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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. 

 



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. 

 



Exercise of the Week- “Twelve to Six” Core Stability Challenge

Filed under: Uncategorized — Shon @ 3:13 pm January 5, 2012

A fantastic exercise  that challenges the entire upper quarter from a both a stability standpoint as well as a unique  use of the latissimus is the "Twelve to Six" movement on the rings (the name comes from the movement of the head from the twelve o'clock position to the six o'clock position when a repetition is initiated).  The video below is yours truly performing a typical set:

 

The movement is initiated from the "dead hang" position with as neutral a spine as possible.  The foam roller helps keep the hip and lumbar spine position "honest" throughout the exercise, which challenges the lats and scapular stabilizers even further.

Begin with a strong bracing contraction of the abdominals, then "set" your lats by isometrically depressing your shoulders. Then, pull your knees toward your hands ( the foam roller is key here, as without it, you easily loose the neutral spine position).  When your knees pass the straps of the rings, pause 1-2 seconds and control the descent to the starting position.  Pause 1-2 seconds, and repeat.  

One to three repetitions per set is a great starting point, with a set range of five to ten sets per session being adequate for good progress.  You can increase repetitions as you wish, as long as technical excellence is maintained.  It is best with this type of exercise to leave "one in the tank" so as not to develop a sloppy motor pattern and/or substitution pattern.

This exercise serves as a nice precursor to a front lever progression, part of which I have demonstrated before:

 

 

 

Why This Exercise is Valuable:

1) The Lats Work Differently Than Usual

In this exercise, the latissimus act in "reverse action"; that is, the origin of the muscle (at the thoracolumbar fascia) moves toward the insertion (the humerus) in closed chain fashion against gravity- a pretty difficult and challenging proposition.  The trunk rotating about the shoulder joint provides different training stimulus versus most "traditional" chin up/pull up progressions. 

 

The sternal portion of the pectoralis major also gets some work as a stabilizer, as does the subscapularis and teres major, with the shoulder being internally rotated and adducted. 

2)  The Abdominals Act as a "Chassis Stabilizer"

Bracing the abdominals (as well as increasing intrabdominal pressure)  set the stage for a rigid frame that the latissimus "engine" drives through completion.  Again, the foam roller held with the heels/buttocks is really important in the early stages of learning, or you loose a key part of what makes this exercise worth doing. Moving the distal end of the body through space requires a high level of not only abdominal activity, but integrated proximal hip stabilization and significant intermuscular coordination between all moving and stabilizing parts.

3) You Are Taken Out of Your Proprioceptive "Comfort Zone" 

The psycho biological/ proprioceptive challenge of overcoming the apprehension of an inverted posture is something that will benefit most trainees. There is a skill component in learning and exercise like this that is more fun than a typical straight saggital/frontal plane movement such as a chin up.  When you do this in a commercial gym, the looks are pretty priceless as well! 

Who This Is Not Probably For

-A trainee who can't perform an "honest" 12 chin ups or pull ups.

-Someone who lacks requesite thoracic spine and shoulder mobility.

-Those who have fair to poor ability to stablize the core.

For those who are ready, though, the "Tewlve to Six" is a great addition to a program that adds a lot of value (as well as a lot of strength) to a solid program.

 

 

 

 

 

 

 

 

 



Video Tutorial-Scapular Depression with Shoulder Extension

Filed under: Uncategorized — Shon @ 1:30 pm December 15, 2011

One of my favorite exercises for upper quarter (shoulder, cervical spine and thoracic spine) dysfunction is scapular depression with shoulder (glenohumeral) extension.  In cases of shoulder impingement, there is almost always a component of scapular dyskinesia, or poor scapular positioning.  Ben Kibler, M.D., one of the pioneering researchers in the area of the scapula, stated here that the prevalence of scapular dyskinesia is 100% in cases of shoulder instability and 94% in instances of labral tears.

Why is my bias toward scapular depression?  First, it is generally non-provocative, as you aren't moving toward glenohumeral elevation.  In cases of impingement, I want to establish exercises and activities that don't provoke symptoms while giving the patient something constructive to do as well.  "Getting back" scapular control with this exercise allows both things to happen pretty seamlessly. 

Second, scapular depression fosters thoracic extension more so than the other scapular exercises.  Thoracic extension goes hand in hand with scapular mobility, and I don't feel you can optimize one without the other. 

Third, with scapular depression, upper trapezius activation/ compensation is limited.  Yes, some upper trapezius is needed in normal shoulder function, but if we are dealing with "abnormal", then upper traps need to be subdued a bit.  Most shoulder and neck patients I see have a difficult time disassociating upper trapezius from middle and lower trapezius activity; this exercise sets the stage for the upper traps to "step off" a bit.

Fourth, as you see in the video, the exercise is easily scaled.  The arm serves as the "weight" the scapular depressors lift; if the demand is too high on the depressors, then the position of the arm can be accommodated until they can meet the demand.

