) "The academic disparity between young children in poverty and children from wealthier families is not a result of what their parents can offer. It is a result of the different types of learning experiences they are afforded at school.  In other words, it is not the “word gap” but the opportunity gap that is the problem."49) “Repeating aloud boosts verbal memory, especially when you do it while addressing another person”50) Why we sleep - including a great video.51) A friend that only shakes your hand is no friend at all. "The closer the person in social relationship, the larger the body area this person is allowed to touch."  Hug it out.52) 4 Relaxation Techniques for Decreasing Anxiety

1) Autogenic Training

2) Progressive Relaxation

3) Applied Relaxation

4) Meditation

53) Great advice on walking on how to get more out of it54) “the U.S. is one of only two countries worldwide in which drug companies are allowed to advertise directly to consumers” #SolveHealthcare55) Sleep deprived or darkness deprived?  "Electric light can delay or shut down nighttime physiology, whereas light from a wood fire or flame cannot."

Best of Twitter

• Seth Oberst‏ @SethOberstDPT- when you base your livelihood on definitions, your perspective narrows a bit #getprefrontal
• Nick Winkelman ‏@NickWinkelman - The benefit of teaching w/ analogy/metaphor... "Storytelling reveals meaning without committing the error of defining it." --Hannah Arendt
• Jenn Reiner‏ @drjreiner - Great clinicians have an exceptional command of biomechanics, but can also appreciate the unpredictability of the nervous system. 
• Aaron Swanson‏ @ASwansonPT - Finding weakness is a prerequisite to finding strength

Best of Instagram

A video posted by Fluent Movement (@fluent.movement) on Oct 22, 2015 at 5:59am PDT

A video posted by Scott Fournier (@scottfournierpt) on Nov 5, 2015 at 8:55am PST

This simple single leg kneeling #treatment and #assessment is very #powerful. It provides a lot of #information but I use it primarily for assessing and/or treating hip/pelvic/trunk #stability. Try it yourself, are you able to maintain a level pelvis and upright trunk? #perfectstridept #physicaltherapy #rehab #ownyourmovement #balance #manhattan #nyc #movebetter

A photo posted by @vikashsharmadpt on Oct 12, 2015 at 7:00pm PDT

Gif of the Month

A video posted by Funny Fail Videos (@funnyfailvideos) on Nov 4, 2015 at 6:08pm PST

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

 [subscribe2]

October Hits (2015)

Clinical

• "Each time we introduce an assumption, we also introduce a new bias into the final solution" -Serge Gracovetsky

1) "Our neurological wiring has evolved into networks of patterned behavior designed to efficiently complete tasks mandated by the environment. Anatomy provides the frame to carry out these behaviors; the changes to structure are the tangible result of our habits. But once we open up some behavioral options for new habit formation, anatomical abnormalities don't seem quite so concrete and problematic."-Seth Oberst2) Here's the last category of the Coaching & Cueing series - Proprioceptive Cues3) Want another tool for decreasing muscle tone? Try shortening the muscle and use some reciprocal inhibition.

The Gait Guys want you to decrease hypertonic muscles by stretching the antagonist?  Interesting article on reciprocal inhibition and muscle spindles.

Erson wants you to try shortening the muscle for 30-60 seconds before you go aggressive.

4) 5 Thoracic Mobility Drills to Improve Overhead Movements5) Great advice from Erson on improving the effectiveness of your interventions “make sure the patient understands the indications and what the treatments do”.  I wish someone would have told me that when I first got out of PT school.  #Expectations6) Dan Pope "Bridges the Gap" with this must watch jump/plyometric progression series

Double Leg Jump Progression

Single Leg Jump Progressions

Advanced Double Leg Jumps

Advanced Single Leg Jumps

7) A new study shows that back pain is correlated with a positive thomas test.  Here’s a basic stretch and how to coach it correctly.  Sometimes coaching this stretch can reduce the positive thomas test.  Other times it requires more advanced techniques.8) Nothing good about prolonged static postures.  Get them to move.  If they can’t get out of the chair, advise them FIDGET.9) Do your patients have control of their long extensors?  The Gait Guys teach you how to test it.10) Pain alters motor control. "This is why you should probably mitigate threat; in doing so, reduce or abolish pain prior to performing ANY movement based treatment." Erson elaborates on the complexity of the mobility/stability debate.11) "Choice is control and in the presence or history of pain we begin lose choices. People in pain have their movement options reduced, losing variability in their task achievement until there may be only one way left to move. Restoring these choices and rebuilding an agile movement system can be done and the research emerging from the field of neuroscience is assistive in showing just how. Changing the brain’s perception of the movement system resides central to this pursuit."

