Click here for this edition’s Table of Contents
1) Everyone is different (joint, osseous structures, myofascial structures, developmental history, etc.). So it’s easy to understand why “there are no systematic advantages of one foot strike pattern over another when it comes to running economy”. #DynamicSystem
2) “Proximal joints act as motors and distal joints as adjustable dampers & springs” -Derek Griffin
3) Are we overlooking the blood flow component of tendinopathies? “Tendon blood flow tends to decrease with age and compression, which often results from increased mechanical load. This decreased vascularization, at least theoretically, can contribute to the probability of tissue damage as tissue compliance and flexibility will be compromised (LER). Oxygen consumption of ligaments and tendons is 7.5% lower than skeletal muscle, which may contribute to longer healing times (2,3).”
4) The Gait Guy’s breakdown of a case study is always worth the time. In this one they find the driver in the spine. In this one they breakdown the biomechanics of 4 different runners.
5) What do we use to regulate ourselves? Thought or awareness? Seth teaches us how using thought can lead to chronic pain. “But we can’t think our way out of a physical “problem”. The autobiographical self (story we tell ourselves) and the embodied self (our experience in the present moment) are separate neural networks.“
6) Michael Mullin teaches us how to use farmer’s walks within the PRI approach. Off set load with more weight on the left or perform a slow pause when in left stance.
7) I put kinesiotape on a knee replacement’s scar. Just a simple vertical piece along the scar. The temperature and swelling of the knee joint decreased dramatically (upon assessment 2 days later). Many professionals talk about the importance of managing scar tissue. But I never thought about it’s effects on swelling and temperature.
8) Charlie Weingroff shares some of his latest thoughts on rehab and training.
9) Leon Chaitow goes over the possible positional release mechanisms – “At its simplest, positional release techniques as used in manual therapy settings, involve the unloading of tissues, placing them into less-stressed, “ease” positions. In such a comfort state, a number of beneficial changes may emerge including reduced pain perception and reduced inflammation, greater local muscular strength, reduced fascial stiffness, reduced pain-medication use and number of days of hospitalization, as well as enhanced peripheral circulation, post-surgically.”
10) One of the better PT business articles I’ve read in awhile from Ben Fung. “If only 8% of the general healthcare consumer population ends up seeing a Physical Therapist for musculoskeletal concerns, we are missing out on 92% of the population who very much NEED OUR HELP! This is a terribly and massively underserved need in our society; we are doing a disservice to ourselves and our customers by not upping our advocacy game.”
11) A well designed study and a good study are not always synonymous. Researcher vs. Clinician. Theory vs. applicability. Scientific respect vs. real life patient outcomes. Confirming hypothesis vs. solving clinical questions.
12) People shouldn’t be allowed to do research without at least 5 years of clinical work.
13) “N=1 for your patient, N-100 for your research” -Matt Dancigers
14) “Like sleep deprivation, chronic poor sleep quality impairs postural control in healthy adults.” –Jordana Bieze Foster
15) Maybe it’s because they’ve lost balance? They need a wider base of support? Maybe the coronal plane isn’t as robust as the sagittal or transverse? Maybe it’s a disuse thing? “older adults prioritized medial to lateral control over forward progression during adaptive walking challenges.”
16) “Exercise is characterized as a test of physical limits, of grit and suffering and never succumbing to defeat. It is a competitive chore for you to conquer and get over with. Play is cooperative. It is a coexistence with task and environment” –Christine Ruffolo
17) Movement and anxiety are linked “Researchers have discovered that the response to anxiety in teenagers may include not only the parts of the brain which deal with emotions (the limbic system), as has been long understood, but also movement control centres in the brain, which may be associated with movement inhibition when stressed (“freezing”).”
18) Get to the joints through the muscles. “Hilton’s law, espoused by John Hilton in a series of medical lectures given in 1860–1862, is the observation that in the study of anatomy, the nerve supplying the muscles extending directly across and acting at a given joint also innervate the joint.”
19) 2016 Exercise and Pregnancy Recommendations
20) Ultrasound is effective as a diagnostic tool for stress fractures. “TUS (5 cm2 probe, 1 MHz) was conducted at the site of pain with continuous ultrasound at highest intensity (2 W/cm2) and the most symptomatic point was spotted for 30 seconds (probe was moved at 1 cm/s)”
21) It took me almost a year, but I finally finished Daniel Lieberman’s Evolution of the Human Head. It’s not a book you read. It’s a book you study. It took me on many different tangents and pointed me to places I didn’t even know existed. I had to put the book down and study from other sources before I could progress through. It may not offer interventions, but it definitely takes you several layers deeper. #FunctionalIntegration #Tinkering
22) Mechanotransduction, again. Although I wonder if these researches have ever heard of something called exercise and physical therapy.
23) “Stretching any part of your body increases flexibility in other parts (more than just a cross-over effect from one limb to another)”-Chris Beardsley
24) Charlie Weingroff writes a nice article on the differences between rehab and training and how they should be used simultaneously. “When we engage in intelligent training in the joints that can sustain it, we create hormonal effects that that can help the tissue in the shoulder heal more quickly and reduce pain.”
