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Six Words Or Less: Powerful Questions For The Clinician and Coach

Filed under: Coaching,physical therapy,Uncategorized — Shon @ 6:50 pm July 27, 2012

Up until recently, I never gave significant thought to the kinds of questions I was casually asking my patients and athletes on a daily basis.  Stream of consciousness pretty much rules the day when I am working with my people, and my communication style remains conversational, open, positive, and free flowing.  My only steadfast rule in casual patient/ client communication is my "Five Minute Rule", where I make it a point to speak with and briefly engage my patients and my other therapists' patients every (you guessed it!) five minutes.  This is a powerful tool, as a simply, perfectly timed  contact keeps your people engaged and focused.

Recently though, I happened to hear myself ask a few key questions repeatedly to a number of patients over the course of the day.  Maybe it was the fact that I had more new evaluations than normal and had to ensure that I nailed down instructions for their home program, or perhaps it was because of the pain that they were dealing with with from some pretty aggressive fascial manipulation work that I have been doing recently. Whatever the case, I thought a bit more about what key questions I ask the people I work with and why I ask them.  

 

Ask appropriate questions, not riddles

 

Brevity is key; six words or less generally is sufficient to get my point across.  Below are my "go to" questions on a daily basis:

 

1)  "Does This Make Sense to You?"

If what you are doing or asking doesn't make sense on some level to a patient or client, they will tune you out very quickly.  Or they won't be back.  And they won't get better.  This negative cascade can be halted pretty easily with the above statement.  Delivered with good eye contact, a light contact to a non-threatening area (dorsal forearm) and undivided attention, this is key in developing early trust, whether you are performing manual therapy, teaching a new movement pattern, or dishing out a helping of metabolic conditioning.

"Do you understand?" also can suffice.  Motivational speaker and business coach Bob Proctor once stated "you do not understand something until you can explain it to someone else, so that they too can understand it." If your people understand your intervention, they should either be able to articulate it or demonstrate it.    

2)  "Are You Sure?"

Following up "Does this make sense to you?" with "Are you sure?" gives the person a parachute.  If they didn't want to hurt your feelings or just felt stupid saying "no" to the above question, you now have allowed them another option.  The patient, client or athlete can now ask for further clarification without feeling like an imbecile.  One caveat:  Don't over-utilize this question, as repeated use makes a person feel that you as an authority don't believe them.  Once and done is good here before moving on.

3)  "Are You O.K.?"

Followed by "with this/ that" ("this/that" being generic for exercise, manual therapy technique, or intervention of your choice) lets your people know you are in tune with their immediate need.  I use this in conjunction with the "Five Minute Rule" for great effect.  Again, sincerity is key, because almost everyone has a sixth sense that acts as a B.S. detector developed after too many years spent in post office lines, high school classrooms, and grocery store check out lanes.  If you don't mean what you are asking, don't ask it in the first place, because invariably, not everyone will always be "O.K." and will need a little bit more of you.

4) "Do You Have Any Questions?"

Always encourage questions.  There should be no such thing as a dumb question in your eyes-and even if you perceive it is, don't let your patient or client think it is.  Clinicians often feel threatened by questions, as they challenge their position as an expert.  Therapists and physicians are especially sensitive to being questioned.  Get over it-people have legitimate concerns that can be allayed with questions.  Use this question very frequently, especially early on.  Not "Any questions?" which is more of a statement and can be perceived as a brush off, but "Do you have any questions?" which engages the individual person more.  Your people should always have questions, especially the more you work with them.  Good questions serve to help you grow as a professional, keep your ego in check, and force you to stay current with knowledge. 

5) "What Are Your Expectations?"

The question that should be asked during the initial meeting. This allows your people to articulate why they are using you and your services.  It gives you  a working platform, and sets up a two way street between you and your client-they know you are in tune to their needs and wants, and allows you to hone in on strategies and tools to allow them to succeed.  If you don't ask this question, then you don't have a clear path toward an outcome as outlined by the person who hired you in the first place.     

 *6) "Thanks!" 

*Not a question, but a statement of sincerity.  Your client chose you-you didn't chose them.  They may not know about your expertise, or that you are good, better or the best; they may not really care either.  They just have a need that you can hopefully help them with.  Let them know that you appreciate the chance to help them,and let them know often. "No, thank you!" is now a permanent part of my vocabulary  This can't be used too much of course. 

 



Anatomy Trains and Acupuncture Channels

Filed under: Anatomy,Continuing Education,physical therapy — Shon @ 12:21 pm June 22, 2012

Yesterday I had the pleasure of spending the afternoon with Neil Mathews, M.D., an excellent general practitioner who is an out of the box thinker with regard to traditional Western Medicine.  He has a burgeoning acupuncture practice and came to visit the clinic to talk shop as well as demonstrate a few acupuncture techniques.

Before we got started, I spent some time taking Neil through the clinic, including sharing with him my copy of Anatomy Trains, which he had never seen before (Anatomy Trains sits on a shelf in my exam room right next to Campbell's Operative Orthopedics, Kendall's Muscles Testing and Function, and Sahrmann's Diagnosis and Treatment of Movement Impairment Syndromes).

As we were leafing through the text, I was pointing out and describing the Superficial Back Line (SBL) when Neil had an "A-Ha" moment.  He ran to his car and grabbed his copy of the Color Atlas of Acupuncture by Hecker et al. and pointed out that the SBL was almost identical to acupuncture's Bladder Channel.

 

 A rough outline of the superficial back line

 

 

 

 

 A diagram of The Bladder Channel

 

As we continued to go through both texts, there were other strong similarities between myofascial meridians/ lines and acupuncture channels.  These included:

1)  The Deep Front Arm Line and the Lung Channel

2)  The Deep Back Arm Line and the Small Intestine Channel

3) The Lateral Line and the Gall Bladder Channel (illustrated below):

 

 

 

The Lateral Line

 

 

 

The Gall Bladder Channel

 

So What?

