2016 - A Year In Review
2016 has been a very interesting year. Some bits have gone as planned, some seemed to come out of left field, but all have an incredible learning experience that has helped shape the course of the next few years. Looking back, the theme of this year can be summed up in two words: "Learn & Persist." There were a lot of new experiences, and a few key goals achieved through persistence.
Some of the experiences I am grateful for during the year so far:
Here's to a strong finish to 2016, and an even stronger start as we head into the New Year. Be safe, enjoy the day, and take some time to reflect on your year and how we can have a positive impact on our world whether it's within our own homes, in our jobs, our local communities, or as far reaching as the country or global community as a whole! On behalf of Athletes Physiotherapy, Happy Thanksgiving!
Course Review: Gibbons & Tehan - Spinal Manipulation 2016
Annual Update for Physical Therapists, Osteopathic Physicians, and Medical Doctors
Last weekend I had the pleasure of attending the Gibbons & Tehan 'Spinal Manipulation Essentials' course held at AT Still University Osteopathic Medical School in Mesa, AZ. The course was hosted by Phoenix Manual Therapy, and I am very happy that I was finally able to attend this course as I had missed it last year!
I won't give a super detailed play-by-play, but I will hit the high points of what I liked about this course and why I hope to take it again next year:
1. World-class Instruction (by two incredibly knowledgeable individuals!)
While they definitely have their thoughts and opinions, as most of us do, it was very refreshing to hear their thought process and what 40+ years of clinical practice has taught them. There were great discussions on Evidence-based & Evidence-informed Practice, and how the three pillars of Best Research, Clinical Experience, & Patient Preference and Values all merge together in the decision making process. Being both Clinicians & Academics, it was great to hear from people who live in and understand both worlds, and how they relate to the care of our patients & clients on a daily basis.
2. The Underlying Philosophy.
What I appreciate most about this course is the chance to learn 'a new twist on an old story.' Yes, I learned a few new techniques and ways of performing manipulation to the different regions of the spine, but some of the techniques and set-ups were familiar to me from the training I received in my Orthopedic Manual Physical Therapy Fellowship Program. What was different about these familiar techniques was the way in which they went about setting up and performing the manipulation.
If you are a manual therapist reading this, you probably are familiar with 'barrier technique', that is, taking up component motions and finding the barrier at the segment you are trying to manipulate, and performing your thrust at and into the barrier. This is much of what I was taught. What you learn in this course is that you can perform a similar set up using coupled motions of the spine to perform your manipulation without hammering away at a barrier. One take away for me personally, was that in the past I may have created too much stiffness in my set up resulting in an unsuccessful attempt at manipulating the joint. The process we learned in this course has definitely helped to refine my skill set, and adds another option which I also find to be more comfortable for the athlete or patient. Manual therapy, and joint manipulation in particular, are very much psycho-motor skills and need to be continually practiced and refined. I would definitely recommend this course to anyone who has had training in joint manipulation and is looking to further refresh and refine those skills.
3. Great Presentation Skills.
I am sure that at some point over the weekend someone was offended, but their presentation style and ability to integrate humor and make a point was great, and made the didactic portion of the course easy to stay present in. (I definitely think I need to make a trip down to Australia, it sounds like a place I would fit in well!)
I'd like to extend a big Thank You to Peter & Philip and Phoenix Manual Therapy for putting on a great course! Looking forward to doing it again...
Dr. Kristopher Bosch
Why do they have this hypersensitivity towards ACL injury?
It is commonly perceived and accepted that a torn ACL punches your ticket for reconstruction surgery, and brings with it 4-9+ months of rehabilitation and generally means missing an entire season in your sport. It has been reported that approximately 200,000 ACL reconstructions are performed each year in the United States costing an estimated $3 billion US dollars. While it's not a catastrophic injury, to say that it is routine or somehow not as big a deal as it used to be due to the advancements in the science & technology related to reconstruction surgery and rehabilitation is misguided at best. And we then have to ask: given the advances in the fields of surgical and rehabilitation sciences and strength & conditioning, why do we still see such a high rate of ACL injury and why do so few athletes get back to their sport following ACL injury.
Yes, you read that correctly. It seems that in the information age we are inundated with success stories of professional athletes returning the following season after ACL reconstruction 'good as new.' But understand this: the Willis McGahee's & Adrian Peterson's of this world are few & far between. They are the Exceptions, NOT the Rule. They are also generally already physically gifted and in those to cases in particular, they have access to round the clock medical staff tasked with the sole job of getting that athlete back up and performing. Current research shows that, for those athletes who sustain an ACL injury, about 60% of these athletes make a full recovery, less than 60% return to sport, and more than 50% develop knee osteoarthritis (most commonly though these individuals also have meniscus injury which seems to be highly predictive of osteoarthritis development).
So Much Literature, So Little Clarity
It is interesting that we have so much research into this topic of ACL injury, yet little practical implementation at the clinical level to aid us in achieving better outcomes for our athletes. What is it that is missing? Well, quality for one...