Stress

Stress is one of the most important variables we have to manage everyday - for both ourselves and our patients.  Understanding stress is just as important as understanding biomechanics and pain science.  Sometimes the keystone variable is something to do with stress.  Being able to identify it and make recommendations can make or break the patient's recovery.12) Books

Polyvagal Theory is a great, complex read on the subject.  It goes over the evolutionary physiology of how we react to stress and why.  It gets quite redundant, but overall is worth the time investment.

Nerve is a much easier, enjoyable read that deals with the neuroscience and psychology of fear, stress, and anxiety.  It's filled with useful anecdotes and gives some solid general advice that you can share with your patients.

Why Zebras Don't Get Ulcers has been recommended by many as well.  I haven't read it yet, but it's on my list.

13) It's important to understand that stress is stress.  It's cumulative and it all matters.14) Then it's important to have a couple different recommendations to help alleviate this stress that is within your scope of practice.15) This is a must read - a new study shows that students are more likely to get injured during periods of high academic stress.  Just being able to paraphrase this study to your patients should help them understand their pain better and decrease the threat.16) Psychoneuroimmunology for Physiotherapists - Stress decreases tissue healing.17) Think about your commuter patients - “Physical activity can mitigate commuting-related stress if workers can include it in their daily routines, but the obvious constraint is time scarcity. Longer commutes mean less time for other activities, which leads to lower life satisfaction.”18) I love living in NYC.  I feed off the buzz and the stimulus drives me further.  But after a couple years of living in the concrete jungle it can start to break you down.  One solution to the high stress environment is practicing meditation.  I took a UCLA course, did some studying, and came to this conclusion for both myself and my patients.19) Living in NYC makes me appreciate getting outside the city much more.  Getting outside into nature isn't just refreshing, but it's healing.  This might be why half of NYC has weekend homes outside of the grind.

Six all-natural (yet scientific) strategies for improving your mind and body.

"This study revealed that forest environments are advantageous with respect to acute emotions, especially among those experiencing chronic stress. Accordingly, shinrin-yoku may be employed as a stress reduction method, and forest environments can be viewed as therapeutic landscapes. Therefore, customary shinrin-yoku may help to decrease the risk of psychosocial stress-related diseases, and evaluation of the long-term effects of shinrin-yoku is warranted."

20) You should subscribe to Psychology Today's email list.  They provide a tone of great articles.  We're not psychotherapist, but we build relationships from the premise of trying to help people get better.  Sometimes this leads to our patients opening up to us and telling us some serious things.  It can help to identify certain patterns and recommend some basic stress reduction techniques, but it's more important to recognize when someone needs some help and to have someone to refer them out to.https://www.youtube.com/watch?v=v-t1Z5-oPtU

Exercise of the Month

This is my go to lateral stability exercise.  Most people perform it too fast and need specific cues for pivoting from the outside of the bottom knee.https://www.youtube.com/watch?v=lG1BjEplYsQ 

Pain & Neuroscience

21) "For true healing to take place, you need to learn how to move out of the intellectual realm and into an experiential one. For instance, if you were hurt and afraid in your past, then you need to be guided to refind feelings of safety and security on an experiential and body level." -Dovid Meshchaninov, MS22) Great write up on pain and diet/microbiome from Andrew Rothschild - "an imbalance between bacteria in our guts can interact with our immune system causing the release of inflammatory chemicals and stress hormones, kicking off our body’s natural stress response, even when we are not truly in a stressful situation."23) Great read on Chunking

“Consciousness and chunking allow us to turn the dull sludge of independent episodes in our lives into a shimmering, dense web, interlinked by all the myriad patterns we spot. It becomes a positive feedback loop, making the detection of new connections even easier, and creates a domain ripe for understanding how things actually work, of reaching that supremely powerful realm of discerning the mechanism of things. At the same time, our memory system becomes far more efficient, effective — and intelligent — than it could ever be without such refined methods to extract useful structure from raw data.”