I think correlations like those above make life worth living in the clinical world, especially in evolving disciplines.  Yes, acupuncture has been around a very long time, but with increasing acceptance into Western medicine, several questions remain regarding precise mechanism of action, as well as long term outcomes.  Anatomy Trains as a concept was developed as a game of sorts by Tom Myers as a teaching aid at the Rolf Institute less than 20 years ago, and fascial research is just coming out of it's infancy (this link from Tom's KMI website actually touches on the association between myofascial meridians and acupuncture channels).  Many clinicians (including myself) are undereducated and ignorant to the deeper facts about acupuncture.  Up until yesterday, I could have had a reasonable cocktail conversation about acupuncture but not much else. 

The same goes with Neil; he never heard of Anatomy Trains prior to our meet-up.  He stated however that one of the physicians who taught in the acupuncture curriculum at Harvard said fascia was an important and integral part of the discussion in mechanism of treatment.  He ended up leaving left with my copy of Anatomy Trains, swapping with me the Color Atlas of Acupuncture.  The fact that we know our clinical worlds correlate more than casually will provide both of us with subjects for further research moving forward.

 

More Questions

I learned a lot hanging out with Neil, and our meeting also left me with many additional questions; I'll list just a few here:

1)  Can we combine acupuncture and exercise at the same time?  An example would be if we are treating for neck pain (generic, I know), can we activate middle and lower trapezius while dry needling is going on along other channels?

2)  Would soft tissue therapy performed immediately before or after needling expedite the desired outcome?

3)  Does dry needling/acupuncture allow synergistic effects of herbal/vitamin/medical therapies? 

I am looking forward to pursuing the answers to these questions clinically, as well as gaining a deeper understanding of acupuncture and how it fits in with what we do, both from a rehabilitation and performance standpoint.

 

 



Two Awesome Continuing Education Opportunities

Filed under: Continuing Education — Shon @ 12:32 pm April 18, 2012

As I enter my twenty fourth year of professional practice, continuing education has lost some of the shine it used to have for me.  While it used to be fun to travel all over for weekend seminars and short courses, family and business commitments have taken the forefront of my life (my son turns 13 this summer, and my daughter will be driving in less than year and a half!).  I am definitely stingier with my time now, and while, yes, attending CE courses are still important for my professional growth and networking, the fact is I have" been there, done that, and bought the t-shirt" over the past 23 years and 1,000+ hours of in-person, hands on lecture/lab/workshop participation.

 

I've felt like this at far too many CE seminars

 

That said, there are still a ton of fabulous seminars and speakers I want to see (the Postural Restoration Institute, Prague School, as well as RKC are on my wish list of topics for further research) while the internet brings us the ability to digest great information and content (strengthcoach .com, sportsrehabexpert.com, and Mike Reinold's dynamite continuing education series to name a few). 

Today I want to mention two resources, one "in person' and one on-line that I will be diving into this summer.

 

BSMPG 2012 Summer Seminar 

 

The awesome BSMPG 2012 Summer Seminar is back in Boston on May 19 and 20 that Art Horne (athletic trainer and strength and conditioning coach for Northeastern Basketball) has put on for the past several years.  I attended for the first time last summer and as I blogged about HERE and HERE, I couldn't have been more pleased.  Every talk I attended was excellent at minimum, and I easily learned a years worth of information in 2 days.  Speakers were approachable and attendees were very laid back and fun.

 

This year's speakers include Dr. Craig Liebenson, Dr. Christopher Powers, Boo Schexnayder, Sean Skahan, and the always popular Cal Dietz.  I didn't think Art could top last year, but it seems he did.  Again, there are multiple tracts (hockey and basketball strength and conditioning, sports medicine, as well as extended workshops in addition to keynote speakers) to appeal to a broad range of professionals.  Attendees also include previous speakers such as Charlie Weingroff, who still has my head reeling from his talk last year (this year I am looking forward to meeting and interacting with Patrick Ward, who always has a ton of great information to share).

If you are involved in any facet of health, human performance, manual therapy, rehabilitation or a combination thereof, it would behoove you to make a serious effort to attend.  Kudos to Art Horne for making this happen year after year, while raising the bar each time!  Registration information can be found HERE.

 

Bret Contreras and Chris Beardsley's Strength and Conditioning Research

What Bret and Chris Beardsley have produced is a fabulous "one stop shop" for all things as they relate to current strength and conditioning research.  Many of us are in a situation where we receive multiple journals form various professional organizations that pile up month after month without a glance.  We then end up suffering from "option paralysis" and just give up on reading anything, which hurts us as a professional and a practitioner.

With Strength and Conditioning research, the tedious work of mining and discerning excellent peer reviewed research  has been done by Bret and Chris on a monthly basis, leaving us with a tight and thorough summary of each study as well as practical applications.  Each month encapsulates fifty studies in four categories: strength and conditioning, biomechanics, physiology and physical therapy.  Other studies that weren't reviewed but deemed important are in a separate on-line catalog for monthly members.

This month, some cool studies included the effects of kettlebell training vs. weightlifting in jumping, strength and body composition, relationships between strength, sprints and change of direction, ACL strain and jump landing, and inflammatory markers following massage therapy.  There were forty six other studies as well, all easy to digest and understand.  Minimally, 60% were pertinent to my daily practice, and that was just after glancing at the table of contents.

I have been after a resource like this for over ten years, and am really grateful that this one now exists.  At $10 a month, it is a no-brainer, and it has already exposed me to over 100 papers that I probably would not have looked at if they didn't show up in my in box seamlessly every 4 or so weeks.  I highly recommend this to anyone who is a strength coach, personal trainer, physical therapist (or PT student), athletic trainer or a combination of all of the above.  To sign up, click HERE (please note, I am not an affiliate, only a fan). 