Let's start with what is accepted. In 2015, The Journal of Bone & Joint Surgery published a paper titled The American Academy of Orthopaedic Surgeons Evidence-Based Guideline On Management of Anterior Cruciate Ligament Injuries. This paper is a clinical practice guideline has been endorsed by the National Academy of Sports Medicine (NASM), the American Orthopaedic Society for Sports Medicine (AOSSM), the National Athletic Trainers’ Association (NATA), and the American Academy of Physical Medicine and Rehabilitation (AAPM&R), so arguably an important paper if all of these organizations have adopted it. The paper looks at the level of evidence supporting common clinical recommendations and practices for the work up and management of an ACL injury. While a good start, the results are not impressive. What is glaring is the need for more high quality research to answer these various clinical questions.
With such a seemingly low rate of return to sport, it seems that there is a need for more impactful injury prevention strategies in an attempt to mitigate as much of an athlete's risk as possible. Certainly as you can see from the McGahee video, there is no amount of injury prevention or strength & conditioning programming that were going to prevent that. This was case where positioning of both players, the force of their collision, and the placing of the impact created a mechanism of injury (that I am confident in stating) had almost nothing to do with any modifiable or non-modifiable risk factors for ACL injury. However, the discussion of non-contact ACL injury, which is the vast majority and affects particularly young female athletes is an entirely different discussion. In this context, these modifiable risk factors do matter, and targeted injury prevention efforts coupled with solid strength & conditioning programming can make a difference.
What is also needed is an identification of what exactly is holding back these athletes that don't get back to their sport. Is it a residual deficit in strength or power, and therefore an inability to perform? Is it a lack of proprioception and joint stability? Is it fear of re-injury and an inability to resume prior levels of confidence when engaging in their sport? (As a side, this was big hurdle for me in getting back to jujitsu after rupturing my MCL.) There is continued research efforts being made to answer this question of essentially "What matters most when getting athletes back to sport following ACL reconstruction?" in a paper published in JOSPT in 2012, Lentz et al looked at differences in demographics, knee impairments, and self-report measures between athletes who were able to achieve pre-injury sports participation and those who were not after 1 year following ACL reconstruction. They found that the strongest factors associated with return-to-sport status were self-reported knee function, episodes of knee instability, and knee joint effusion.
"The highest positive likelihood ratio for the yes-return-to-sports group classification (14.54) was achieved when patients met all of the following criteria: no knee effusion, no episodes of instability, and International Knee Documentation Committee Subjective Knee Evaluation Form score greater than 93." (Lentz et al, 2012)
Certainly there are other variables to look at as well. It is said that for many of the professional athletes that do return, there is a significant decrease in their overall performance. They struggle to make the same impact that the did prior to their injury. More discussion needs to had on deciding what the standard should be for return to play criteria, and how do we capture potential gaps in both the physical and psychological variables that my not be fully resolved.
More on this topic to come....
Weight Training for Dancers
The concept of cross-training is not new, and is fairly well accepted among those in the dance world. The idea is that engaging in an activity that is not dance in an effort to maintain strength, flexibility, balance, and overall body awareness will ultimately result in a stronger, more resilient dancer.
Cross-training is promoted in an effort to improve physical development, decrease injury rates, and aid in maintaining body composition. Some of the most common cross-training tools engaged in by dancers tend to be movement practices like Pilates, Gyrotonics, and Yoga. These are all well accepted disciplines, and it would be surprising to find a dancer who didn't know of or already participate in one or more of them.
But what about Weight Training?
"Wait, what do you mean? Weight Training...For Dancers?
No, that isn't for us. It will _________ (insert your favorite myth here)."
Weight Training Myths
The above list are a few of the most common excuses we hear as to why some people discourage their dancers from engaging in traditional weight training. The first thing to understand as a dancer, is that these are all MYTHS.
Myth #1: "The TOO Muscular Physique:
Anyone who has actually lifted weights in an effort to add muscle mass (or what those in opposition would call 'bulk') will tell you that it is NOT easy to do. Simply starting a weight training program will not produce a body builder's physique. It takes very specific training and nutrition regimens (an sometimes a little extra "juice", but that's a whole different conversation!) to get to that end result. The concern that a dancer will gain an overly muscular physique or lose the desired "ballet body" is based on misunderstanding & misinformation. Additionally, the majority of professional, high level dancers tend to be fairly muscular and have a body composition that is below "normal" for body fat percentage. Body image, nutritional habits, and eating disorders is, once again, another whole topic of conversation but is part of every discussion regarding the health of the dancer.
Solution #1: Application of Weight Training
I find that weight training is often feared because it is viewed as being one dimensional. When we start the discussion of weight training for dancers, the go-to mental image that usually pops up is of an Olympic weight lifter, an NFL football player, or a body builder, as these are most often portrayed in mass media. Understandable, but what also needs to be realized is that weight training is very individualized based on the athlete, the requirements of their sport, and the desired attributes we are looking to develop.