Does this mean I don't work on other scapular exercises?  No way!  I just feel this exercise sets the stage for patient comfort, success in an important movement pattern, as well as disassociation between upper trapezius and middle/ lower trapezius activity.  It is just one activity in a "parts to a whole" approach to upper quarter dysfunction.  Enjoy the video!

 

 

 



Farmer’s Walk Forerunners

Filed under: Exercise Instruction,Exercise Technique,Random,Strength Training,Uncategorized — Shon @ 1:08 pm December 12, 2011

First, thanks to everyone on the positive feedback related to my first published T-nation article, "Quantifying the Farmer's Walk".  Again, the purpose of the article was to give some options that challenge core stability in a more biomechanically friendly way during everyday training.  It was obviously not meant to supplant the traditional Farmer's Walk as a test of strength endurance, but to serve as a way to challenge frontal/saggital plane stability while moving through space. 

I don't write about or espouse the virtues of an exercise, drill or physical therapy intervention unless I have used it myself, and the variations I covered have been implemented with patients, training clients and athletes very successfully.  I'm no historian when it comes to the Farmer's Walk, but I am approaching 30 years as a traditional karateka; Farmer's Walk variations (with large ceramic pots known as "Nigiri Game") have been used for a long time in traditional Okinawan karate systems such as Uechi Ryu and Goju Ryu as Gushi sensei demonstrates below: 

 

Shinyu Gushi going old school with Nigiri Game.  I think I'll pass on fighting him…

Actually Nigiri Game is only a small part of Okinawan karate's "Hojo Undo", or supplementary exercises.  Hojo Undo is basically the Okinawan equivalent of GPP and/or SPP, utilizing paddocks, clay jars, and even rudimentary dumbbells and barbells integrated with traditional stance work and whole body isometrics, such as seen in "Sanchin" kata. 

Hojo Undo implements in good working order at the Higaonna Dojo.   

Getting it done with the Chi-Shi

I have read several interviews with Mr. Gushi (pictured above) and he states he never trained with weights.  Now, we know physiologically and biomechanically that there is massive co-contraction, irradiation, overload and strength being built in the carry performed above, but I don't think I would really get into a debate  with sensei whether or not we were "weight training" with such implements.  Here is a more recent picture that I stumbled upon of Gushi sensei in his late 60's:

 

 

 

Contemplating Age 70 While Simultaneously Opening Up a Can of Whoop Ass!

 

I think a steady diet of what he is doing is better than 90% of what is being done most other gyms.  I also think he probably doesn't have any problems with frontal plane stability, hip mobility or poor glute function.  My guess is that his mid and low traps are well developed, and I bet he never did a proper "YTWL" in his life. 

Again, it goes to show that a mix of basic, biomechanically correct, physiologically taxing training  can bring up just about any weak point that a person has, and that what is perceived as new isn't actually so new. 

 



Positive Posture Changes-Chronic and Acute

Filed under: Case Studies,Posture,Uncategorized — Shon @ 7:16 pm December 1, 2011

 

Appropriate posture is the foundation for both upper and lower quarter functional mobility.  If you are reading this, chances are you already know this, either as a professional or as a patient.  The question is how quickly can we affect changes with our people, both in chronic, long standing cases as well as acute changes from traumatic injuries.   

Recently, I had the chance to take a few "before  and after" pictures of a few pateints.  Below is a District level high school cross country athlete who I saw for 10 visits this fall for a diagnosis of neck strain.  What we were really dealing with was a combination of  Janda's  upper and lower crossed syndrome (a quick review: upper crossed syndrome-weak deep neck flexors, overactive upper trapezius/ levator scapula, weakened sccapular depressors; lower crossed syndrome-.weak, underactive gluteals and abdominals, tight illiopsoas and erector spinae).   

The picture on the left is his first visit, while the picture on the right is at the time of his last visit:

 As you can see, there are pretty significant changes.  Lower cervical extension is better, as is thoracic extension, both passively and actively.  The thoracic spine being more upright allows a better "table" for the head and cervical spine to sit on.  His rounded shoulder position is improved by virtue of improved scapular retracion; scapular retraction is better just as a result of thoracic extension being improved. 

Just as impressive are the changes in lumbopelvic posture:

On the left (obviously, the first visit) you can see the ASIS/PSIS relationship as marked by the tape.  Arms overhead didn't help this (but were necessicary to capture the picture), as this further accentuated his lordosis secondary to his tight thoracic spine dragging his lumbar spine and pelvis into further extension.  On the right side, not only is lumbopelvic positioning more ideal, with a beautiful neutral spine posture, but the "arms overhead" position isn't a problem anymore because thoracic extension is also much better, leading indirectly to improved scapular and glenohumeral mobility. 

How did we achieve these changes?  Primarily with low load prolonged postural stretching of the thoracic spine into extension, improving mobility of lower cervical extension with concurrent upper cervical flexion,, as well as a bunch of time spent showing him "pelvis neutral" along with low load stretching of the psoas and rectus femoris.  Many of these activities can be performed concurrently, once the patient understands what is expected. 

