1) Bill Hartmen uses the downward dog to increase pre-load on the diaphragm, activate the serratus anterior, and unload the scalenes while facilitating deep neck flexors. All this can significantly help your breathing patterns. Check out this months post on breathing.2) This is a great thoracic mobility technique using the NMT T-Bar. A good way to increase thoracic mobilization andintegrate with scapular movement.3) Nice summary of FMS corrections (from Mike Reinold's site).4) Neuroplasticity, motor control, and neuromuscular effects all in an easy 2.5 minutes. Finger strengthening study: physical exercise group improved 30%, mental exercise only group improved 22%! If that doesn't make you believe in the importance of the CNS I don't know what will.5) Just learned about Charlie Weingroff's Core Pendulum Theory. Charlie does a great job of brining the FMS, SFMA, and DNS together for his assessment. He describes the FMS as a stability assessment and the SFMA as a mobility assessment. This might be an oversimplification, but it helps to classify your patients into each system. His pendulum theory provides a great visualization of the joint centration (or path of instantaneous center of rotation) concept.6) Eric Cressey goes over 6 aspects proper warm-up. 1. Soft-Tissue Work (foam rolling) 2. Mobility Drills - Ground to Standing 3. Mobility Drills - Single to Multi-Joint 4. Focus on ankles, hips, t-spine 5. Takes into account natural joint laxity 6. Actually warms up body temperature. Great examples and easy to implement in your patients tomorrow. Might be better for your patient than that arm ergometer and moist heat pack.7) Bret Contreras gives a nice example of a glut strengthening program. For a baseline movement pattern correction, Dan John goes over the hip hinge. If your patient can't hip hinge then they'll have bigger problems then glut strength.
Breathing - Part I - Anatomy & Mechanics
The average person takes about 21,000 breaths a day. This makes it one of the 3 biggest aspects of our patients life that we can have a profound effect on (other 2: posture & walking).This post will discuss the holistic effects of breathing, anatomy, and the important cascade of events for proper breathing and inner core stabilization.
Why Work On Breathing?
Because everyone is doing it. Power lifters have been controlling their intra-abdominal pressure to lift massive weights for years. Yoga and eastern medicine have been using breathing for over 2,000 years (PT isn't even a century old) . Gray Cook and the SFMA require a full breath at the end-range of every movement test to achieve a FN. The neuro-orthopedic approach leans on breathing and even mentions that a deep breath glides the median nerve 1 inch. There is an increasing amount of approaches that are including breathing (PRI, SFMA, DNS). Many of the leading experts in the field are incorporating breathing. And there is more and more research coming out discussing the benefits of breathing. So if you're not doing it, or at least aware of it, then you are probably that guy.
Holistic Breathing
Breathing has a huge influence on the entire body. Breathing influences sympatho-vagal balance. Dyfunctional breathing can induce hypocapnia (effect of hyperventilation). Hypocapnia causes increased neural activity and synaptic transmission. You know those patients that feel that every muscle is tight and you can never decrease their muscle tone for more than 24 hours? Maybe it's because of their breathing. Breathing can actually produce an amplification of the parasympathetic nervous system. This can have a tremendous effect on muscle tone (a nervous system issue).Breathing also has a significant role in the circulatory system, pH regulation, and metabolism. It has been tied to many psychological disorders and can have a major effect on self-regulation of stress and emotion. Breathing even has an important role in some religions and spiritual practices.Breathing has a therapeutic, homeostatic, regulatory, psychophysiological, and spiritual function. If your patients are alive, then breathing should be considered as an aspect of their care.
Breathing Anatomy
A global understanding of breathing anatomy can be expanded from knowledge of the deep front line. This line from Anatomy Trains goes into the fascial attachments of the diaphragm in great detail. Or simply stated, "the 12th rib is where walking meets breathing"-Tom Myers.