Essentially, this is a long-winded way of saying: a weight training program FOR DANCERS is designed FOR DANCERS. This will ensure that we do not create 'bulk,' nor do we need to do advanced technical Olympic lifts. We tailor the program for the specific needs of the individual in an effort to ENHANCE their dancing and aid in building a more resilient body.
The reality is this: if you are engaging in a program based on sound practices and you are dancing on a regular basis, there is NO reason why you should lose mobility or flexibility because you weight train. Probably the best all around example of this is gymnasts. The are extremely powerful, yet also incredibly flexible. Their training ensures that they maintain these qualities, and it should be no different for a dancer.
Solution #2: Application of Weight Training
Flexibility and mobility can be optimized through weight training. Bold statement? Perhaps. But think about this:
We often see athletes - including dancers - who complain of being "tight" even though they have tremendous amounts of flexibility & joint mobility. In a fair number of instances this "tightness" is not due to muscle needing to be stretched or because it has been overworked in training, but instead is a compensation due to lack of strength/stability somewhere else. Couple that with the fact that many dancers are hyper-mobile, and we can easily see how strength training can help address these issues. Optimizing breathing and increasing true strength are generally our first order of business for that athletes we work with.
Myth #3: Weight Training will result in injury
I am not sure where this notion came from. The idea that weight training causes injury is about as rational as saying dance is dangerous because dancers often get injured. The reality, of course, is that any activity done incorrectly, with poor form, or in a volume that is above the body's ability to positively adapt can result in injury. However, a weight training program based on sound science, and tailored to the needs and activities of the individual athlete will rarely cause injury.
Solution #3: Application of Weight Training
Weight training as an adjunct to Dance training can aid in preventing injury by improving overall strength, proprioception, and cardiorespiratory endurance. The key is in the programming, which must be tailored to the needs of the individual dancer. It must take into account things like the style of dance, movement & energy system requirements, and training age of the dancer.
The Unique Challenges Of Working With Special Forces Operators
It truly is a sports medicine setting, modeled after your top Division 1 athletics programs or professional teams, where the focus is on high performance. You want your guys to perform at their best, stay healthy, and get them turned around and back into the game as quickly as (safely) possible.
It's funny though, because every time we discuss this topic, the first analogy people go to is a comparison of special forces to professional sports. What many fail to realize, and was so eloquently pointed out to me recently, is that this is a rather poor analogy. You see, the professional athlete has one job - to be an athlete. They train so they can perform their role for their team come game time. For our military operators, this simply is not the case. Their job is not to be an athlete, their job is to be a Ranger, SEAL, Pararescue, etc. and perform the specific job duties of that career field. Being an athlete helps these individuals do their jobs, and while it is a necessity it is not the sole focus. As we will discuss in a moment, this is the biggest challenge in working with these individuals.
Of course, the REAL kicker here is that this ISN'T a game.
The reality of the situation is that their work is dangerous - honestly, even their training is dangerous! There are generally no do-overs or mulligans. They know their mission, and they work as a team to complete it, each having their job and one relying on the other. It is 100% teamwork - all day, everyday. As such, it is that much more important to make sure that their rehab is on point, their strength & conditioning is tailored to their specific needs, and that neither are the cause of more injury or delay in returning to full duty. There are piles of open source research articles detailing the fact that the vast majority of injuries sustained by military personnel are related to musculoskeletal injuries, the vast majority of which are non-combat and generally tied to poor practices when it comes to their strength & conditioning. Thankfully, many units are now getting well qualified strength & conditioning coaches, who are in many instances working along side physical therapists and athletic trainers. The theme is work smarter AND harder.
"If you had to choose 1 challenge, what would it be?"
When this question is posed, it's actually a quick and simple answer: consistency & time.
While that looks like two, they really are one in the same when you come down to it. As I mentioned above, the job of an operator is not to be an athlete. Their job is whatever it is that their service career field does. But is should be easy to recognize that when you have groups that do multiple activities in any AND every terrain and weather, there is more than a metric ton of training involved. First to make it onto a team, then to stay qualified. Think about the things that you see in the articles, news clips, and even the often embellished Hollywood movies. There is parachuting, fast roping, diving, mountaineering, rock & ice climbing, skiing, navigation of small vehicles like quads, boats, jet skis, etc. Your Pararescue operators are full blown Paramedics performing battlefield emergency medicine in often hostile environments. Keeping up on these skills takes time, and often takes them out of the hands of the human performance team.
Here's another professional or college sports analogy: Imagine you are a physical therapist, athletic trainer, or strength & conditioning coach for a professional football team. You have to train and rehab your guys, and help them with generally staying healthy and fine tuned. Your strength & conditioning coach has a plan for getting them in peak shape so they are strong, fast, and can utilize all energy systems to meet their specific positional job demands. The PT & ATC are working to mitigate the small issues that pop up during training, and also work to rehab the 'big stuff' which are your post-surgical athletes and your bigger injury, non-surgical athletes - say something like a hamstring tear.