This athlete has a bit more work to do independantly, namely get stronger.  He has done limited weight training activities with his cross country team, but hasn't performed what I would consider "proper" strength work yet.

 

Another patient presented recently after suffering a whiplash injury.  Below are "before"  pictures from his first visit:  

Following are pictures taken immediately afer his first  visit.  We did only low load thoracic/ cervical  passive positioning this visit to achieve these changes. You can see significantly less activity in the upper trapezius and levator scapula, as well as decreased sternocleidomastoid activity.  Needless to say, he felt a whole bunch better, at least for the first few hours post treatment.

In subsequent visits, we did hone in on more specific soft tissue work to the left upper quarter, as the left levator and rhomboid was significantly flared up.  You can also see winging of the left scapula, which we addressed aggressively with high set (10/ session) serratus activation work (30 seconds per repetition).  His levator/upper trapezius pain impairments are more than likely tied to his serratus dysfunction, as the scapula acts as a "roundhouse" for shoulder function with many significant competing vectors of pull (reference Anatomy Trains, specifically page 164 to see the relationship between serratus anterior and the rhomboids).  As his serratus improves, I believe his rhomboids and levator will improve as well.

The long term key with him is to make sure that chronic adaptations never take hold, or he may develop an upper crossed pattern.  Continued targeted soft tissue therapy, appropriate low load postural stretching, activation and strengthening of  underactive and weak musculature should be the ticket to achieving a long term improvement in his upper quarter posture. 

 

 

 



Isolated Muscle Strains-Are There Always Underlying Causes?

Filed under: Uncategorized — Shon @ 6:43 am September 20, 2011

To that question, I would say many times yes.  The art is to find the movement impairments that exist around the strain.

To this point,I recently had a high school soccer player in the clinic who came to me with a diagnosis of hip/groin strain. He had noted increased anterior right thigh pain after winding up for a shot and striking the ball with his right foot early in the pre-season. He had continued to play through discomfort, but still had issues with running and kicking using the right leg.

When I evaluated him, it became apparent that the injured muscle (and pain generator) was the sartorius.  I came to this conclusion based on symptom reproduction with manual muscle testing as well as point tenderness along the course of the muscle from origin through insertion:

 The sartorius has the distinction of being the longest muscle in the body.  It acts as a hip flexor and external rotator; it is well developed in athletes such as hurdlers because of this action.  The mechanism of this  athlete's injury made sense, as preparation for the shot placed the right leg into a stretch position of the sartorius (extension, adduction and internal rotation), but  then I gained more insight when I observed him moving the right hip in prone lying:

 

Look closely at the right side; I attempted to have the player lengthen the sartorius with activation of the antagonistic musculature in prone lying to assess movement quality. This video shows a  laundry list of right lower quarter movement impairment:

1) Hip internal rotation mobility stiffness exceeds left sided trunk stability. When the right hip goes into internal rotation, the pelvis and lumbar spine take a ride into left rotation. Stated simply, left trunk rotation is more flexible (or less dynamically stable) then right hip internal rotation. Remember, the stiffest anatomical segment will dictate compensatory movement at a less stable segment.

In his case, Thomas test was positive for both illiopsoas and rectus femoris tightness (not shortness) . Since the illiopsoas is both a hip flexor and external rotator, internal rotation will place it under tension. With my soccer player, I believe illiopsoas caused the trunk to rotate, as its' passive tension could not be controlled by the trunk on the opposite side.

 

 

The solution:In the same prone position, teach him how to resist trunk rotation as he rotates his hip in with an aggressive abdominal brace in neutral spine. Progress to a point of increasing speed of hip IR to allow a quicker response of the abdominals in keeping trunk rotation neutral.  Also, I gave him a bilateral bridge with hip internal rotation (a standard bridge, except feet are wider than knees).

 

2) With active hip extension, there is compensatory anterior pelvic tilt.Again, this is because the athlete also has rectus femoris and illiopsoas tightness as well as decreased superficial abdominal control. There is significantly less anterior tilt when the left side is tested (rectus femoris and illiopsoas tested normal on the left).

Also, look at the amount and quality of hip extension: there is significantly less on the right side vs. the left.  Toward the end, the thigh drops , allowing more anterior tilt to occur, creating a bit of a vicious cycle. Gluteal contraction in a static position on the right was also notably poorer in quality, with the hamstrings contracting prior to the gluteals with the leg straight, indicating hamstring dominance and a bit of "gluteal amnesia", manifested in what was seen here.