24) "it's the lack of "other things to do" or be aware of that really flares up the pain at night" -Erson with a great post on a question that patients often ask us25) "Sleep deprivation is associated with disturbance in descending pain inhibitory control mechanisms and results in increased pain sensitivity." Great read on pain and sleep from Rayner & Smale26) "providing contrasting information is a known and effective way to promote optimal learning" It's also best to use 2 examples with this approach. #Education27) Many of the best clinicians have struggled with their own injury. "This finding suggests that pain empathy is grounded in neural responses and neurotransmitter activity related to first-hand pain."28) “The part of the brain that is responsible for seeing, for the apparently ‘simple’ act of generating the picture in our mind’s eye, turns out to have the ability to do something akin to choosing, as it actively switches between different interpretations of the visual input without any help from traditional ‘higher level’ areas of the brain.”29) “Our study hypothesis was supported.  Individuals with more alpha asymmetry (reflecting greater left than right sided frontal alpha; that is, a relative suppression of left frontal activity) reported more subsequent catastrophizing”30) "Researchers have demonstrated that the music we prefer has greater positive effects on pain tolerance and perception, reduces anxiety and increases feelings of control over pain. In older people with dementia, listening to preferred music has been linked with decreasing agitated behaviour."31) "In adults, it has been well-documented that stress promotes habits and reduces cognitive flexibility"32) This is a big part of why my bosses are so successful in treating patients - "The results show that pain thresholds are significantly higher after laughter than in the control condition. This pain-tolerance effect is due to laughter itself and not simply due to a change in positive affect. We suggest that laughter, through an endorphin-mediated opiate effect, may play a crucial role in social bonding."

Training

33) You should share this with your patients in a newsletter or print it out for the waiting room.  3 Signs that your relationship with exercise is unhealthy:

Cancel social plans to exercise

Exercise to make up for your diet

Continue to exercise despite fatigue, illnesses, and/or injuries

34) Interesting read on using mindfulness for performance.35) Here are some nice tips on coaching and cueing from Eric Cressey. For a more detailed overview on coaching and cueing, check out my new series that simplifies cues into easy to understand categories.36) 6 things you should focus on with your baseball players (attributes of elite hitters)37) Always good coaching cues from Eric Cressy38) "In many ways, fitness should be viewed as a long-term concept, much like saving for retirement." -Dean Somerset39) You should do some cardio40) Reverse engineer to meet your goals. Use the the SMART method (Specific, Measurable, Attainable, Realistic, Time-Bound).41) Some must read advice from Eric Cressey

Instagram

A video posted by C. Shante Cofield DPT OCS CSCS (@themvmtmaestro) on Sep 28, 2015 at 6:22pm PDT

A video posted by TPI (@mytpi) on Oct 11, 2015 at 3:53pm PDT

A video posted by HundredEighty (@180.degree) on Oct 12, 2015 at 5:32am PDT

A video posted by Gymnastics Strength Training (@awakengymnastics) on Sep 13, 2015 at 4:42pm PDT