Those of you who have worked in this setting or similar are thinking "Yeah, so what. That's just a normal day at the office."
Now imagine that for chunks of time your Wide Receivers are away at 'Catching Clinic' for two weeks return for a month and then leave for 'Route Clinic' for two weeks, your Offensive Linemen are away at 'Blocking Camp' for one week, your Kickers & Punters go to 'Kicking Qualification' for three weeks, your Quarterbacks go to 'Throwing Clinic' for 2 weeks, your Linebackers & Defensive Backs go to 'Tackling Clinic' for two weeks come back for a week and then all go to 'Pass Coverage Clinic' for three weeks...and so on. Many of these clinics overlap, and are spread out across the entire year,some for days some for multiple weeks. Oh yeah, and of course you have to do you Pre-season and actual Season to play, which for Operators would be a deployments....
Starting to see why this would be a challenge?
Working with these individuals is a privilege and probably the most rewarding setting I have ever been involved in. They say excellence begets excellence, and you are the sum of the people you are around most often. You can't help strive for success and push yourself to perform beyond what you thought possible when you are around that mentality all day long. There is much to be taken from this experience, and I look forward to seeing how it continues to evolve...
Why mobility matters in these areas
Certainly there are other areas that also require mobility. The decision to discuss the thoracic spine and hips was born out of the realization that on a daily basis I find myself discussing these two areas with many of my clients and athletes. Some of these discussions are in response to:
There are 3 main reasons that I think these areas are important to maintain, and therefore would be considered the 'biggest bang for your buck' areas to hit if you have limited time to spend on mobility drills and warm up:
1. Effect On Adjacent Areas -- It's All Connected!
Regional Interdependence is a term you may come across, particularly in the rehabilitation world. To keep things simple, this is the concept in more of a biomechanical model looking at how one area of the body can have an effect on other areas of the body. These areas may be in direct proximity to one another, or they may be far away from one another. As an example in the first instance, we can see cases where lack of mobility in the hip contributes to problems at the knee of the same side. In the latter, we see cases where lack of mobility in the ankle affects the opposite shoulder (the pitcher in baseball comes to mind here). When talking mechanics, we are looking for an efficient distribution of force across the various joints and segments of the body. Lack of mobility in a joint that should be fairly mobile can result in increased stress or load on other joint and creates an inefficient movement system.
One thing to note and try to get ahead of based on that last statement -- I am NOT insinuating that the lack of mobility or inefficiency, and therefore biomechanics is the CAUSE of a pain in a particular situation. Is it likely to be a contributor? Yes, I believe it is. Pain science certainly tells us that pain is an experiential construct of the brain brought about by the brain's perceived threat to the body. The question I have always pondered - Is the brain perceiving threat due to repetitive overloading of a tissue resulting in that area becoming painful, whereby we are then forced by the brain to pay attention?
2. Rotation is Power -- Own Your Transverse Plane!
Forget about the basic fundamental fact that we are 3-dimensional creatures moving about a multiple axes in just basic activities like walking for just a moment. If you are an athlete, you must absolutely have ownership of rotational movement. I have heard Dr. Perry Nickelston of 'Stop Chasing Pain' say that "you need to own your transverse plane," and it is such a spot-on statement.
There is a reason why a shot putter doesn't just load the shot on his or her shoulder and thrust it forward. Same reason a javelin thrower doesn't just stand in a static position, wind up, and launch the javelin down field. Also the same reason a baseball pitcher winds up to deliver a pitch. The transfer of power that occurs in rotational patterns is huge. The two areas of the body with arguably the greatest contribution to rotation are the hips and thoracic spine.
For more detail on owning your transverse plane, check out Dr. Perry's article on the topic HERE. I know I am certainly looking forward to the pending release of his first book!
3. An Ounce Of Prevention = A Pound of Cure
Maintaining the mobility of these areas is relatively simple, and does not take much time. Clients and athletes are often shocked by the difference they feel after we work on improving their hip and/or thoracic motion when these are identified as sources of dysfunction. This could be the difference between a movement being painful at the start of a session and then being pain-free at the end. It can be the difference between having difficulty getting their body into a certain position and then being able to do so with ease. It can also be the difference between struggling to move a certain weight, and now being able to break through the plateau or hit a new PR. If you can improve the mobility in these areas, improve the force distribution and efficiency of the system, you can improve the economy of motion and potentially the overall work capacity of the individual for an activity.
There are a number of ways to improve thoracic and hip mobility, certainly more than we cover here in this post. We will review a couple of my favorite mobility drills that are taught to athletes and clients as part of their home program. Why the home program? Because giving practical solutions and things that someone can keep up with at home and as part of their warm up makes all the difference. Patients/clients cannot simply rely on their visits to the clinic to improve. Improving thoracic or hip mobility can be done in clinic very effectively with interventions like manual therapy & dry needling. However, once we make this change we then have to work on keeping it.