The solution:Get the glutes in line with static contraction/ isometrics, as well as work on "pelvis/lumbar spine neutral" through superficial abdominal bracing statically.  These can be done either in prone or supine lying (I chose supine at first, as it was easier to get him to understand the concept in this position)

Once the  pelvis is stable, actively stretch the rectus femoris form prone:

Kinda, sorta.  No need to pull with the hand-just bend your knee actively abs braced

When he can get better isometric contraction/ activation of the gluteals and keep a neutral spine with and abdominal brace (as well as having decreased rectus femoris stiffness),  then we can add active hip extension:

Pretty solid…I will be happy if my guy does it like this in 2 or so weeks

 

But why is the sartorius strained?  My hypothesis is that the sartorius "got bullied" by the lack of gluteal contractility and abdominal stability, as well as rectus/illiopsoas tightness.  The sartorius, while the primary pain generator, was merely the conduit for more significant impairments as outlined above.  Without a stable pelvis and lumbar spine, the sartorius more than likely has to eccentrically load, concentrically contract and/or lengthen beyond it's normal means, leading to pain/ symptoms.

I believe this is an example of how an "isolated" problem actually has root in more profound movement dysfunction.

As we address my patients' impairments as outlined above, I believe the sartorius will become less "edgy"and  become less symptomatic without significant direct intervention.  That is not to say I won't also include  direct static contraction/ activation work to this muscle (I still think it needs to be  "bullet proofed" a bit), it's just that by addressing the other key impairments, the sartorius should take care of it self. 

How will we know for sure?  As we always do, we assess (as we have done above), intervene (as we are doing currently in the clinic as well as with his home routine) and re-assess progress-then we know if we are on track.  We will also listen to the athlete and see how he feels he is doing with regard to his practice and game day abilities.  My plan is to video again in 1-2 weeks in the same position to see both qualitative and quantitative improvement  and post.   



Strength Training After Spinal Compression Fracture

Filed under: Uncategorized — Shon @ 9:54 am September 7, 2011

Many times I am caught off guard by the fantastic progress my patients an clients make at our clinic.  I had one of those moments last week with my former patient and current training client, Scott Alloway.  His gains have been outstanding in a brief period of time, and given  his injury and training history, I felt compelled to write about it .  Scott is the kind of guy who just brings it every time he walks in my door-never complaining, always smiling, and  steadily moving forward.   

First, a bit of background:  Scott suffered a burst fracture of his L1 vertebra after falling off a ladder on August 30 2010.  He spent an additional two weeks in the hospital with DVT's (blood clots) on his back. The next 3 months were in a clam shell orthosis with limited activity prior to beginning physical therapy. 

Scott's impairments were what you would expect for someone who spent this amount of time sedentary in a back brace:  decreased abdominal and hip strength, decreased thoracic mobility coupled with middle and lower trapezius weakness, significant paraspinal pain and point tenderness as well as very poor activity tolerance.  As if this wasn't enough, Scott is a self employed landscaper who not only has to managed his employees, but also has to perform significant manual labor tasks 20-30 hours weekly when in full season.

The only bright spot was that Scott arrived to us as a patient in late December, well ahead of his busy season in early March.  Physical therapy emphasized progressing active and passive hip mobility, thoracic mobility, abdominal/ middle/ lower trapezius  strengthening, and activity tolerance ahead of his busy season.  Manual therapy also played a role to address his lumbar paraspinal pain and point tenderness.    

Scott had a successful outcome 4 months later, gradually returning to more physical work in that time period, with full return in late April.  Happy with his overall progress and essentially seamless return to a very physical job, Scott had expressed interest in training with me twice weekly.  Scott had already had a good education in appropriate lumbar stabilization/thoracolumbar mobility coupled with great hip mobility and strength, as this was front and center in our physical therapy plan, so squatting and deadlifting  progressions were seamless. 

Teaching proper and progressive upper body exercise in the form of push ups and chin ups/pull ups was where most of our time was spent initially.  Low repetition sets with emphasis on technical performance (usually 3-5 reps/ set with 45-60 seconds of rest between sets) as well as a  larger volume of sets (8-10 per exercise) took precedent for the first three months.  Chin up/pull ups were initially performed with mini bands for assistance, progressing from two to one, followed by body weight reps.  Push up reps remained low, with weight added (by way of plates on the upper back) as quality reps increased beyond 6-8/set.  Lower quarter exercises (kettlebell front squats, trap bar deadlifts, and back squat patterning) followed the same loading and volume guidelines as the upper quarter.  Abdominal training is anti flexion/extension yielding isometrics, between exercise pairings.

Over the last month, we added interval training on the Concept 2 rower as well as Versaclimber, combining either short burst at high intensity (15-20 second sets) with longer rests (45-75 seconds) as well as longer intervals at a lower intensity (60-90 seconds/ set) with shorter rests.  Kettlebell squats and bodyweight push ups were also staged in interval fashion, usually 30 seconds on/off, alternating with a climbing/ rowing interval.

The two exercises which we limit in terms of load are the back squats and overhead press ( his L1 compression fracture is not real fond of axial loading).  I love the back squat with a bar (load limited appropriately) to engage the latissimus/thoracolumbar fascia/gluteal "tent" through a functional range of movement, as well as the overhead press (again, appropraite load to allow a  reasonable pressing pattern to take place) to gage scapulothoracic stability/ mobility in conjunction with appropriate glenohumeral mobility and coordination in my clients.