 



Advanced Core Stability: One Arm RKC Plank

I love the RKC plank ever since learning about it several months ago from my friend Bret Contreras. It's simple to teach, difficult to perform and satisfying in the feel of whole body muscular activation you get with it.  It's one of the only "floor" exercises that gives you the sensation of intense whole body contraction similar to gymnastics open chan movements such as the planche.  As opposed to a regular plank, where whole body tension is often times not very significant and can be held for prolonged periods, an RKC plank relies on developing large amounts of whole body tension and susequent  neuromuscular "irridation", where the whole muscular system becomes a tightly wound spring.

 

 

Credit obvilously goes to Pavel Tatsouline for the genesis of this exercise, which takes a traditional plank and adds "muscle" to it via increased lattissimus, quadriceps, and gluteal contraction.  By doing this, the abdominals are forced to contract more intensly than in a standard plank, with the net effect of increased dynamic stiffness and "pillar stability" around the lumbar spine.  I believe the magic in a properly performed RKC plank is in it's "anti lumbar extension function"- where the force couple of the quadriceps, abdominals and gluteals, along with added isometric tensioning of the latissimus/thoracolumbar fascia really lock down the lumbar spine in an appropriate fashion.  Creating dynamic stiffness and strength in this position transfers nicely to activities on two feet in strength or regular sport.

As I was progressing myself as well as my clients and teams through this exercise, I thought of how I could make a hard exercise even harder.  Not just for the sake of making it harder arbitrarily, but to add another musculoskeletal and performance challenge to the activity; in this case to resist lumbopelvic and trunk rotation.

 

Enter The One Arm RKC Plank

The One Arm RKC plank is a great progression for an already tough exercise.  By removing the support of an arm, you now require your stabilizing musculature of the trunk (internal/external obliques, quadratus lumborum) to work extremely hard to resist falling into rotation.  The natural inclination is to elevate the pelvis to counter the trunk rotation; this is what we are trying to avoid.

Additionally, you will notice a significant overflow of muscular activity of your triceps, as your forearm and fist is the only upper extremity contact with the ground at this point.  In addition, the latissimus fires extremely hard, leading to "tenting" of the thoracolumbar fascia, which further lends to additional lumbar stabilization.

You will find that the quadriceps, gluteals and abdoninals contract even harder than in a traditional RKC plank as a result of the induced instability. This is involuntarily if performed correctly, and another example of "self limiting" exercise. 

 

Setting Up

The one arm RKC plank is performed by first setting up into a traditional two arm plank, then contracting the quadriceps as well as the glutes (into posterior pelvic tilt), which leads to increased abdominal contraction.  When these muscles are set, then "pull" your elbows to your feet isometrically while at the same time isometrically "pull" your toes (your foot contact in the plank position) toward your elbows.  What you will feel is a boatload of whole body tension that we will use to our advantage soon.

Now, while continuing to hold the tension, slowly and deliberately remove one of your forearms from the floor placing your hand palm up in the "small" of your back.This requires an even further intense contraction of the support arm, and can be facilitated by pushing your support elbow and fist into the floor. Intent is everything here-push hard! 

At the same time, you will feel gravity trying to pull your pelvis down on the unsupported side.  This is normal and expected.  To counter this, focus on bracing  your quadriceps and gluteals even tighter on the unsupported side, as well as focusing on keeping a neutral spine position and not allowing your hips to "pike".  At this point, the intensity of whole body muscular contraction increases even further as you fight to keep your trunk and hips parallel to the ground.  This is the crux of the exercise:  Whole body tension from the supporting forearm through the toes, while working hard to keep your pelvis and trunk level.

The video below outlines what you should be striving for in the performance of this exercise:

 

 

 Here is an alternate view of the transverse plane from "top down", again avoiding pelvic and /or trunk hiking:

 

 

Program Placement, Sets and Time

This exercise can be flexible in terms of program placement.  It fits nicely in a warm up/ movement prep, between sets of your main exercises, or at the end of a session.  I have utilized it as a facilatory activity with sprinting and plyometrics, sandwiching a set or two between repetitions as a "potentiation" primer. 

In terms of sets, 4 to 8 sets, lasting from 6-15 seconds/set is a good place to start.  Obviously, you will do an equal number of repetitions on each side, although you will more than likely have a more dominant side with better perfoormance, so adjust set times accordingly.  At least 1-2 minutes rest between repetitions should be taken; more rest may be needed if technical performance suffers.  Of course, technical failure is the end point for this exercise; learning to judge this is important as well. 

 



Sucessful Group Coaching: Squat Edition

Many of you know that  I recently started as the strength coach for a pretty good football team here in Pennsylvania.  The group is fantastic; they show up consistently, do what is asked by me, ask really good  questions, and make great progress every week.   

Last week during training, I had one of those moments, where I noticed over 90% of the athletes doing things correctly, several of whom I've never even spent face to face time with. With a group that fluctuates between 45 and 60 per day (depending on their winter/spring sports schedules) in a smaller than average facility (where we perform power cleans in the hallway), you just cannot train every athlete individually.  The athletes train in groups of four, which rotates every 6-8 weeks.  Upperclassmen are grouped with underclassmen, as well as novices with advanced. This is the major difference between being a strength coach and a personal trainer-a true strength coach has to be extremely resourceful in handling a large group of athletes often in environments that are less than optimal.

One of the bigger challenges with regard to this is achieving technical excellence throughout the group in our most important lifts. Since beginning over six weeks ago, I have been hammering home the message of proper technique first, then loading the barbell appropriately, as long as proper technique is maintained.  The squat is the keystone lift that can show just about any bystander if your kids are indeed doing things correctly.  If you squat well, obviously you have great hip mobility and strength, a stable and powerful torso, and the  ability to make great gains in overall muscle size and strength.  I think watching your athletes squat shows both you and the outside world two things.

1)  You have a reasonable grasp of how to coach movement correctly.

2)  Your athletes actually listen to you and buy into what you are saying.

 

A good squat is like a good golf swing– the movement remains consistent over time, with the "number on the iron" the only variable  for both

 

What I saw during one of our sessions last week really cemented the point that my kids had bought into what I had been preaching.  I saw a 90% compliance rate with proper squatting technique among all the athletes there that Friday.  Proper bar position, elbows "up", a tight arch/lordships and awesome depth across the board.  Many of these athletes I had never coached "one on one"; again with such large numbers, it just isn't always going to happen.  However, what they did do was:

1)  Listen to me with full attention when I did group instruction on the finer points of squatting.