1. The Bretzel -- This is a movement that I have grown to love myself, and it is one I use often in the clinic. It is less of a 'site specific' movement because it also integrates the hips, lumbar spine and thoracic spine at the same time, and I put a big focus on breathing. Note that the set up and cuing is important, as you are going after thoracic rotation, not lumbar. If you have limitations in shoulder mobility due to thoracic restriction, this is a money exercise. Click here for detailed instructions.
2. Quadruped Thoracic Rotation
This is an exercise that is often given to many of our athletes and clients with shoulder issues who also show a lack of thoracic mobility. It is also one that they will do after we have done soft tissue mobilization, joint mobilization, or dry needling as it is an active movement. The intent here is to now use and reeducation the increased range of motion that we hopefully have now gained access to. Click here for detailed instructions.
For more Advanced Thoracic Mobilization Exercise, check out this article by The Barbell Physio: "Five Advanced Thoracic Mobility Drills."
3. Banded Posterior Hip Mobilization with Hip Flexor Stretch
Anchor the band on a solid structure, and place band high on the thigh close to the hip joint. Move away from the anchor point to stretch the band, and assume a 1/2 kneeling position for your hip flexor stretch. Spine stays tall, front knee is at 90 degree angle with knee over ankle; perform a posterior pelvic tilt, engage core, and squeeze the glute of the back leg which you are stretching.
Ideally, as you perform the hip flexor stretch, the band is inducing a posterior femoral glide. You can also add small pulses forward to increase the posterior moment on the hip.
4. Banded Long Axis Distraction
Anchor a band to a secure structure. In long sitting, place the other end of the band around the back of your heel, and then run the band over the top of your ankle/foot so that it forms an 'X' across the top of your ankle. You can adjust the position of the band, as it should not be painful, and should stay secure. Using your arms and opposite leg, slide yourself away from anchor point to stretch the band, then you can lay back and allow the band to create a distraction on the hip. (It should be obvious, but this IS NOT something we do with a patient who has a total hip replacement!)
Learn Dr. John Rusin's dynamic warm-up to improve hip mobility: "Improve Hip Mobility with Dynamic Warm Up Stretching."
There are numerous other options and ways to work on improving the mobility of your hips and thoracic spine. A few notes to add as we wrap up:
Have questions, or curious to learn more about how you can improve your mobility? Send us an email HERE:
Building Resiliency into Your Life & An Opportunity Not To Miss: Tropical Yoga Immersion In Costa Rica
noun - re·sil·ien·cy - \-yən(t)-sē\
Latin: resili (ēns), present participle of resilīre - to spring back, rebound
There are two great definitions of the word Resiliency, and both will apply quiet nicely to the current topic of discussion:
1. the power or ability to return to the original form, position, etc., after being bent, compressed, or stretched; elasticity.
2. ability to recover readily from illness, depression, adversity, or the like; buoyancy.
But What About You?
If you are a professional who works with athletes, or are a high level athlete yourself - generally collegiate, Olympic, or professional - then you are probably well aware of this concept of resiliency training. If you're not, then reach out to use and we'd be happy to help you as you progress through your athletic career!
If you are not currently involved in the health or training of athletes, then this may be somewhat new to you by name, but probably not in concept. The biggest take away I want to provide is this -- Resiliency is a quality that applies to ALL OF US! We live in the 'information age,' a world in which we are constantly plugged in and bombarded with information, requests, and perceived responsibilities. One of, if not THE greatest health challenge we face today is that of stress.
Too often we as individuals tend to bypass the things that would help us the most - exercise, meditation, time in nature, or just alone time with a good book in order to "get more done." I know I am guilty of this.
Recognize two things:
1. There is a huge difference between 'begin busy' and 'being effective.' Many of us are incredibly busy, yet seem to get nothing done. Looked at another way -- how much of what you are getting done is actually helping you meet your goals? If you're looking for more on this topic, Tim Ferriss' "4 Hour Work Week" is a great start!
2. Taking time to unplug, step away, and recharge will result in greater effectiveness and gains when you then return to your normal world. I believe this to be true for all areas - occupation, education, relationships, and even exercise.
Strength & conditioning is actually an ideal example here, and it's been shown time and again. We often seen our athletes just dumbfounded when they are in a maximum strength block and they reach a off-loading week. This is a week that might be around week 4 or 5 (depending on the length of the programmed block) where we decrease volume significantly but continue with training at a decently high intensity. There are usually concerns expressed by the athletes that if we decrease their volume and give them a "lighter week" that they will lose strength. While it seems counter intuitive, the opposite is actually what results. They come back the next week and usually crush their previous numbers, as a super-compensation occurs and you allow the nervous system and body to recover more fully from the previous week's stimulation (because remember, your workout is a stressor!)
So What's The Point?