Diaphragm
The diaphragm has a dual function: respiration and stability. It should be able to perform this dual function at all times. A common injury is caused by a failure of this mechanism. The overweight, sedentary, desk-jockey wakes up to shovel snow out of his driveway. After 5 minutes he's exhausted and his diaphragm has to devote all of its power for respiration. Now his diaphragm has lost it's stability function. Now he can't control and use his intra-abdominal pressure (IAP). And now he just hurt his back.Want another reason why we should know about the diaphragm's stability role? It's the most proximal muscle...to everything. There's nothing more proximal than the diaphragm. It helps to organize and stabilize the upper and lower quarter. Sue Falsone agrees that the diaphragm is the most proximal. Regarding this concept she has said that she always starts rehab "from the belly button out."
Zone of Apposition
The Postural Restoration Institue defines the ZOA as the "cylindrical aspect of the diaphragm that apposes the inner aspect of the lower mediastinal (chest) wall." This is one of the most important aspects of breathing. The ZOA is responsible for:
- Efficient length-tension relationships of the diaphragm
- Maintains vertical alignment of diaphragm muscle fibers
- Allows postero-lateral (bucket-handle) movement of the lower rib cage
Overall the ZOA is paramount for proper diaphragm function. Some have found it to be as much as 30% of the inner surface of the ribcage. A decreased ZOA will result in inefficient diaphragm contraction, lung hyperinflation, increased accessory muscle use, lack of postero-lateral movement of the rib cage, and an increased anterior rib flare.
Abdominals & Pelvic Floor
The abdominals and pelvic floor play a huge role in inspiration (eccentrically) and expiration (concentrically). During inspiration they contract eccentrically to increase the intra-abdominal pressure (i.e. stability) and ensure that the ZOA is maintained long enough to produce postero-lateral expansion of the lower ribcage. During expiration they concentrically contract to help push the diaphragm cephallically, thus restoring optimal ZOA.
Thoracic Cavity
The thoracic cavity is where the actual breath occurs. It's where the air molecules and gas exchange occurs. The thoracic cavity must have the appropriate amount of mobility to accommodate this pressure change and flow of molecules. During inspiration the ribs must be able to ER and the spine must be able to extend. During expiration the ribs must be able to IR and the spine must be able to flex.Breathing plays a major role in the hydration of the thoracic discs. If you look at the anatomy of the ribs attachment to the thoracic spine it almost looks like a lever. This lever actually pry's open the thoracic spine and elongates it, thus bringing hydration and nutrition to the discs.
Breathing Mechanics (Core from the Inside Out)
There is a cascade of events that leads to controlled intra-abdominal pressure through the activation of the diaphragm and core musculature. By using the breath with the core you are achieving natural muscle activation and increased intra-abdominal pressure. This pressurized stability is much more efficient than muscle activation alone (abdominal hallowing/isolated TVA activation).The best way to have a proper breathing pattern is to get it right from the inhale. A proper inhale will put you in the correct position for a proper exhale. Clinically there are many things that can go wrong with inspiration, whereas the only thing that often goes wrong with expiration is decreased expired air (hyperventilation/decreased ZOA).The inhale is the initiation of core stability.
Inspiratory Cascade of Events
1) Diaphragm Concentrically Contracts
2) Beginning of Increased IAP
3) Abdominals and PF Eccentrically Contract
4) Controlled Increase in IAP & Inner Core Stability
Bottom Line
Understanding breathing anatomy and mechanics will allow you to easily assess and intervene respiration. The effects of proper breathing are: adequate respiration, proper biochemical balance, decreased/prevention of psychological distress, and most important for physical therapist - natural activation of the inner core stability. Part II will deal with ideal & dysfunctional breathing patterns, assessment, and some simple interventions.