2)  Model technique from other athletes who had squatted correctly within their groups.

3)  Take feedback from others in their group.

4)  Give feedback to others-even if they are a much stronger and larger upperclassman.

3)  Continue to strive for technical excellence throughout.

I was really blown away-my goal for these kids was 90% compliance by the end of April, and we had achieved it at the end of February!  Overall, I give the group a grade of A- at this point on this lift. 

 

Below are two of my athletes who did a really nice job squatting-one a beginner, and one a bit more advanced:

Example 1:  A High School Freshman New to Squatting 

This athlete never squatted before we began training in late January.  He weighs about 140 lb.  Here is is using 225 lb. for a double:

 

Yes, it's not the most weight in the world, but keep in mind he hasn't really done this before January.   Everything is being done correctly-elbows up, tight arch, knees out and great depth.  You can't ask for more-a kid who attends regularly, pays attention to detail and gets it done.  The crazy thing here is that I had never spent direct time with this athlete before I filmed this!  He listened to my instructions to the whole group as well as my cues to other athletes, worked hard with the athletes in his group (spotting, cueing, and lifting while receiving feedback from his group), as well as observing others doing it right.  My job just got  much easier as a result! 

As I said before, most of of our kids are now squatting with good mechanics, so modeling of appropriate technique is easy-just look to the racks on your left and right and you will more than likely see someone else doing things right.

 

Example 2:  A Sophomore With Some Prior  "Under the Bar" Experience

Here is a sophomore athlete who had squatted before, and as you can see has some pretty good potential for moving some serious weight.  I did spend time with him coaching trunk stability, as this was not great a few weeks ago, as well as his ability to "sit back".  Here is the result: 

 

 

Great depth, good arch maintenance and a nice "pop" at the top. Again, this type of form and power comes from listening to instruction, buying into philosophy (good form vs. just more weight), taking feedback from his group, they applying effort.

There are obviously many more success stories in the Wood weight room, but I think you get the idea from what is seen here.   

Wrapping Up

Successful large group coaching comes down to a few key factors including listening, modeling, feedback and (obviously) hard work.  Once these are implemented, programming becomes that much easier to implement, gains are made, and coaches (as well as athletes) are happier.  The squat is an "acid test" lift where things just can't be faked; if your athletes can squat, then I bet everything else is probably just fine in your overall program as well as with your coaching.



“Micro Cases”: Random Patient Stories and Videos From The Clinic

Filed under: Case Studies,physical therapy,Random Thoughts — Shon @ 4:23 am March 5, 2012

As a physical therapist, the patients I see vary significantly in mobility, strength, and activity level.  This being the case, the challenges in treating them are all unique, based on their impairments (mobility, strength, and pain) as well as their functional level and activities they wish to return to.

Below are a few videos of recent patients (BTW, a sincere thank you to all of them for kindly allowing me to share their unique stories of their recovery here) in observation, assessment and treatment at the clinic:

 

   

Video One:  Functional Shoulder Weakness in a Swimmer

This young lady came to me after five months of physical therapy in another facility with a reputable physical therapist.  Her strength had significantly improved according to her mother, but she still was in pretty much constant pain in her left shoulder.  As we examined her, yes, traditional measures of mobility and strength were within normal limits and equal bilaterally, but there was nasty tenderness and trigger point activity in the teres major and infraspinatus.  Oh, and another slight problem:

 

 

This is a classic example of scapular winging on the left- which changes the working relationship of all the other muscles that attach to the scapula (teres major and infraspinatus-where she had significant tenderness), as well as a host of others  If the scapula is unstable, there isn't a good platform for the other muscles to work off of, and you have the "shooting a cannon from a canoe" situation, with the scapula being the canoe.  

 

 

 Scapular Instability:  Up the River Without a Paddle, Especially when the Canoe is the Scapula

 

Also, if you observe the right side, you also see decreased eccentric control of the middle and lower trapezius when the shoulder lowers from the elevated position, which happened to be a bonus pick up, as she is asymptomatic on the right. 

Hmm, I wonder what we are going to work on with her?  Stay tuned for the outcome, as she reported a pain free shoulder  for 24 hours after our first treatment- the first time in six months her shoulder hasn't hurt!

 

Video Two:  Joint Mobllization With Movement in an Anatomy Trains Context

I have recently treated a Division One lacrosse player with an acute onset of illiotibial band (ITB) "tendonitis".  He had not practiced for over a week due to pain at the patellofemoral slip of the illiotibial band rated 9/10 with (10/10 pain is akin to being hit in the shin by a Tim Lincecum fastball).  Pain was primarily present with the swing phase of full speed running, as well as with stair climbing.  A cortisone injection 5 days prior didn't help pain at all.  Ultrasound and electric stimulation anddistal  ITB "stick" work and massage were the treatments he was receiving, with no impact on his pain. 

When I assessed him:

1) There wasn't any significant ITB tightness or illiopsoas tightness, and strength in key areas was normal (glute med/ max, psoas).  There was however an audible and palpable "clunk") at the fibular head with passive deep knee flexion in prone-and it wasn't painful. 

2)  Ligamentous tests for laxity/instability were unremarkable and there wasn't joint line tenderness or swelling.  The patella (kneecap) was mobile enough and pain free, both passively and with active quadriceps contraction.  One legged squatting was with good control, again without pain/ symptoms being reproduced.  

3) There was pain with palpation/pressure to the distal ITB, the fibular head, the proximal anterior tibilalis as well as the ITB/ vastus lateralis interface, as well as the tensor fascia lata (see below).  There was also a mild anterior pelvic tilt, and decreased ability to brace his abdominals   

 

The Illiotibial Band- A Small Chapter… 

 

I felt the pain generator was primarily soft tissue in origin, with most of his tenderness following the spiral line outlined in  Anatomy Trains. 