A video posted by Aaron Swanson (@aswansonpt) on Oct 7, 2015 at 4:46am PDT

Research

42) Very interesting article on cranial biomechanics - “It is proposed that the cranium behaves somewhat as if constructed of cardboard, with the sutures acting as pre-folded lines or perforations.”43) “A careful analysis of EMG activity and kinematics during gait suggests that, in the transverse plane, the adductors may be eccentrically controlling internal rotation of the femur at the hip during the loading response, rather than the previously reported role as concentric internal rotators. In addition, these muscles may also concentrically produce external rotation of the femur at the hip during terminal stance and preswing.”44) “The consensus in the research is that the tendon gap will gradually fill in with tendon-like tissue and be nearly healed between 2 & 3 years.”45) Sleep and your cardiovascular system.  "Findings showed that adults who slept less than five hours a night had 50 percent more calcium in their coronary arteries than those who slept seven hours. Those who slept nine hours or more a night had even worse outcomes, with 70 percent more coronary calcium compared to those who slept seven hours."46) Pelvis thorax counter rotation. "This is because during bipedal walking in humans, the ribcage and arms rotate in one direction, while the legs and pelvis move in the opposite direction. You can see this as your arms and legs move in opposite directions when you walk. These opposite rotations are beneficial because they help to conserve a physical quantity called ‘angular momentum’. The angular momentum of the upper body cancels out the angular momentum of the lower body. In humans, this helps to reduce work, and saves energy during locomotion."47) Mindfulness improves performance and skill acquisition.48) ACLs that were reconstructed with allografts had three times higher failure rates than autograft reconstruction49) Fascinating read on how the jaw/mouth can profoundly influence the rest of the body.  “In fact, unilateral anesthesia of the trigeminous causes a shift in body weight onto the contralateral limb, which leads the homolateral inferior limb to contract.”  Probably one of the best articles I’ve read in a while.50) The moment I got on one of these I knew it had some value.  It requires good frontal plane control, single leg stability, focus and attention, and allows for full kinetic chain integration.  It was only a matter of time - Slackline was shown to improve postural control in this study.51) “It was shown that young adult men with cam-type FAI presented with excessively inverted hindfoot at heel strike with a reduction in the overall maximum eversion during stance phase.”52) “Tendon-related issues seem to have increased inflammation, while torn tendons have significantly lower inflammation than tendon-related conditions in intact tendons.”53) “A single resistance training bout of isometric contractions reduced tendon pain immediately for at least 45 min postintervention and increased MVIC. The reduction in pain was paralleled by a reduction in cortical inhibition, providing insight into potential mechanisms.”54) The importance of the mouth - “These findings suggest that it is advisable to use a customized bite-aligning mouthpiece to improve strength and power performance.”55) Cellular Mechanotransduction - “The presence of isometric tension (prestress) at all levels of these multiscale networks ensures that various molecular scale mechanochemical transduction mechanisms proceed simultaneously and produce a concerted response. Future research in this area will therefore require analysis, understanding, and modeling of tensionally integrated (tensegrity) systems of mechanochemical control.”

Twitter

• Tom Myers‏@myers_info - #FRC4 Proprioception and Myofascial pain are like oil and water. The more Proprioception the less pain and ice versa. Langevin via Schleip
• Christopher Johnson‏@chrisjohnsonPT - Rules of Running Injury Management: 5 will give you 20...5% increase in step rate will reduce energy absorption by 20% at the knee. #running
• Michael J Mullin‏@mjmatc - With reaching activities w/breathwork, don't reach faster or further than the airflow allows. The air & diaphragm mvmt will "reach" for you
• Aaron Swanson‏@ASwansonPT - Developing Motor Control: I sometimes forget that adding load is a great way to reinforce the pattern. #NotJust10000Reps

Other Good Stuff

• "Time is a created thing. To say 'I don't have time,' is like saying, 'I don't want to.” ― Lao Tzu

56) If somebody is unsure about a decision, their pupils dilate

“We think of persuasive people as good talkers, but maybe they’re also observing the decision-making process,” he says. “Maybe good salespeople can spot the exact moment you’re wavering towards a certain choice, and then offer you a discount or change their pitch.” #Communication

57) Before you give advice (#Communication):

1. Listen for emotional undertone

2. Name the core emotion

3. Relate to the emotion to show understanding (mirroring, vulnerability, validation)

4. Withhold Judgement

5. Offer Advice Last 

58) "So empathy is distinct from expressions of sympathy — such as pity or feeling sorry for somebody — because these do not involve trying to understand the other person’s emotions or point of view." Listen, practice loving kindness meditation, read fiction, and get a dog to increase your empathy.59) True experts are able to say they don't know something. "Accepted knowledge can get in the way of healthy ignorance" -David Butler on the importance of ignorance60) Diet and Depression #Variables61) A nice quick review of the vagus nerve and 9 things it's good for62) 9 great tips on how to read emotions and influence people. #psychology63) Control your emotions by labeling them - "affect labeling seems to pull us out of an emotional quagmire by engaging our executive brain."64) "the previous week’s effort influenced this week’s passion, such that more effort led to more passion."65) "Touching is incredibly powerful. We just don’t give it enough credit. It makes you more persuasive, increases team performance, improves your flirting… heck, it even boosts math skills."66) ““Never Make ‘Em Feel Stupid.” – The Cardinal Law of Persuasion” #Communication