Dig Deeper
Dean SomersetHans Lingren - Core Stability Inside OutRosalba CourtneyErson ReligiosoSportsRehabExpert - Ron Hruska InterviewMike Robertson - Video CoachingPatrick WardPostural Restoration InstitueConnor CollinsCraig LibensonBill HartmanTara RobertsonSeth Oberst - 1 & 2
References
Tom Myers & Leslie Kaminoff. The Breath in the Pelvis - Seminar (NYC 2012).Courtney R,Reece J (2009). Comparison of the Manual Assessment of Respiratory Motion (MARM) and the Hi Lo breathing assessment determining a simulated breathing pattern. International Journal of Osteopathic Medicine.Courtney R (2009). The functions of breathing and its dysfunctions and their relationship to breathing therapy. International Journal of Osteopathic MedicineCourtney R (2011). Dysfunctional Breathing - It's paramaters, measurement and relevance. Thesis RMIT University. (a must read - click here)Kaminoff L. (2006). "What yoga therapists should know about the anatomy of breathing." International Journal of Yoga Therapy.McLaughlin L. (2009). "Breathing evaluation and retraining in manual therapy." Journal of Bodywork and Movement Therapies.McGill S , Sharratt M ,Sequin J P. (1995). "Loads on spinal tissues during simultaneous lifting and ventilatory challenge." Ergononomics.Janssens L , Brumagne S, Polspoel K, Toosters T, McConnell A. (2010). "The effect of inspiratory muscles fatigue on postural control in people with and without recurrent low back pain." Spine.Hodges P , Heijnen I, Gandevia S C. (2001). "Postural activity of the diaphragm is reduced in humans when respiratory demand increases." Journal of Physiology.Hodges P , Butler J ,Mackenzie D K, Gandevia S C. (1997). "Contraction of the human diaphragm during rapid postural adjustments." Journal of Physiology 505(Pt. 2Wang S., McGill S (2008). Links Between the Mechanics of Ventilation and Spine Stability. Journal of Applied Biomechanics.McGill S, Sharratt M & Seguin J (1995). Loads on the spinal tissues during simultaneous lifting and ventilatory challenge. Ergonomics.Robey J, Boyle K (2009). Bilateral Functional Thoracic Outlet Syndrome in a College Football Player. N Am J Sports Phys Ther.Boyle K, Olinick J, & Lewis C (2010). The value of blowing up a balloon. N Am J Sports Phys Ther.Kolar P, Sulc J, Kyncl M, et al. (2010) Stabilizing function of the diaphragm: dynamic MRI and synchronized spirometric assessment. J Appl Physiol.Kolar P, Sulc J, Kyncl M, et al. (2012). Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. JOSPT.Hagins M, Lamberg EM (2011). Individuals with low back pain breathe differently than healthy in- dividuals during a lifting task. JOSPT.Clifton-Stmith T, Rowley J (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession. Physical Therapy Review.Hruska R (2005). ZOA Position & Mechanical Function. Postural Restoration Institue.Cook, Gray. Movement: Functional Movement Systems : Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.
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January Hits
1) Maybe we should slow down a little bit. Todd Hargrove goes over why slow movement is important for coordination and movement efficiency. This can be very useful when attempting to teach the "motor morons" how to move right. I specifically liked the Weber-Fechner Law, which describes that the relationship between the physical magnitiudes of a stimuli and the perceived intensity of the stimuli.
2) Overhead movements are usually butchered by patients. When trying to activate the lower trap many patients compensate with a rib cage flare, hyperlordosis, forward head, and unusual grunts. Cressey quickly goes over how to teach the TRX Y's in this 2 minute video.3) The placebo effect is very important when treating patients. However, it is just as important to consider the nocebo effect (negative). Many times patients with pain or poor expectations cause more harm and difficulty with self-administered (or worse, therapist administered) nocebo effect.4) Trouble getting that stiff big toe moving? Bill Hartman goes over how to proximally address this issue. Working on the structures involved with the windlass mechanism can help increase hallux mobility. He goes over a metatarsal mobilization to "restore 1st metatarsal plantarflexion and restore flexor hallucis longus function".5) For those of you worried about job security just remember, there's still people out there doing things like this.6) Here's another article about the neuro based approach in treating chronic pain patients. If you're not on board with this yet, than you're going to become "that guy".