 

 

The Spiral Line-The Rest of the Story

 

The elevator speech version of the spiral line is that it follows from the TFL through the ITB,  connecting the anterior tibialis and peroneals as well as the biceps femoris in "jump rope" fashion (Anatomy Trains, second edition, pp. 132, 140).  The spiral line correlated well to where he was tender on palpation, and with no other significant motion/ strength deficits present, involvement of this myofascial meridian made clinical sense to me.    As this athlete had driven 2 hours one way to see me between classes and practice, and given that his time and resources were limited, I wanted to achieve 3 goals during his visit:

1)  Decrease affected "spiral line"soft tissue tenderness by 80-95%

2)  Decrease/soften the fibular head "clunk" by 75-90%

3)  Allow stair climbing and running > 10 mph at  less than 2/10 pain.

Manual soft tissue work (to the TFL, proximal ITB, anterior tibialis and biceps femoris tendon (where it inserted on the fibular head) achieved my first goal and was 50% effective in decreasing pain to 5/10 with stairs and running (traditional fibular head mobilization did nothing to soften the "clunk", which while pain free, was a barometer of sorts for his residual symptoms).  I devised the following mobilization  using a Mulligan belt, gliding the tibia and fibula anterior while moving into knee flexion, and ankle/toe plantar flexion/inversion in an attempt to decrease both the "clunk" as well as the pain: 

 

 

I really don't know why I utilized for this mobilization technique, but I was glad I did.  I just suspected that it would be useful.  After several repetitions over 10 minutes, his pain went to 0/10 with 10 mph running at  3 degrees incline (no Woodway treadmill in my place, sorry) as well as 0/ 10 up and down stairs repeatedly.  He returned to school and practice without incident, only needing to be seen for one visit.  Needless to say he was very pleased (in addition to his his coach and his team). 

Home exercise revolved around stretching the lower spiral line, both in prone and supine, with emphasis on the athlete "feeling" the affected areas under stretch tension.  Additionally, he was given some basic abdominal bracing strategies to decrease his anterior pelvic tilt and engage the superficial/global abdominal musculature (as the external/ internal obliques are  a big part of the spiral line).      

My rationale, as well as the mobilization certainly weren't "classic".  All I had was my gut feeling, based off of examination (with palpation playing a large part), previous patients with shades of this problem, as well as my increasing appreciation for myofascial meridians; my gut proved right in this case.  In the end, what I really did was assess, intervene and re-assess.  If you do this and if improvement is present, I believe you are on the right track, especially if what you are assessing is addressing  the patient's legitimate concerns.  In this case, the intervention (soft tissue work and the above mobilization) met his goal (run without pain) and mine (decrease the tissue tenderness as well as the annoying "clunk" at the fibular head).  Win-win for everyone. 

 

Video Three: An Example of Extreme Hypermobility

 

 

A long time patient voluntarily demonstrated this crazy level of upper extremity mobility to us the other day. We are treating her for a lower extremity issue (where she has just as much mobility). She is an advanced ballet practitioner and her mobility is obviously an advantage in her chosen endeavor. Our challenge is to help her understand that dynamic stability and functional strength are key in minimizing her symptoms; increasing these in the context of her high level of mobility will be our biggest clinical challenges.

 Wrapping Up

Mine is a fun job, especially whenso many different types of patients with unique problems present for treatment.  Having multiple treatment  approaches to draw upon and understanding how to implement them based on what you see, what you have seen, evidence, and (most importantly) what the patient is telling you usually leads you in the right direction.



Band Assisted One Arm Pushups: A Better Alternative

Filed under: Bodyweight Training,Exercise Instruction,Exercise Technique,Strength Training — Shon @ 5:22 pm February 22, 2012

An often heard knock on the push up is that it is hard to load externally, once proper form and performance have been dialed in.  Weighted vests, plates and (always popular) chains are options to add load and muscular challenge to this awesome staple exercise, but at some point most people won't be comfortable with 150 lb or more. of plates piled on their back.  

This guy is obviously not "most people"!

 

While the traditional one arm push up has been expoused as an option to add challenge and resistance, I usually find that the trainees who best tolerate and succeed with this variation have a pretty straightforward mesomorphic somatotype; more of a "wrestler/gymnast" physique versus a taller, leaner individual who has a generally harder time controlling their longer levers. 

 

One arm push ups are probably out for our friend on the right. 

 

I also don't prefer the one arm variation because it really takes a person out of the position that makes a traditional push up such a great exercise.  To clarify further, let's break it down segment to segment:

Feet to Hips

Two arm push up:  Feet hip width or shades of hip width. 

One arm push up:  Feet wide apart, which also abducts the hips and encourages increased lumbar lordosis (sometimes subtly, and sometimes not so subtle)

 

Trunk to Shoulders

Two arm push up:  Trunk moves in a "straight plane" throughout the repetition; concentration is on maintaining a tight core/ abdominal brace and avoiding the lumbar "sag". 

One arm push up:  Trunk rotation occurs naturally, and must be coordinated with shoulder rotation, you must be able to control both throughout the repetition.  If you have a weak link in the chain, technique can quickly disintegrate.  

 

Shoulders to Floor

Two arm push up:  Upper arm 45 degrees or so from the trunk, a balance of triceps, pectoral and anterior deltoid activity,  and ample scapular mobility.

One Arm push up:  Upper arm essentially parallel to the trunk, with the triceps contributing more so, as elbow extension is primarily driving the torso away from the floor and the glenohumeral joint trends toward a rounded shoulder position within the repetition.  As such, scapular mobility is definitely not optimized, and  may actually may be impaired-something we really want to avoid. 

 

Rocky is grimacing because his rotator cuff is fighting him harder than Apollo Creed!

 

A Better Way

Over the past few weeks, I have been looking for a way to safely load a push up for a group of already strong high school football players. As stated above, too many  45 lb. plates stacked on the trunk of a 16 year old is a recipe for disaster, while the "Rocky" style push up would land 75% of the team in the training room.  From this problem, a solution arose:  The Band Assisted One Arm Push Up. 