The point we are making from the above is simply this -- You need to add some off-loading into your life, just like you do in your training. Going 100 miles per hour every day is not sustainable, at least not as well as you think it is. Blocking out a hour a day, a day per week, or any arrangement that generally works for you will be good so long as you do it! I know some people who religiously block out two weeks twice a year for their own resiliency retreat.
Your Ultimate Resiliency Week
Here is a fantastic opportunity to spend a week in a tropical paradise recharging your body, mind, and soul. Join us in Costa Rica May 7-14th, 2016 for a week of yoga, sun, and fun! The retreat will be lead at Hacienda Del Sol in the Nicoya Province of Costa Rica. It is one of only five “Blue Zones” in the world, where people are proven to live measurably longer.
For More Information: Tropical Yoga Immersion Costa Rica
I love TED Talks.
Thankful to a few colleagues who posted this up on Facebook this weekend. It is really worth watching, particularly if you are in field of healthcare and work with patients. His points are very spot on, and it's a notion that I personally subscribe to.
People often ask:
"Why don't you just take insurance, hire a bunch of Techs, and work in groups. It's much more lucrative and cost effective."
Many patients come in looking for an educated, hand's-on approach. While the research is conflicting, there certainly is enough of it out there to support the notion that manual therapies have a treatment effect. No, we may not be actually stretching fascia, breaking up 'scar tissue' or moving bones in one direction or another. Yes, it still is mostly a less than well understood neurophysiological mechanism, as much of the most current research is showing, but that does not mean that it doesn't work.
Many are quick to throw down the "it's just placebo" card -- but can it still be called placebo if measurable biochemical effects are seen in things like neurotransmitters, hormones, and other homeostatic effects designed to keep the bodies systems in harmony?
The Importance Of A Good Clinical Exam
Years ago -- back when I was just finishing the DPT program at University at Buffalo and working as a Pilates teacher, I had a client who was an older physician. He had been in medicine for many decades, and working with these kinds of clientele was always (and still is) a huge treat for me. Not because of who they were in stature and who they knew, not for the sake of the name drop. No, it was WHAT they knew, and the generous manner in which they shared that knowledge that I loved.
One particular conversation that has stayed with me is exactly in line with what Dr. Verghese is stating in his TED Talk. My physician client told me a story about how when he was a young resident a billion years ago, they all gathered with the Chief of Surgery to do their normal recap after Rounds. This particular day was a bit different conversation, one in which the Chief sternly scolded his young residents. He was very displeased with the amount of diagnostic testing that the residents were ordering. This wasn't due to concerns about cost or insurance reimbursement. No, instead it was a concern about quality patient care and getting the diagnosis right the first time.
You see, there is the notion that the more you look for something, the more likely you are to find it. The more tests you order, the more you're going to get back -- but it's the relevance of what you get back that then comes into question. The Chief's advise was a follows (though I'm certain these aren't exact words):
"You don't meet a new patient, get a little bit of history, order a whole barrage of tests, and then make your diagnosis based on what comes back. That is TOTALLY wrong. Technology is getting better, new tests and measure are emerging and more options will continue to be added. You don't throw the kitchen sink at them and see what washes out.
You need to start by taking a good, thorough HISTORY. Then you do a good, thorough CLINICAL EXAMINATION. Now you make your differential diagnosis, and decide what diagnostic tests will best confirm your suspicions & rule out other potentials to get you to your formal working diagnosis which then will lead you to a decision on course of treatment, more testing, or referral."
This exchange has stuck with me, and is something I think on often. It has helped me educate my patients, particularly the ones who as "shouldn't I have an MRI first? How will we know what is going on and what to treat without diagnostic testing?"
Hopefully hands-on patient care and a commitment to quality will make a resurgence in our world of modern medicine.
Here are a few closing thoughts presented by our favorite memes of 2015:
Happy New Year!
Here on the West Coast we are on the heels of 2016! In some areas of the world they are already there! As we move into the New Year, I thought it might be fun to recap a few points that have been discussed in the worlds of fitness and rehabilitation over this past year. Some of these have been longstanding, but it seems this year many of these topics have come up rather frequently, and some with rather fierce debate. Enjoy!
Ah, yes. Happy New Year my people!
It's time once again for the New Year's Resolutions to be make. I do love this time of year for reflection on what has gone on over the course of the last 12 months, how did I do on meeting the goals I set last year at this time, and I always ask myself: "What would it take to do even more this year?!"
I my opinion, it starts with setting good goals and then taking action to achieve them. If you have a goal related to fitness or becoming pain-free and getting back to an active lifestyle, then odds are you are going to need help doing so. Check out our last post: Top 5 Reasons You Missed Your Fitness Goals in 2015 for more information on this process, and some great resources to help get you there!
My doctor said I just "slipped a disc."
Then either your doctor missed a major medical emergency, or discs don't actually slip. The intervertebral disc is firmly attached to each of the bodies of the vertebrae above and below it. Phrases like "slipped disc", "back went out," etc are all poor choices of how to explain to a patient why they have back pain -- and in most cases is totally incorrect as most of time the exact pathology or tissue at fault is unknown.