December Hits
1) Pain is usually the main reason why patients come to see us. The traditional orthopedic approach always uses a pathoanatomical explanation for pain, but this might not always be correct. Lorimer Moseley gives a very entertaining presentation on explaining pain. My recent post also goes over some of these central processing mechanisms. And Todd Hargrove has a great review (part 1, 2, 3, 4) of Moseley and Hodges conference on pain and this neurologic approach.2) The dead lift is an essential movement pattern. It is hip hinging at it's best. Gray Cook and Brett Jones go over the dead lift and some great variations with kettlebells. If you think the dead lift is a bad exercise than you should read this (and stop being such a pansy).3) The International Pain and Spine Institute has an awesome newsletter that provides clinical commentary, insightful articles, and current research. Sign up for their newsletter.4) Kelly Starret has a very innovative blog that focuses on high level performance and cross-fit. One of the common mistakes I see in my patients that do cross fit is that they go into an excessive varum moment at the knee joint. They have been taught some type of "knees out" cue (which isn't wrong, just incomplete). While preventing a valgus moment is imperative for knee health, just shoving your knees out by inverting the ankle isn't much better. In this video, Kelly teaches the importance of keeping the 1st metarsal head down and creating torque and knee varum by "screwing the feet into the ground".5) Any questions about the Front Squat are answered by Eric Cressey.
NOI - Mobilisation of the Nervous System
On November 3rd & 4th I had the pleasure of taking the NeuroOrthopedic Institue course - Mobilisation of the Nervous System. I was lucky to have Adriaan Louw as the course instructor. I learned a tremendous amount over the weekend and returned to the clinic on Monday with an additional approach to treat patients with. The NOI provides a paradigm shift in the way we view the nervous system and pain. While it is impossible to cram a weekends worth of great information and techniques into a post, I'll try to provide some key points I learned from the course.
NeuroOrthopedic Approach
Their approach is simple...Tissues Heal!!! If your patient is having pain and it doesn't correlate with the normal tissue healing time then you should consider another mechanism. Traditional medicine usually assumes that pain is directly correlated with a pathoanatomical structure. It often ignores the influence of the PNS (neurodynamics) and CNS (central sensitization). The NeuroOrthopedic Approach allows you to treat the mechanism of pain (input, processing, output), regardless of whether or not you know the exact anatomical structure.
Nerve Principles
The Golden 3
It was highly emphasized throughout the course that nerves need 3 things to function properly. When they don't get these 3 things is when most problems arise. And you can usually fix these problems by giving nerves back the 3 things they need.
- Blood
- Space
- Movement
Neuroplasticity
Neuroplasticity refers to the ability of the nervous system to adapt and alter it's synapses in response to new information, sensory stimulation, development, dysfunction, or damage. This is widely known to most people when discussing the brain and the role of the CNS. However, the ability of the peripheral nervous system to adapt via the ion channels is often overlooked.There are many different types of ion channels in the PNS. Our entry-level physiology education only emphasized the electrical ion channels. What we must consider is that there are many other types of ion channels that play a role in mechanical transport and conduction. Like the CNS, these ions change almost instantaneously and are highly adaptable. For example, when you hear on the news that a blizzard is coming, your ion channels immediately start to prepare by changing to handle the decrease in temperature.The clinical pearl to consider with this is that your manual intervention and language can have direct influence on your patients nervous system (neuroplasticity, ion channels).