 

 

 

This variation of  the one arm push up trumps a traditional one arm push ups on many fronts.  First and most important, the overall body position is the same as in a regular two arm push up, meaning the ability to maintain hip width positioning, an efficient abdominal brace/ core, as well as a safe, appropriate scapulohumeral (shoulder blade to upper arm) position.  Your shoulder will behave here as it does in a regular two hand push up, with the only difference being the increased demand using one arm vs. two.  

Second, because trunk position is so stable in this variation, plate loading across the trunk can be done.  However we needing far less load for an appropriate training stimulus because of  the fact that we are using only one arm.  This adds both safety and resistance to an already challenging exercise. The need for multiple plates is minimized, save for the total freaks. 

Third, progression is as simple as changing band tensions and/or the height you hang the band from as your needs dictate. 

 Here is more of a bird's eye angled view to appreciate how similar to a regular push up this actually is:

 

 

 

Technique

First, loop a mini band from a height between 45-85 inches off the ground;   A power rack works great here (and it's a tough enough exercise that no one will complain that you aren't using the rack for squatting); I am using an old fashioned set of parallel bars, which serves the same purpose.  Place your "free" arm through the loop; the closer the distance the band is to your shoulder, the easier the repetition will be, as leverage is decreased. Optimally, the band should meet  at the wrist.  The shoulder should be in neutral rotation ("palm down") or slight external rotation ("thumb up").  The arm is either perpendicular to the trunk or slightly higher  (My choice in general).

Get used to the feel of the band supporting your arm and make sure that the band tension is such that your arm drops with your trunk naturally through the repetition.  This can be figured out quickly.  Set your support hand in a cambered position, then proceed as a normal two hand push up through your selected repetition range.      

Sets, Reps and Program Design

I prefer to stay in the 5 set/ 4-5 repetition per set range myself for this exercise, but higher reps are certainly an option.  This can be used as the main horizontal push option for a given day in a lower rep/ higher set fashion, or in a moderate to higher rep scheme as a supplementary exercise.  Program placement is where ever you are comfortable; I have found that it pairs nicely with RKC planks and other core work.  A frequency of one to two days weekly is a good place to start.

Progression

Experiment with any mini band tension that allows the free arm to travel with the trunk through the repetition.  This is important, as too heavy a band will "drag" your free arm and cause unwanted trunk rotation and a general loss of flow as mentioned above.  You can progress by either adding load through a weighted vest or plates.  The great thing here is that "a little goes a long way" when using plates in a one arm option.  Below I am using a 10 kg. plate for a set.  With a regular push up, I can easily get 30-35 repetitions; here I am good for about 3 reps (and I am trying to move as fast as possible!):

 

   

 

In Summary 

This one arm push up variation makes great sense on multiple levels, plus it achieves the goal of of intense unilateral loading and the strength gains that come with it.  Unless your last name is Balboa, you should infinitely prefer this exercise over the oft butchered "Rocky" push up.

 

 



Exercise of the Week: Advanced Abdominal Brace

A long time favorite in my clinic, this "anti extension" exercise fits the bill for  aggressive abdominal co-contraction, lumbosacral stabilization, and whole body frontal plane stabilization.  It is also a "self limiting exercise", defined by Alwyn Cosgrove and Gray Cook as one that "requires engangement and mindfulness, and provides an automatic yet natural obstacle that prevents you from doing it wrong, or doing an excessive volume".  In this case, the "obstacle" is the neutral spine position itself- you can either sense and hold the correct position or not.  When you lose the position, it becomes very apparent, as it is easy to sense this quickly.  I refer to this feeling as "fatigue extension" and I have never had a patient or trainee not understand how this is sensed.  

Below, I outline two progressions, using an adjustable 45 degree back raise for both.  Equally as useful for the advanced progression is a GHR machine or Roman chair. 

 

PROGRESSION ONE

The first progression here is at 45 degrees.  This allows a shorter lever arm for the trunk musculature to deal with initially, as this exercise is harder than it looks. 

The key to set up is ensuring that appropriate neutral spine is achieved by guiding the trunk position at first using the arms. This is important at first, as a person with weaker abdominals may end up in too much of a lordosis to start.  Once you have the strength and motor control to understand the position, arm guidance isn't as imperative. 

Another important technique note includes appropriate neck positioning.  You can use the "neck pack" position, or just imagine a tennis ball sitting between your sternum and chin (the way I learned it ~20 or so years ago from Beverly Biondi).  This way, you also get great deep neck flexor activity, which in turn helps reflexively reinforce the abdominal activity (which is why you're here in the first place!). 

 

 

 You can also see that the lower quarter is pretty active as well.  This is important, as your shins, and or feet (as we will see below) are the anchor point for the whole technique, and vital if you want the pelvis to stabilize neutrally from "bottom up" (which, obviously, you do). 

When used in a strength and conditioning program, I start with 10 to 15 seconds per set, with 45 seconds to 1 minute of rest between sets.  5 to 10 sets per session are performed.  We progress up to 30 seconds per set before going "arms overhead", and then start back with decreased rep times (10-15 seconds) until 30 seconds can be maintained  for multiple sets.  Dumbells can be added after this, again decreasing time under tension at first, until good lumbopelvic control can be maintained and progressed. You can also choose to perform this activity between sets of your main strength exercises, as it shouldn't interfere with technical performance of your main lifts.

When we use this clinically for our lumbar spine patients, it is always later in their overall program, usually a minimum of 4-6 weeks after treatment has started.  Symptom control, hip and lower quarter mobility, and good understanding of basic abdominal bracing progressions are needed before moving to such an advanced activity.  Sets and reps can be progressed as outlined above.  The lumbar spine patient population is generally good with the first progression, and does not need to move on to the next progression unless their sport or activity level demands it.  

 

PROGRESSION TWO

Here, we are using a "parallel to the ground" position, increasing the lever arm that the abdominals have to deal with in resisting extension.