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 6 - Proprioceptive Cues)

This is a very common intervention in movement coaching (whether the practitioner knows it or not).  Simply changing an exercise to achieve the same goal is essentially a proprioceptive cue.  Changing from a clamshell to a fire-hydrant can be a proprioceptive cue by altering the ascending sensory information during an isolated transverse plane glute strengthening exercise.There are plenty of resources out there on this aspect of coaching, so I’ll keep this section of the post brief.As mentioned in the previous posts, the top-down cortical aspect of movement will have profound effects on body awareness and thus proprioception.  Since these topics were already discussed, this post will focus on the novel “bottom-up” proprioceptive sensory changes.The concept of proprioceptive cueing can be summed up on one sentence:

• Sometimes the best cue is to shut your mouth and change the physical environment.

Proprioceptive cues come down to the simple concept that changing the body’s input will lead to a change in movement output.  It’s common sense.  The better the information, the better the resulting decisions.Here are some (of many) easy ways to create a proprioceptive sensory change through the environment.

Motor Chunking

Motor chunking is when a movement is broken down into segmental pieces and slowly put together as a whole.  Motor chunking “is thought to be necessary for overcoming the limited number of items humans can consciously hold at any given time within working memory”.  While this could easily be apart of the internal cues section, I’m going to include it in this post because it can allow for easier proprioceptive processing and the assimilation of complex movements.In movement coaching, it is common to see someone have a difficult time with a certain exercise.  However, it’s not a problem from a tissue load capacity perspective, it’s a problem from a cognitive perspective.  Some people just can’t put all the proprioceptive pieces together to complete the whole movement.  This is where “chunking” the movement into smaller proprioceptive pieces can allow for the individual to understand the whole movement better.Instead of giving 8 steps or attempting various different cues, it might be best to break down the movement into smaller proprioceptive chunks.  It can become pretty formulaic:

• Master Chunk #1
• Master Chunk #2
• Master Assimilation of Chunk #1 + Chunk #2 = Chunk A
• Master Chunk #3
• Master Assimilation of Chunk A + Chunk #3 = Chunk B

For example, coaching the reachback requires proper thoracic centration with eccentric upper extremity control (Chunk B).  First you need to coach them to fully exhale (Chunk #1).  Then coach them to exhale and keep their ribs down with their obliques (Chunk #2).  Then have them practice both those movement together (becomes Chunk A).  Once they have this, you work on the eccentric reach back part of the movement (Chunk #3).  Then you put it all together for a nice clean, compensation-free reachback (Chunk A + Chunk #3 = Chunk B).How many chunks you need and how much time it takes depends on the patient.  Athletes can usually handle larger chunks over shorter amounts of time, where as my sedentary patients require more attention focus on the basics and more time to master the movement.

SFMA/TPI 4x4 Matrix

 This is a very user friendly system that provides a step by step approach to progress (or regress) movement to achieve the desired output.  It uses the developmental progression with a graded exposure to load, gravity, and degrees of freedom.  This is great for everyone from your chronic pain patient to your elite athlete (who often have holes in regressed postures).To keep with the theme of this series, here's a deadlift proprioceptive cue example.  If some has difficulty keeping their ankles in neutral and preventing anterior translation of the tibia requires a lot of real estate in the brain, then there’s no way the patient will be able to focus on their hips/low back dissociation.  So you can alter the proprioceptive input by regressing the posture and putting the person on their knees.  This alters the sensory input and allows for more brain real estate to focus on the proprioceptive input from the hips/low back instead of having to deal with all the input from below the knee.  Or in SFMA terms, this takes it from 4/4 to 3/4.

Taping / Tactile Cuing

Simply providing more sensory information to a specific area via tape or tactile cueing can improve the cortex’s ability to process it.  It’s like adding cutaneous mechanoreceptors to an area that may have a “smudged” homunculus.