Neurodynamics & the Continuum
Neurodynamics is "the study of the mechanics and physiology of the nervous system and how they relate to each other". It encompasses how the nervous system interacts with the body on a physical, biological, and neurophysiological level. There are 5 Laws to Neurodynamics: Container Concept, Joint Relationship to Pressure & Load, Pinch & Elongate, Continuum, and Sequence & Order. While each law is equally important, the law of the Nervous System as a Continuum is a concept that many people overlook.The nervous system is a closed-chain continuum, much like the tensegrity properties of fascia. Nerves do not move independently of each other. When you perform an SLR the whole nervous system moves, not just the sciatic nerve on the moving leg. Movement in one part of the nervous system will always result in movement in the rest of the system.Clinically this becomes very useful when treating an acute or post-surgical patient. Mobilizing their adjacent nervous system will result in a low load mobilization of the affected area. This is something that can easily be implemented into your treatments tomorrow. The apprehensive neck patient, the post-op shoulder, the tender ankle sprain...these could all benefit from mobilizing the nervous system away from the site of injury. Dr. Louw discussed how effective this is with his acute whiplash patients. He places them in a brace and mobilizes the rest of the nervous system and has them perform light aerobic exercise on a treadmill. And they get better, faster.
Structural Differentiation
Structural Differentiation is to the nervous system what kinesiology is to ART or what the concave/convex rule is to joint mobs. It is using the continuum to examine, assess, and treat the nervous system. To fully understand this concept one must have knowledge of the peripheral nervous system the associated movements that tension and slacken the nerves. I have created a Neurodynamic Chart as a reference.The concept of Structural Differentiation is simply manipulating the nervous system to either add or subtract tension to evoke a response. This will strengthen your neurogenic hypothesis during the examination and is the basis for treatment. For example, if you're trying to differentiate a hamstring strain from a sciatic neurodynamic dysfucntion you would put the patient in the slump test position. If it is a neurodynamic dysfunction the patient will get relief from slackening the nervous system (either neck extension, lumbar extension, or ankle plantarflexion). If it is solely a hamstring strain the patient will have no relief with neck extension.
The 5 Base Tests (and further differentiation)
We were taught 8 "base tests" in the course. These base tests provide a starting point for assessing the peripheral nervous system. Using the Strucutral Differentiation concept you can adapt these tests to make them functional for your specific patient.
- Straight Leg Raise (Tibial, Common Peroneal, & Sural)
- Sidelying Slump Femoral (Obturator, Lateral Femoral Cutaneous)
- Slump (in sitting and in long sitting)
- Saphenous
- Upper Limb Tension Test (Median, Median 2, Radial, Ulnar)
Intervention
Treating the nervous system consists of applying the principles above to the individual. You want to bring blood, space, and movement to the system. Use the continuum and structural differentiation. Treat the containers (manual to surrounding tissues). Sliders and Tensioners. And explain pain (which is a whole 'nother animal).Of course this is an oversimplification, but the course wasn't taught with a strict "in the box" intervention. Instead we were taught the principles, systems, and methods and encouraged to be creative when applying them to the specific patient. Since we are dealing with a highly adaptive individualized system, I think this process works best.
Bottom Line
There are many approaches for treating the musculoskeletal system, but very few approaches exist for the nervous system. The NOI group provides a great approach for this system and creates a great opportunity for clinicians to grow and add to their "tool box". They're not trying to get you to change the way you practice or trying to convince you to join a cult (like some of the other approaches out there). It's not just a trendy method or technique. Instead, it's a new way to view and treat your patients. It offers another "lens" to look through during assessments. It gives you more options for treatment. It allows you to confidently and systematically work with the the nervous system.For further information on NOI Group and future courses click here. --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.