 

 

 

 Again, I utilize my arms to set up the "neutral spine" position, both entering and exiting the set.  This is even more important in the second progression, as the abdominals have to work ridiculously hard to maintain a neutral position due to the leverage demands.

Other things to consider with this progression:

1)  Set the glutes by squeezing your butt as well as isometrically externally rotating your hips.  Again, this provides a firmer pelvic foundation for the abdominals to work off of.

2)  Notice that my instep is the base of support for my feet vs. the shins.  This is a subtle way to increase the lever arm, making the exercise more challenging.

3)  Arms overhead should be used ONLY after a good, solid repetition can be held for 10-15 seconds over 5-10 sets.  This goes for dumbells in the hands as well.

4)  The set terminates when the lumbar spine falls into fatigue extension.  Trust me when I say this is easy to figure out when this occurs. 

5)  Remember to use your arms to "rescue" yourself from the, as "sitting up" is nasty for lumbar spine shear forces.

 

 



The Single Leg RDL-Baby Steps, Training Wheels and Driver’s License

Filed under: Balance/proprioception,Exercise Instruction,Exercise Technique — Shon @ 3:44 pm January 25, 2012

The single leg RDL (also known as the one leg single leg deadlift) is an extremely useful and functional exercise for many training and patient populations.  In one movement, you get: 

1) Fantastic triphasic (eccentric-isometric-concentric) activity of the hamstrings through a functional range of movement.

2) Great gluteal (maximus and medius) activity and stabilization throughout the movement.

3) Appropriate involvement of Janda's "deep longitudinal subsystem" and Myers'  "lateral line" (including the peroneals and anterior tibialis in concert with the lateral hamstrings, sacrotuberous ligament and gluteus maximus/ medius).  In simpler terms:  Awesome co-contraction and integration from the foot/ ankle through the hip and pelvis. 

4) An excellent stimulus for torso muscular stability training.  Appropriate dynamically stiffness of the torso is much easier and efficient to "drive" though the SLRDL movement pattern then one that is limp wristed. 

The problem that I have with the exercise is inherent in the fact that most people I see in the clinic generally have multiple impairments, not limited to strength/ contractility, mobility /stability, and balance, all of which will generally disqualify them from going full bore into the single leg RDL.  In particular, most, if not all post operative anterior cruciate ligament (ACL) patients are significantly deficient in all of the above, especially early in the rehabilitative process.  This study in the Journal of Sport Rehabilitation shed light on significant motor control deficits 12 months after ACL reconstruction, while Howells and colleagues in a systematic review of the literature noted impaired postural control as an issue in post operative ACL patients. 

So what does this have to do with the single leg RDL?  Really in the way it is taught most of the time.  Most texts and or instructional videos teach the SLRDL in a "hands free" mode, which while acceptable for many healthy trainees as well  as proprioceptively gifted patients (an outlier group for sure).  It is the way I taught it for a long time as well, with the expectation that sooner or later most people would catch on to the "correct" technique.  Recently, however, I decided that I was wasting both my patient's  and my own time by not streamlining the process better by incorporating additional external stabilization, tactile cueing and environmental constraint to facilitate capture of the technique.  

Below, I give you three simple but effective steps to teach just about  anyone how to subliminally slip into the single leg RDL. 

Phase 1- "Baby Steps"

Below is video of one of my patients, six weeks post ACL reconstruction, demonstrating the first progression of the SLRDL.  We are assuming the person has major issues with unilateral balance, let alone moving through space on one leg.  Here we are using maximal support of both arms for balance as well as to keep the pelvis and shoulders level, allowing a proper hinge at the hip (as well as a hurdle to allow tactile cueing of the back leg): 

 

Keeping the trunk and pelvis level without using the arms for support would have made this much more of a difficult proposition so soon after reconstruction.  Here, the pattern gets grooved quite nicely, with the ability to steer posture through the upper body, while the foot learns to make tactile adjustments without having to control the whole chain by itself.

Phase 2- "Training Wheels"

The next phase involves utilizing a dowel (or similar prop) for support, decreasing the upper extremity involvement as well as adding a bit more proprioceptive challenge:

As you can see here, we are using a kettlebell in the opposite hand to add load.  Weight can be utilized as soon as the athlete/ patient/client demonstrates appropriate trunk/ pelvic control; adding weight too soon can lead to trunk rotation-something desirable for Stuart McGill's excellent "Hip Airplane" exercise, but not the response we are looking for in this particular progression. 

Phase 3- "Driver's License"

After we have grounded and sealed technique using the first two progressions, we then take off the "training wheels" and allow performance to roll without props/ support: 

At this point, we have the outcome we want- appropriate head to toe alignment, good pelvic/ trunk stability and the hinging mechanics we are looking for.  More importantly, the patient is now independent in the performance of the exercise-it's his for life.  Of course, it will be useful not only in his clinical care, but as a performance enhancement tool after discharge.

In Summary

The single leg RDL is a fantastic exercise, but can be a challenge for certain clients and patient populations to master, namely due to impaired proprioception/ balance and whole system stability.  Fortunately, the remedy for this is pretty simple: use your available environment to externally stabilize and groove the movement pattern you are looking for.  Rely on upper body support, tactile cues, or whatever other tools you have available to get your patient/ client to understand the basic pattern, then take support away as technique allows.  Before you know it, they will perform the way you want independently, with great technique that they now own. 

   

 

 

 

     



Serratus Anterior Training Progressions

The serratus anterior is like that kid you knew in high school everyone knew: a bit mysterious and misunderstood, who was not necessarily in trouble, but was always around trouble when it happened.

 

Kato Kaelin may be the human equivalent of the serratus anterior

 

It isn't really a muscle that takes a regular beating like the long head of the biceps in a thrower, nor is it "married" to a joint complex like, say the supraspinatus.  However, more often I see it being a problem in people with traumatic neck pain (such as whiplash injuries) in addition to older patients with non-athletic shoulder pathology.