As our imaging meme touches on below, the picture is not always the cause. Lot's of classic studies, round up a 100 people, scan their low back in an MRI, and you will find something notable in over 80%, while the vast majority to do not have any pain.
So, while you should be careful on the ice this winter, feel reassured knowing that discs don't slip. For more great info on this topic, check out The Manual Therapist discussion on Explaining SI Joint Pain.
Boy were people butt-hurt when those studies came out...
Here's the crux of this post in general -- it's not always that what we are doing is wrong or bad, it's that the information being disseminated is outdated and not keeping up with what the research is showing.
Manual therapy can be very powerful, and while there are some good working theories out there, the harsh reality is that we just don't definitively know the mechanism of exactly how & why it has an effect. Does that mean we can't or shouldn't use it because it's not evidence based? Of course not -- at least that's my opinion.
Manual therapy, foam rolling, self-soft tissue mobilization with a lacrosse ball -- these are not stretching fascia or breaking up scar tissue. What you are doing is giving input into the nervous system, which is then driving a change in the ability of the the tissue to relax, release, elongate more...however you want to phrase it.
For more geat info on the topic, check out this write up by The Barbell Physio: Why Foam Rolling Isn't Helping You Like You Think It Does
Another favorite question from our patients: "How do we know what to do or work on if we don't have an MRI?"
This is where we then educate the individual on the pitfalls of imaging, the value of our training & education, and the usefulness of a through examination.
Yeah, while I don't think this needs too much explanation, it seems that the debate between squats, deadlifts, and the good old leg press still rages on. Which is best, which is bad, which is harmful, which produces the greatest "Gainz."
The answer is actually simple -- there is no right answer.
Ughe! Seriously, I don't know when we are going to learn. There is so much wrong with this statement, and yet we continue to hear things like this regularly as our patients recount their visits with other providers.
Your words matter! They can do just as much good as they can harm, so be mindful of what you are saying, how you are saying it, and that the information you are conveying is actually correct.
One of the greatest accomplishments of 2015 for me at Athletes Physiotherapy was finally getting through Adriaan Louw's courses on Pain. It's really helped in addressing the issue of pain and putting it in a way that patients can relate to and that also helps to alleviate a lot of their anxieties and concerns, especially in our athletes!
For more great information on these topics, check out the Stop Thought Viruses webpage!
I wholeheartedly believe in self-treatment strategies. I also give self-soft tissue techniques to our athletes and clients on a regular basis. But here's the rub, and I see this almost EVERY day:
If you have to continually smash out your shoulder or hip with a ball or foam roller between every set because it's painful, and you have been doing that for months at a time...it's time to actually get evaluated by a healthcare professional.
If smashing it was going to work, it probably would have at some point earlier on. Again, we're not talking about using these as warm-up/cool-down or self-management strategies to keep you progressing in your workouts or to aid in your recovery. If there's pain, and it's persistent, then you owe it to yourself to get it looked at.
An ounce of prevention is worth a pound of cure!
Top 5 Reasons You're Missing Your Fitness Goals, How to CRUSH IT in 2016!
...we've reached the end of a year.
2015 is rapidly coming to close, and many are looking to the new year ahead. This is often the time when we reflect on the year that, if you're anything like me, seemed to just fly by!
I like to reflect and establish goals, because it's hard to know where you're going if you are not aware of where you have been. It is also hard to know how to get somewhere, if you don't have an established destination in the first place! Part of the process of reflection is looking back on the year, on the goals we had set and the things we hoped to accomplish in all areas of life. Setting goals related to business, family, finances, recreation, and fitness are all very common areas of focus.
Were you successful in meeting your goals for 2015? Did you even set goals for 2015?
Did you know that:
So, if you were one of the many who set a New Year's Resolution to get fit, lose weight, run your first marathon, complete your first Mud Run...and failed...don't be too hard on yourself. You're actually part of the majority.
But who want's to be in THAT majority? Let's make a commitment to getting it right this year.
HERE & NOW! Say it out loud where you sit, even if other people are going to look at you funny if you're out in public reading this on your phone - "I am going to CRUSH my Fitness Goals this year! 2016 is MY Year!"
Let's start by looking at WHY you and so many others didn't meet your fitness goals in 2015, and then I'll walk you through a few strategies to give you a leg up on 2016!
Top 5 Reasons You Missed Your Fitness Goals in 2015:
1. Lack of Goal Setting:
Sure, you made a New Year's Resolution. Maybe you told a best friend, significant other, or co-worker that this would be the year you get in shape. Come Monday morning, you're joining the gym, and you're going to drop a few pounds and get that toned body you keep seeing on all the magazine covers.
Best of intentions? Yes. Setting you up for Success? Nope.