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The Hits
November Hits
1) My co-worker, Michelle Briancisco, has been talking about using eccentrics to increase ROM for years. She has found it really works well when patients aren't responding to traditional muscle lengthening techniques. She hypothesizes that it neurologically alters the afferent motor output and also provides the patient with a sense of control during the lengthening.2) Saw this on Erson's site. I remember doing this at the TPI course. There's a plethora of good shoulder warm up exercises to choose from for your patients.3) "How to develop monkey feet" by Dr. Andreo Spina. Seriously though, Dr. Spina gives an amazing progression for foot intrinsic strengthening here.4) We always talk about controlling the femur to increase patellofemoral congruency. What about controlling the rib cage to increase scapulothoracic congruency? Lisa Bartels discusses this in part 1, part 2, and part 3.5) Most shoulder programs involve the cue "back and down" and focus on reducing the UT/LT ratio. Eric Cressey points out that this might not be the best approach for all shoulder patients. He talks about how most people spend all day with gravity already pulling their shoulders down and rarely bring their arms overhead. So maybe thats what's missing. There is research out there that shows shoulder impingement patients have decreased upward rotation (specifically delayed UT activation). Cressey explains this theory here and further expands on it with corrective strategies here. He goes into different shoulder rowing patterns here.6) Cuboid Syndrome. Just in case that foot eval tomorrow isn't a normal ankle sprain.
Don't Be "That Guy"
I've been in over 25 clinics and worked with over 75 physical therapist. While this helped me gain knowledge and experience in the field, it has also shown me the different "types" of physical therapist out there. Most PT's are great clinicians and want to help people to the best of their knowledge. However, there are some PT's out there that become "that guy". If you've worked in a couple different practices or if you think back to PT school you have probably met one of these "guys". There are 3 types of "that guy" in the PT world: the hipster PT, the research snob PT, and the ancient PT. It's fun to humorously classify these types of PTs, but it's also important to make sure you don't become one of them.
Hipster PT
This is the hippocritical PT that hates any idea that isn't his own. He likes to think he's extremely innovative and ahead of the curve. He thinks disagreeing and saying no makes him better and smarter than you. No one else's ideas are as good as his and if there's any other way, it's wrong. His strong beliefs in his own accepted theories prevent him from learning anything new or expanding his skills. He practices his physical therapy approach like it's a religion. These are the PT's that subscribe soley to one method and look down at any other method.There are many different approaches out there (SFMA, DNS, PRI, NOI, Paris, Mulligan, Maitland, McKenzie, Feldenkris, etc.). Thus, there are many ways to accomplish the same thing in the rehab world. Instead of utlizing all of these great methods into a blend that will best serve the patient, the Hipster PT sticks with the one he decided was cool before everyone else thought it was cool.
Research Snob PT
This is the guy that spends way too much time pretentiously quoting exact authors and articles to everything he does. He says "the latest research shows..." in almost every sentence. He thinks that just having a reference makes him right. He almost robotically applies EBP and there's no creativity or art to his treatments. The biggest problem with this is that research always lags behind clinical advancements. Instead of giving the patient what they need, he forces the best evidence approach for the pathology they have.
Ancient PT
This is the guy that goes by the motto "if it ain't broken, don't fix it". They're still spending over 20 visits using only VMO strengthening for their patellafemoral patients while shunning dynamic valgus as a trend that will come and go. They are either too lazy or too narcicistic to adapt new techniques and new evidence into their practice. Sure there are some things that will always be applicable, but if you're not up to date with the latest stuff then you're already behind.
Bottom Line
It's important for physical therapists to work together and support one another to better our profession. Clinical advancements and professional autonomy will only be hindered with a closed-minded approach.We will all be better off if we focus on what we are trying accomplish instead of arguing about what we do differently. Principles always outlast methods.
- Help People Feel Better
- Help People Move Better
Hopefully this post provided you some humor and possibly some sympathy. If this post offended you, than you might be "that guy". --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.