A photo posted by Aaron Swanson (@aswansonpt) on Oct 1, 2015 at 1:17pm PDT

If you don’t have tape you can simply use your hands.  For example, lightly touching someone’s spine during a quadruped exercise can help increase their sensation to that specific area, thus potentially improving the motor control.

Foot-Environment Interface

The feet have quite a lot of mechanoreceptors.  They take up a lot of space in the homonculus.  Thus, they provide a lot of information regarding proprioception and set the stage for the rest of the body.  Changing shoes, orthotics, and/or ground surface can have a huge impact on proprioception.However, footwear is a very complex topic and requires in depth understanding to  properly prescribe foot surface interfaces.  The wrong advice could have serious consequences on movement mechanics.  For more information regarding foot mechanics check out the Gait Guys website and biomechanics course.

Resistance

Load

It’s common sense to lighten the resistance if someone can’t perform a movement without compensatory motion.  However, I’ve also found it helpful to add resistance when patients are having a difficult time “feeling” the movement.  Loading up the body will add compressive forces to stimulate the joint mechanoreceptors (approximation=stabilization), increase the magnitude of the muscle contraction, and apply greater tension to fascial structures.  Plus, it can reduce the variables in an exercise.  Kettlebell enthusiasts have been coaching people to go heavier with their swings for this exact reason.  A heavier weight promotes the proper muscle activation patterns and to removes the option of lifting the bell with their arms.However, it doesn't just have to be a modulation in weight.  It can also be intensity.  Using high intensity local exercises to increase the proprioceptive input for a specific area.  For example, if someone can’t feel their hamstrings during a single leg deadlift then I will have them perform a prone hamstring physioball squeeze.  Then return them to the previous exercise.  It’s pretty much just using the post-activation potentiation concept for lower level exercises.   

Type

Altering the type of resistance can provide a profound sensory change.  Going from dumbbells to kettlebells, cable to elastic bands, or kettlebell to barbell provides a significant proprioceptive change.  The type of resistance is limited by your imagination (medicine balls, body weight postures, chains, indian clubs, tires, trail running, boulders, significant others, pets, etc.) .  Just look at people who exercise outdoors to see an example of this creativity. 

Reactive Neuromuscular Training (RNT)

• "The main objective of the RNT program is to facilitate the unconscious process of interpreting and integrating the peripheral sensations received by the central nervous system (CNS) into appropriate motor responses" -John Guido, Jr

 https://www.youtube.com/watch?v=KMe8YpYvoW8RNT is a great way to use resistance to correct aberrant movement patterns.  You don't have to set up any targets, educate the patient on the movement correction, or give specific directions.  You simply pull the patient into their compensation and watch their system react to this perturbation by over correcting the faulty movement.In RNT the example above, the resistance is pulling the patient lateral over their base of support (trendelenberg moment).  To prevent falling over, the patient will have to fire their frontal plane muscles to prevent from falling over.  This is obviously useful for patients that don't have frontal plane stability and have difficulty with contralateral hip drop.The RNT example below is great for patients who try to perform the single leg deadlift with an upright trunk (squatting the hinge).  Holding the bands will pull the trunk upright.  To counteract this movement, the patient will have to flex their trunk down to counteract the band's resistance.

A video posted by Aaron Swanson (@aswansonpt) on Oct 7, 2015 at 4:46am PDT

Summary

Proprioceptive changes are  an easy way to troubleshoot an aberrant movement pattern.  The options are many and the results are profound.  But keep in mind that improving movement is rarely a linear process.  There are a ton of variables when it comes to movement.  And these variables interact with one another to create an infinite amount of movement situations.  Thus, due to the dynamic systems involved with movement, you cannot perfectly predict the exact movement output that will result from new input, but changing the proprioceptive environment is one variable that often has a positive impact.  Assess, cue, re-assess.

Giving Credit

My understanding of proprioceptive cues, environmental influence, and the nervous system bias of movement was heavily influenced by Gray Cook and SFMA/FMS System.  Studying his work opened my mind to a new way of changing movement patterns and provided an important foundation for my continued education.

References in Previous Articles

Coaching & Cueing

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