As mentioned above, Scott trains with me twice weekly.  This past Tuesday (August 30), he casually mentioned that it had been one year since he had fallen and broken his back (as well as his heel, which I forgot to mention).  I shot some footage of Scott during his session that followed.  Check out Scott during one of his chin up sets exactly one year after his injury:

http://www.youtube.com/watch?v=Ip32TZPzSdY

Here is Scott pressing within 2 weeks after learning the exercise:

http://www.youtube.com/watch?v=gQtraviXGuA

Go into most commercial gyms, and chances are you will not see many trainees performing exercises like these with form like this.  What I think is amazing is that Scott has been training for only four months and had never lifted weights prior.  I think his progress is testament to a few factors:

1)  Good physical therapy teaches movement patterns that transfer seamlessly to activities of daily living, both easy and hard.

Scott learned how to hip hinge, brace his abdominals, and move his shoulders overhead with good thoracic mobility as a patient.  These were all goals of ours in physical therapy, as his job demands required these abilities.  When Scott decided to train, there wasn't a need to re-teach basic patterns he had already learned as a patient.  All we did was progress and manage load for the lower extremity movement patterns.

Teaching upper quarter exercise progressions were no problem, as Scott already had great ability to set his abdominal and hip musculature, resulting in a stable base for a  proper push up.  Having appropriate thoracic mobility and abdominal contractility made it easy to tolerate chin ups and pull ups (as well as the press pattern).

2)  Mastering "need to have"exercises gives you currency to purchase "nice to have" exercises. 

Scott's program doesn't include much fluff.  As outlined above, we concentrate on hip hinging, pushing and pulling in a whole body manner.  Interval training utilizes the Concept 2 rower and Versaclimber-not real fun, but very effective.

At Scott's request, I have included some direct biceps and triceps work.  However, this is always done at the end of the session, so as not to interfere with our "money" exercises.  Obviously, if we emphasized triceps pushdowns, dumbell curls and leg pressing at the expense of our current program , progress wouldn't be where it is.  Again, I have no problem with inclusion of these things, but they should be looked at like you look at desert at the end of dinner-not something to start with, and not to be consumed in excess.

3)  Slow, steady progress-boiling the frog or melting the snow pile,-ensures long term success.

Steady progress in a strength and conditioning program is similar to the analogy of boiling a frog-turn up the temperature with a frog in a pot of water, and you can boil the frog without it even being aware of the process (I am not reccomending you try this BTW). When a huge snow pile melts too fast it results in flooding, or at least an undesirable mess. When left to gradually warming temperatures and sun exposure, the snow subliminally retreats without you really noticing it until it is gone.

Prior to chin ups, we utilized cable lat pulls in a tall kneeling position, again in a low rep/ high set fashion.  This allowed abdominal engagement and good latissimus force production.  When pulley column weight was at a level I deemed appropriate, we switched to chin up and pull up progressions. Scott started off with chin ups using a mini band for assistance, struggling with 3 reps per set initially. This was in mid June-just shy of two months ago.  Progress remained steady on a weekly basis, and external load was added as tolerated, progressing to the point where we are performing solid reps with 25-30 lb. of external resistance.

The same progression was utilized for trap bar deadlifting and push ups.  Typically we perform 10 sets, at 3-5 reps/ set, adding weight, decreasing reps, adding reps, adding weight.  The end result is Scott can now push up with solid form and 45 lb. external resistance for 10 sets of 5.  Deadlift progressions have been slower recently as Scott's job demands take a toll on his lumbar spine at the end of a 12 hour day, but his form remains rock solid.

All the above factors played into Scott's successful physical therapy outcome as well as his current progress in training.  Moving forward, what he has developed is a great foundation for future program progress, the ability to tolerate demanding job activities as a self employed landscaper, and an appreciation for what it is like to be mobile, strong and functional following a solid training program.

Guys like Scott are why it's easy  for me to get up everyday and do what I do.



The Cambered Hand Push Up

Filed under: Uncategorized — Shon @ 5:22 am August 15, 2011

Push ups are one of two staple  upper body exercises that should be in all athletes' strength programs (the obvious answer to the other will be given at the end of this post).  The chances are if you are reading this, you already know that a properly performed set of push ups is an exercise not only for shoulder, chest and triceps, but also allows for balancing forces in the trunk and lower quarter while keeping a neutral spine posture.   However,one thing that I have noticed that is never really coached in a push up is hand posture. Hand position maybe, but certainly not hand posture. Why do I bring this up?  Because I believe a properly "set" hand posture can accomplish the following:

1) Decrease perceived exertion as well as fatigue in the triceps.

2) Allow the trainee to focus more on proper trunk/ hip posture now that triceps fatigue is decreased.

3) Express more power during the concentric phase of the repetition secondary to a reinforced base of support.

4) Improve plyometirc/ explosive push up performance by allowing a more stable base of support through the wrist, hand and forearm.