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The Hits
October Hits
1) The suboccipitals and occiput-atlas articulation are paramount when it comes to normal cervical function. The fact that our society is spending an increasing amount of time in the forward head posture makes this area even more important for cervical patients. Adding THIS to my soft-tissue work when appropriate has been very helpful.2) Everyone seems to be talking about the Turkish Get-Up (TGU) these days. I've been adding more kettlebells into my own workouts and have been working on the TGU. It's much harder than it looks when done correctly. It takes a great deal of mobility and stability throughout the entire body to complete it without compensations. Mike Roberton has a great step-by-step and Gray Cook has a video demonstration.3) Ron Hruska and the Postural Restoration Institute have a blog and an article section for free education. Jason Mesek has a great post that gets into some of the concepts behind PRI and the importance of the pelvis, diaphragm, and rib-cage.4) Trevor Winnegge does a post on high ankle sprains. This tidbit is clinically useful - "A general rule of thumb, though not set in stone, is that the higher up the leg symptoms go, the larger the severity and longer the injury will take to heal."5) If you like deadlifts and want a lot more information you should click here.
Have a Little Help From My Friends
1) Josh Gellert is a PT at NISMAT. He brought to my attention the importance of addressing the shoulder ligaments in adhesive capsulitis patients. He sent me to this article.2) Shante Cofield is a PT at Duffy & Bracken. She recently had a patient with the rare lateral plantar fasciitis and found this article helpful.3) Jesse Cullen-DuPont is a PT at Spear Physical Therapy. Jesse sent me this great post on increasing ankle dorsiflexion with a cubiod mobilization. He also told me about CE4YOU and how they have some great videos on their youtube page.
Functional Hip Strengthening
It is widely known that hip strenthening plays a significant role in the rehabilitation of knee pain. When it comes to our sagittal-plane loving runners the hips become even more of an issue. However, in 2011 Wiley and Davis published an article in JOSPT that found hip strengthening alone was not enough to alter running mechanics. This gave movement hipsters and research snobs more fuel to trash talk exercises that aren't "functional" or that "research shows" it doesn't elicit some desired EMG number. While I find remedial exercises to be an important step in rehab, I do agree that there needs to be a better transition between rehab and sport specific training.
Assessment
One of the most common hip faults that we see is the contralateral hip drop (trendenlenberg). Many runners have weak hip abductors from overtraining in the sagittal plane and having movement atrophy in the frontal plane. One way I evaluate this is with the single leg stance frontal plane displacement test. To assess for this frontal plane movement dysfunction I look to see how much they shift their weight (COM) over the stance leg. If there is dysfunction, you will see excessive lateral weight shift towards/over the stance leg.
Intervention
Reactive Neuromusclar Training (RNT) is a great way to treat movement pattern compensations. This is done with tactile cues and forces that exagerate the compensation. It alters the afferent stimulation to the CNS and leads to associated changes with the feedforward and feedback motor control systems. The result is that the body's reflex stabilization response is amplified, thus reducing the compensation.Running has been said to be the act of jumping from single leg to single leg. Your body needs to be able to reactively fire your hip abductors to prevent contralateral hip drop upon immediate impact of single leg stance. By going from a double leg stance to a single leg stance with an lateral trunk force you will be training your hip abdcutors to reactively fire and stabilize. It is important to consider that the immediate stabilization and reactive muscle firing is more important than the force attenuation. Below is an exercise I use to help develop dynamic stabilization. It is used for motor control, not for strengthening.http://www.youtube.com/watch?v=KMe8YpYvoW8&feature=plcp
References
Willy RW, Davis IS. The Effect of a Hip-Strengthening Program on Mechanics During Running and During a Single-Leg Squat. JOSPT. 2011;41(9):625-632, Epub 12 July 2011. doi:10.2519/jospt.2011.3470Bouisset S, Zattara M. Biomechanical study of the programming of anticipatory postural adjustments associated with voluntary movement. J Biomech. 1987; 20:735-742.Cook, Gray. Movement: Functional Movement Systems : Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. www.graycookmovement.comAlexander, A. "The Organization of Anticipatory Postural Adjustments." Journal of Automatic Control 12.1 (2002): 31-37Bittencourt N, Juliana M, Ocarino J, et al. Foot and hip contributions to high frontal plane knee projection angle in athletes: a classification and regression tree approach. JOSPT. 2012 --The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.
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