We need to make an important differentiation -- citing a New Year's Resolution is NOT Goal Setting. Setting goals is a process. Once you know what it is you want to achieve, you then set out the plan for getting there. There's no one specific way to set your goals, but there are a ton of resources out there in the business world to help you. At a minimum, get a notebook and dedicate it as being your Goals Book. Take time out, uninterrupted by kids, others, or technology, and write down your goals. Then, be sure to check back often in order to stay on track and revise / add as necessary. Some say you should check & rewrite them every morning, some say weekly, etc. Find what works for you, but generally speaking, more frequently will increase your chances of actually meeting them!
2. Nutrition -- or lack there of:
Notice I didn't say 'Diet'.
Throw that word out. We don't diet, dieting doesn't work and has so many negative connotations it can't help but set you up for failure.
The ultimate key to meeting any fitness and performance goals is nutrition. And there is no magic pill, powder, or potion. It starts with eating REAL food, and newsflash -- real food can taste amazing of you take the time to learn how to prepare it. If you're an adult, by now you really should know how to cook for yourself.
No judgment - well, okay -- maybe just a little.
Okay, a LOT! Come on now people, every home has a stove and you all are reading this so you can find and read a recipe!
There is no way to 'out train' poor nutrition.
There are a few simple tips to get you started:
Second only to good nutrition, is good program design.
There is no one-size-fits all approach to fitness program design. This is especially true if you are someone who has already achieved a moderate to high level of training, such as a college or professional athlete, or a fitness enthusiast who has consistently been training -- yes even they fall short of meeting their fitness goals!
There are few realities to consider here. If you are a novice, haven't worked out in a while, and are not a high level mover (athlete, dancer, etc) then it is likely that progress will be seen with almost any program. Certainly there are starting points and strategies that will be more advantageous in creating a long term plan to cover an entire year's goals, but being CONSISTENT with a basic program will get you well on your way.
Translation: You do not need the workout of a Pro athlete, nor do you need huge volume or crazy training sessions. Consistency, achieving your program goals for each workout, and adhering to your nutrition plan will get you there. And NO -- there is no short cut. There is, however, a much longer road and that is the road of walking into the gym without a predetermined plan or following the latest & greatest fitness magazine workout. Ideally, your program should be tailored to meet Your needs and based around your specific goals.
Also keep in mind that a year is a long time! The workout out & goals you start with today will not be the same ones you are working on 6, 9, or 12 months from now...if you have stayed the course!
4. You're slacking on your Intensity:
This is a big one!
From athletes, to active individuals, to our rehabilitation clients performing their rehab exercises. It is often the case that your effort and intensity level are not matching with what is needed to drive the changes you are working toward. Many people become frustrated with their lack of results after joining a gym, and often it is do to the fact that, as seen in #3, they have no real program, and they are not exercising at an adequate intensity to change their body composition.
'Intensity' is more than a measure of effort or how hard you are working. It is a variable which is adjusted to provide a training stimulus that your body will produce as specific adaptation to. There is a continuum between high intensity, moderate intensity, and low intensity training and each has it's place. For the novice, low & moderate intensities may be and adequate place to start to build a base from which higher intensities and heavier loads can be managed.
For athletes, high intensity training certainly is our method of choice, but with the understanding that:
One simple tool to use to gauge intensity level is RPE - Rating of Perceived Exertion. This scale has been used in many settings as a self-report measure of how hard or intense someone is working. It's not perfect, but with a little practice and an understanding of the characteristics of each numerical category, it can be a simple and effective way to know if your intensity is too low or too high.
As the saying goes, sometimes you don't know what you don't know. And sometimes what you do know is based on outdated information. The one tool that I think everyone does need is a good coach.
Professional athletes at the most elite level still have coaches. Professional singers & musicians have coaches. The most successful business people on the planet have their own coaches. This is a point which can't be stressed enough. If you truly want to make a lasting change, you're going to need help along the way.
Coaching can come in many forms, from on-site training to remote coaching at a distance. Ideally, coaching will provide you the framework & accountability required to be successful in achieving your desired fitness goals. Your coach will help you identify and set your goals, perform baseline measures that can be used to mark your progress, and educate you on the nuances of how to meet your goals most efficiently. The coach will then create your program, and will provide consultation and feedback by whatever schedule and format your coaching program has established.
Make no mistake, it's still up to YOU to put in the work and follow the plan as instructed. But one thing is for sure: If you follow the program, are honest with yourself & your coach throughout the process, and put in your best effort, there is no reason you shouldn't be successful!
Learn how Remote Coaching can help you meet your goals for 2016!
Click on 2 amazing program options below for more information:
In our opinion: FHT is an absolute steal at $99 bucks!
One of the very best values in the industry from a coach that not only knows training but has a
physical therapists mind for injury prevention and performance!
Thank you for stopping by the Athletes Physiotherapy Blog! Kristopher Bosch founded Athletes Physiotherapy in Las Vegas, NV. He is a Father, physical therapist, athletic trainer, pilates teacher, & perpetual student!
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