 

What constitutes a properly set hand in a push up? Not what you may think:

Nope…at least not for a healthy wrist/hand

 

 

I believe the ideal hand set up for a push up is something I refer to as a cambered hand position. I initially was  exposed to this concept while reading a post on Jim Bathurst's site , highlighting his training session at a circus school here in Philadelphia.  Jim mentioned that curling his hands while transitioning from a two arm to a one arm handstand.  The rationale from his instructor was to allow improved hand strength, ultimately preparing the acrobat to perform a handstand on another person.  Curious, I played with this position in my own pursuit of a reasonably lengthy handstand, and found the position to be extremely supportive, almost instantly improving the quality of my handstand, as well as decreasing upper quarter with my handstand support on the wall as well.

What I initially noticed was an increase in activation of the forearm musculature, both in the flexors and extensors.  Secondly, I noted decreased fatigue in the triceps and anterior shoulders, which became more apparent as my sets progressed.  I then attempted a few sets of push ups after my handstand training, where I was even more pleasantly surprised.  Almost all triceps fatigue that I normally experienced (which was my limiting factor in performance) decreased by greater than 50% qualitatively.  The majority of the stress was now felt in the posterior aspect of the shoulder, particularly the posterior deltoid.  This also allowed me to concentrate more on keeping my hips and abdominals engaged, as my focus wasn't on triceps fatigue.

Once I made this "discovery", I started to utilize it with my patients, training clients and athletes.  Without cuing them on where they felt fatigue primarily, the large majority noted substantially decreased fatigue/ discomfort in the triceps, as well as more engagement in the posterior shoulder.  Almost all preferred the cambered hand position over the traditional hand position once they became proficient in it (which took place within 1-2 sessions).

Set Up for the "Cambered Hand"

1) Place both hands together in opposition.

 

 

2) Bring fingers and thumb together, so they are touching.

 

 

3) Keeping palms and thumb touching, now pull your fingers away from each other.

 

 

4) As best as you can, touch the tips of the second through fourth fingers together while keeping your fingers and thumb together (this takes a little practice)

5)  Seperate the hands, and inspect them.  They should look similar to this:

As an aside, this position is almost identical to the "shuto" or "knife hand" position in Shotokan and other forms of traditional karate

 

6) Set up for your favorite push up variation and perform.  Over the course of your next 2-4 training sessions, you should feel more comfortable as well as proficient in both hand positioning/ set-up as well as push up performance using the cambered hand position.

 

 

I took a few photos of each position, after I was "chalked up" for comparison on two different occasions.  Here is what a "traditional" hand position looks like:

 

Here is what a cambered hand position looks like:

 

As you can see, the fingers (actually the proximal and distal phalanges) are not making contact in the cambered hand position.  You may also notice that the finger tips are closer together (as is the thumb tip) in the cambered hand position.  Additionally, look at the thenar and hypothenar eminence imprint on the cambered hand-definitely more aggressive and engaged.  The cambered hand to me looks actually more like an animal paw print rather than a human hand print.

 

So,What Is Happening Here???

I have pondered this since my  first training session using the cambered hand, and I believe there are several factors involved:

1) Massive co-contraction and activation of the finger and hand musculature

The hand intrinsics, finger flexors and extensors, as well as the  forearm flexors and extensors all activate to the extent they are able to, stiffening the hand dynamically.  As the agonist and anatgonistic hand musculature is activated,  Sir Charles Sherrington's concepts of irradiation and successive induction take over, allowing spread of excitation, activation and contractility to the forearm musculature.  In a traditional push up, little attention is usually paid to the setting of the hands; as a result there is no real "overflow" to the forearm musculature.

 

 

 

2) "Strutting" of the Forearm

The wrist extensors and flexors (and possibly the forearm pronators/ supinators) undergo increased active and passive tension, thereby stiffening the radioulnar joint by way of the interosseus membrane.  This sets up a "rebar in concrete" like structure (the "rebar" being the radius, ulna and interosseus membrane, while the "concrete" being the active and passive muscle/ fascia interface).  With the forearm strutted along with the hand, you now have a very stable base for the prime movers in the push up.

Think of your forearm as this pillar-two metal rods reinforced with concrete

 

 

3) Attenuation of Forces Below the Elbow, Decreasing the Perceived Exertion in Other Musculature

As the forces from the ground meet the newly stiffened wrist, hand and forearm complex, one of the first things you will notice is a decrease in triceps fatigue as you move toward your individual higher repetition ranges.  This also allows you to direct attention in maintaining proper stiffness in the trunk, which is a point of contention in many people, especially deep into a set.In most trainees, cambering the hand leads to increased quality repetitions per set, both with loaded and unloaded push ups.  At this point, anyone who I have trained in the cambered hand position continues to prefer and perform them in this manner, from kids as young as eleven, to people in their fifties.

 

 

In Summary

The cambered hand position is a functional position for distal arm stability that allows improved performance metrics in most push up variations.  By increasing  the  static and dynamic stability of your base, power is more easily transferred through the distal upper quarter  through a combination of neurophysiology and biomechanics.  At the end of the day, this is what we are all after-making an exercise that is already great even better.