Obviously, overhead athletes (particularly tennis, baseball and swimming) with shoulder pain may have serratus activation/weakness issues, but the big trend I'm noticing is serratus under activation/ weakness in cases of neck pathology, particularly those of a traumatic nature.  This applies again to acceleration injuries such as whiplash, but also to athletes involved in collision sports (football, wrestling, MMA).  This recent study highlights the link between serratus dysfunction, poor muscular activation and cervical/thoracic dysfunction.

Anatomy of the Serratus Anterior

The serratus is definitely an oddly shaped muscle.  The best way to think of the serratus is to think of a hand. The origin(s) of the serratus are shaped like fingers and grasp the superior borders/ outer surfaces of the upper eight or nine ribs (o.k., we don't have nine fingers, but I get a pass on this one).  Your palm is the "body" of the muscle, while the wrist crease is the insertion of the serratus on the medial scapular border.

 

The "classic" anatomy book rendition of the serratus anterior

 

 

Typically what we think of when we see a serratus in a lean individual

 

 

The serratus wholly dissected looks  kind of like this, that is if we had eight or nine fingers

 

Function of the Serratus Anterior

According to Kendal (Muscles Testing and Function, fourth edition), the functions of the serratus anterior are numerous, including letting the glenoid cavity of the scapula (the "socket" of the shoulder joint) rotate upward, as well as holding the medial border of the scapula against the rib cage. Also, the lower fibers may depress the scapula a bit.  I think both clinically and from a performance standpoint that the last two functions are very important. 

First, keeping the scapula held firmly to the rib cage by way of proper serratus function allows properly functioning "anchor points" for the rest of the scapular musculature,  the rotator cuff, as well as the middle and lower trapezius, as well as the levator scapula and upper trapezius.  Secondly, as an end range scapular depressor following the mild  concave contour of the rib cage, I believe we may ultimately help foster qualitatively improved glenohumeral elevation by lessening anterior scapular tilt

The Serratus/Rhomboid Fascial Connection

In "Anatomy Trains", Thomas Myers points out the fascial/septal connection between the serratus anterior and the rhomboids.  We know from Kendall that the rhomboids are antagonistic to the serratus (or as she puts it "direct opponents"). Myers coins the term "rhombo-serratus" muscle,pointing out the two muscles form a myofascial scapular sling, setting up scapular "ballast".  The two muscles appear as "kissing cousins" in these illustrations/ dissections.  So, as the serratus goes, the rhomboids will go (and vice versa), both from a length (short/stiff) issue as well as an activation/contractility issue.

 

Thomas Myers- The "Christopher Columbus" of the Anatomy World

 

These passive, active, and cozy connections provided me with an "a ha" moment when working two patients recently, both who had traumatic neck injuries related to whiplash, and my approach to their treatment.  

Both had multiple issues, including loss of neck and shoulder mobility due to soft tissue injury, and the loss of mobility was due to multiple factors, including segmental tightness at the cervical facet level and posterior shoulder capsule/element tightness.  Obviously these were treated in concert with soft tissue work to the rhomboids (at the point of insertion on the medial scapular border), activation work for the middle and lower trapezius, and postural restoration activities.

 

Weaving the Serratus/ Rhomboid Tapestry

When it came time to train the serratus, I utilized a three phase approach based on 1) supporting still sensitive, sub acute healing  cervical/ thoracic structures 2) gradually decreasing external support as our injured tissues allow 3) giving the rhomboids "equal time" to allow seamless integrated contractility/ activation in conjunction with the serratus.

Phase 1

I use a massage chair for trunk support to dial in what I want the patient to perceive as appropriate serratus function (scapular protraction with shoulder elevation).  The key is to maintian scapular protraction while elevating; retraction during elevation indicates poor serratus function and/ or too heavy a load.

 

 

Phase 2

As the patient gains an understanding of how to activate the serratus and control the scapula, we then move to a seated position to allow/ integrate trunk stability while the serratus does it's job:

 

 

Phase 3

After we have mastered the first two progressions, we then move to a standing position, which integrates further the trunk with the hip.  Again, Thomas Myers notes a fascial/septal connection between the serratus as well as the obliques and tensor fascia lata; standing allows potential stabilization/ integration between these elements:

 

Integrating Rhomboid Activation

The X factor that was missing in the equation for me in the past was addressing rhomboid function.  I had been so focused on not aggravating the upper trapezius/ levator scapula that I avoided rhomboid activation as I felt it encouraged too much "turn on" of the aforementioned groups.  However, with recent patients, careful integration of specific rhomboid work "greases the groove" for the rhombo-serratus anatomy train, and allows appropriate tri-phasic (concentric/isometric/eccentric) interplay in a scapula with great myofascial ballast (courtesy of early and appropriate soft tissue work, joint mobilization and postural restoration).  

Here, we perform a static rhomboid activation, careful to minimize upper trapezius and levator activity:

 

 

Beyond Basics:

After we've got our "new normal" scapular function, we can progress through our preferred  "pushing"upper body exercises.  I am biased toward push up progressions at first, as scapular mobility is encouraged vs. locking the scapula down with a bench press.

My personal favorite test of good serratus function is a handstand hold, as I feel  a real satisfying scapular position on the ribcage with this exercise: 

 

 

 

 

At The End of the Day…

1) The serratus anterior is a tough muscle to wrap your head around from a three dimensional standpoint; however it's function really is a keystone for proper scapular function (and the scapula is a keystone for trunk/ extremity integration, if you really think about it). 

2) Serratus function is an interplay between both the serratus and the rhomboids, both from a passive (shortness/ stiffness) perspective, as well as an active one; both need to be addressed.

3) Strengthening the serratus is more about proper, integrated activation in conjunction with the rhomboids after appropriate positioning/ballast of the scapula has been established through appropriate manual therapy/postural intervention.

4) Advanced upper body push activities should allow free scapular movement, such as push up, dip and pressing pattern progressions as tolerated (remember to pick your candidates carefully for pressing and dipping)