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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.



“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.

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)