By the way, the answer to the question at the start of the article is pull ups; chin ups also count as a correct response.

If you somehow got this wrong, drop and give me fifty push ups-with a cambered hand of course.

 



Reflections on the BSMPG, Part 2

Filed under: Uncategorized — Shon @ 7:04 am July 7, 2011

Again,all appologies about the delay between Part 1 and Part 2. As a relatively new blogger, I am still finding my equilibrium with regard to writing, posting and editing as well as running my clinic, treating patients and training athletes.  Plus, I can't get Wordpress to stop replacing my quotations with some odd code edit (") when I use spellcheck, delaying this even further.  Picking up where I left off:

Day 1 Recap-Great Presenters, Great Content

Again, day 1 was everything I expected in the seminar, plus more.  At this point in my career, I don't attend many multiple speaker/ multiple subject seminars, but I felt I had gained some great insight from the day 1 presenters.  The happy hour afterwards was a good time to meet some interesting attendees, say hello to a few people I had only known through e-mail, as well as plan out my day 2 strategy. 

After happy hour, I hooked up with my old college roommate Mark, who owns a successful business  near Boston.  Even though Mark has over 250 employees and 400,000 square feet of factory and warehouse space, to me he is still the guy who painted our room yellow, green and red, while hanging a Bob Marley flag on the ceiling in 1985.  Always a blast hanging out with guys like that.   I broke from my normal pseudo Paleo plan and chowed with him on French-Chinese  fare at Jae's Restaurant nearby, and finished with Belgian frites as well as a Belgian waffle with salted caramel in Faneuil Hall.  It was enough of a carb load to allow me to sleep past 3:30 AM.

Day 2

Saturday, I woke by alarm at 6:30 and headed back to the "Y', as they had a Treadwall which I wanted to try.  In the middle of the session, I got a call from Ben Bruno (yes, I had my cell phone at the gym, but for good reason-I was responsible for my wife's wake up call at 7:30 so she could get my son to flag football).  While talking to Ben, I felt extremely guilty for climbing something like the Treadwall without a 100 lb. weight vest strapped on or 75 lb. of dumbbell hanging from a belt.  Ben was at Perfrom Better with the staff from Mike Boyle's gym, and we were trying to arrange dinner later that night.

After heading back to the Northeastern campus, I got a good seat (again, in a university lecture hall, generally all seats are decent) for the first lecture of the day, outlined below:

Lecture 1-Peter Viteritti-Contemporary Concepts in Manual Medicine

The first keynote of day 2 was delivered by Dr. Viteritti, a chiropractic sports physician who practices in  a collegiate program at Northeastern, as well as with a forward thinking physical therapy group in Boston.  He explained that he works closely with physical therapists and physicians in a team approach to manual therapy and rehabilitation, and really seems to have an open mind with regard to mixed manual interventions as they relate to  traditional chiropractic skill sets.  I think we are seeing more of this professional mutual respect across the country, especially over the past 3 years.  I hope it continues, as athletes and patients benefit when turf wars are minimized and professionals work with each other's strengths vs. trying to "be all things to all people". 

Dr. Viteritti's lecture focused on comparing load (force applied to the body that has direction, magnitude and time, or stated simply: how much you ask your body to do) vs. capacity (how much can the system handle without breaking down) and respecting this relationship in the treatment of musculosketetal injury.  One  immediate takeaway as a clinician was that patients should expect 5-10% improvement per visit (which falls in line with what we see typically in our clinic), ot 10-20 visits for full resolution.  The relationship between symptoms (a sign of disease/pathology) and dysfunction ("any part of the body that is not working properly, or in some way is deficient").  Treatment would focus on increasing buffer capacity between the combination of dysfunction blocks (weakness  or adhesion for example)  and the symptom threshold.  This brought me back to my time at a seminar with Jim Porterfield and Carl DeRosa 14 years ago (in Boston,literally right up the street from Northeastern), where Jim spoke of  expecting a 2 to 5 hour window of decreased fluid /inflammation congestion and subsequent symptom control, increasing in length of time  with each sucessive treatment; "designed to enhance healing  and progress toward functional repair" (Porterfield and DeRosa, page 210; figure 6.28). 

 "Patient Centered Care" was discussed and can be best summarized  where providers (physical therapists, chiropractors, athletic trainers) who have, the most appropriate set of treatment tools to address the dysfunction at the appropriate healing timeline are utilized.  Compare this to "Clinician Centered Care", where communication is poor between providers and a redundancy of care can occur across disciplines to the ultimately hampering the recovery of the athlete/ patient.   As a physical therapist, I think Dr. Viteritti's definition of  "dysfunction" can be interchanged with "impairment" (based on the Nagi model), but that is really just semantics, as overall the presentation was excellent and informative.  A patient demonstration was performed live, which highlighted Dr. Viteritti's manual skills in neural/soft tissue mobilization on a conference attendee, rounding out the talk.  

Lecture 2-Norman Murphy-New Concepts in Foot Function and Gait Anylisys Assessments and Treatments

Dr. Murphy followed up with a technical talk on foot function analysis using pressure mapping, which is simply (and at times not so simple) measuring compression forces on the weight bearing foot as the body moves forward.  Plenty of operational definitions were reviewed with regard to biomechanical loading parameters in the foot, while guidelines for appropriate utilization and evaluation of them were discussed. Dr. Murphy's information was well organized, and technical terms were broken down enough that they were easily digested by attendees.

Overall, the presentation was more of an introduction of what pressure mapping can offer the performance and rehabilitation communities.  As concepts were introduced, some practical examples of how the data/information could be used practically.  One interesting comparison was that of the loading of a basketball player vs. a triple jumper in an actual jumping condition.  The differences were reasonably dramatic in terms of raw data (the triple jumper had more of a two phase load distribution in quite a short time vs. the basketball player); what this means in a practical arena probably has yet to be determined.  This certainly doesn't mean that the information is  not useful; it only means we now have access to a  tool (in this case, the Tekscan technology) that can help perhaps define loading parameters through the foot.  This can allow both clinicians and coaches the ability to track trends in performance throughout a training cycle, screen for loading patterns as they pertain to lower quarter injury, or determine wether footwear/ orthotic changes need to be tweaked.  

In terms of my own training, I would be curious to see my own  foot pressure map in the first 25 meters of a 100 meter race (my best part) vs. the latter 25 meters.  I would also be interested in looking at right vs. left side differences during squatting, deadlifting, as well as the quick lifts and unilateral training.  In the clinic, I think it would benefit my patients to see a pressure map of their stance phase in level surface walking as well as with stair climbing and unilateral balance activities.  Pressure mapping would be a useful tool to allow feedback and make meaningful changes in combination with other forms of therapy, and I look forward to seeing where companies like Tekscan take this down the road.

Lecture 3-Cal Dietz-Sub-Maximal High Velocity Peaking Method using Tri Phasic Undulated Periodization

Hands down, Cal's lecture was the most fun I had out of the 10 I attended.  I was initially torn between Dave Nolan's running injury lecture and this one.  However, I had seen Dave speak at the excellent "Foot Hits the Ground" biomechanical seminar in 2004, plus I was very familiar with this information as I treat a large number of running injuries in the clinic with great outcomes.  So, it was off to see Cal…

I was about 2 minutes late for the beginning of Cal's talk, and I missed his initial comments.  However, from what I could gather, he has worked with several elite track and field athletes as well as multiple Olympic and professional athletes.  Cal also has a training group of professionals that work with him in the off season, so his results pretty much speak for themselves.  The thing that I really liked about Cal was that he had a classic crazy strength coach intensity throughout the lecture.  You could tell he literally stayed awake at night thinking about and refining his concepts for his athletes.

Cal's emphasis involved utilizing an undulating block periodization model, but making the third training day the lightest day , utilizing weights generally between 55-90% 1 RM, depending on the phase of training.  Taking this a step further, he utilizes 2 week blocks emphaizing one aspect of muscle contraction in a triphasic model (concentric-isometric-eccentric).  Eccentric emphasis is the first 2 week block, followed by 2 weeks of isometric emphasis, finally finishing with 2 weeks of explosive training.  Eccentric time under tension  is generally 3-6 seconds/ repetition, while isometric holds (actually a stretched isometric/ yielding isometric) fall in in the 3 second range.  For his explosive training, sometimes a Tendo unit is utilized, with no more than 5% fall off of bar speed expected with a given exercise.  AFSM plyometrics, where antagonistic muscle relaxation is emphasized and exploited, allowing force to be expressed better in training/ competition was also covered and explained.  Timed sets, as they related to the triphasic model and utilized at Minnesota was also discussed. Video examples of training were plentiful, and Cal's XL Athlete website has hundreds of videos and articles for those interested.  

Cal explained the reason for developing this method of training was to have a more reactive athlete who could express force in season, with an implement or on the field vs. an athlete who could express strength in the weight room.  He had 3 case studies (which, of course I always am partial to) of Minnesota athletes' responses to his approach.  Some confusion arose during his talk where it seemed that he was not training maximum strength capabilities during the year.  This was not the case, especially as I clarified with him after he was done speaking.  Maximum strength is important in the Minnesota program, but as the season approaches, especially for an advanced athlete, sports specific force generation becomes the priority, not "straining strength" (as Cal put it).  He actually placed things in perspective for me in my own training, as I have been chasing both 100 meter speed and maximum strength at the same time for the past few months without great success.  As I said before, it was a lot of fun to listen to this slightly crazy and innovative coach from Minnesota.

At the risk of making this series into an R. Kelly video, I will close for now, covering Shirley Sahrmann's and Charlie Weingroff's lectues in my next installment, as well as answering a few questions from a regular reader.