25) Seth Oberst teaches a short class on mindful movement “But moving in real-time frees us. We aren’t anticipating pain or tension, or remembering pain and tension the last time we moved.”
26) “Do clinicians spend too much time trying to change stressors rather than working to develop coping skills? #stress #resilience #coping” -Derek Griffin (nice info graphic)
27) Tell your patients to go for a walk outside. Meta-analysis shows walking is an effective intervention for chronic pain.
Cervical & Cranium
28) “Extra ocular muscles are 300x stronger than mechanically necessary to move an eye in a socket. #thingsthatmakeyougohmm” –Alex de la Paz, DPT
29) Five of the 6 muscles that move the eye attach to the sphenoid bone
23) I like reactive and antalgic postures. They help with diagnosis. And are a fun way to predict diagnosed when watching injuries happen on TV (I can’t be the only sick PT that enjoys this, right?). Examples of antalgic postures are an AC joint dislocation unloading their affected side by holding it up. Or a fresh ACL trying to posteriorly glide their tibia. Here Sian sharing some antalgic postures for cervical radiculopathy. What are your favorites?
24) I did not know there were this many different types of headaches.
“To breakdown the neural and vascular mechanism of migraine we can say that a migraine headache depends on:
1.The Activation of the trigeminovascular pathway by pain signals that originate in peripheral intracranial nociceptors, and
2.Dysfunction of CNS structures involved in the modulation of neuronal excitability and pain“
25) “Chronic neck-shoulder pain: Heavy strength training improves strength and rate of force development” –Lars L. Andersen
26) Solid summary of cervicogenic dizziness by Sian
27) It’s always nice to have studies that back up what we see in the clinic. Neck patients are respiratory patients. “Patients with chronic neck pain have reduced vital capacity, expiratory reserve volume, FVC, and minute volume.”
28) Proximal > Distal. “Neck muscle fatigue alters upper extremity proprioception”
29) Unfurrow your brows to stop the headaches. “Research from the journal of Plastic Reconstructive Surgery in 2007 specifically points to the corrugator supercilii as a chief culprit of headaches and “complete resection” of this muscle is necessary for “effective decompression of the supraorbital nerve and supratrochlear nerve branches in the surgical treatment of migraine headaches.”
Thorax & Upper Extremity
30) Homo naledi had an upward rotated and laterally positioned scapula. Suggesting the upper extremity was used for locomotion as opposed to throwing and manipulating objects.
31) Christine Ruffolo dissects wrist motion through her movement exploration practice – “Wrist movement is directly affected by forearm rotation”
32) Clinical pearl from Eric Schoenberg, “Prone external rotation with no support results in increased use of deltoid to support the arm against gravity”
33) I like this upper thoracic MWM
34) Hand Grip Strength from Noah Harrison (massive article)
Predictor of mortality
Directly correlated with respiratory muscle strength
Associated with overall body strength
Dominate the homunculus
“Hands are extensions of our eyes”
Integrated with shoulder stability muscles
4 Areas that increase irradiation: feet, jaw, respiration, hand
4 Forms of gripping: pinch, open, closed, hook
3 Ways to work on it: farmers carries, bottoms-up KB, hanging based movements
35) Forward shoulders. Is it a tight pec minor? Postural adaptation? Or maybe your body’s way of making up for the lack of center of gravity shift that a normal thoracic kyphosis would cause? #PRI #GaelynRogersBeerThoughts
36) “Back muscles of healthy individuals had a type 1 percentage ranging from 54%-74,3% and type 2 from 16,4%-30,2%. In the thoracic muscles, there is a higher percentage of type 1 fibres.”
37) The best way to treat extension based low back pain is to perform the SFMA break out and address the impairments and patterns. For those who don’t use that system, try this great shotgun approach from Dan Pope.
38) 5 easy extension based low back screens
39) The drama continues…”Stabilization exercises are better than general exercises for people with chronic non-specific low back pain.” My thoughts…don’t get caught up in the professional drama. Don’t be that guy. Do what gets YOU positive outcomes in the clinic. If your chronic back pain patients aren’t getting better, then YOU need to get better. And that might mean finding a different approach. n=1 goes for not only the patient, but for each clinician, and each clinical relationship.
40) Sacral autonomic neurons are sympathetic, not parasympathetic. “the parasympathetic nervous system receives input from cranial nerves exclusively and the sympathetic nervous system from spinal nerves, thoracic to sacral inclusively” (via Michael Mullin)
41) “Use step under uninvolved limb to address compensatory weight shift during bilateral exercises.” -Terry Grindstaff
42) The Gait Guys teach us why external tibial torsion can limit hip extension “When the hip is in an externally rotated position it is easier to extend; the femur head moves anteriorly, the femoral joint capsule becomes tighter and stability is created”
43) If you want to be active, move well, and prevent injuries, then you should strengthen the hips. It’s associated with ankle sprains and shoulder dysfunction.
43) “The superior portion of the gluteus maximus had significantly greater relative EMG activity than the inferior portion of the gluteus maximus during exercises that incorporated elements of hip abduction and/or external rotation”
44) It’s not always about mobility and stretching the hip flexors. “Hip flexor muscle strength was found to be decreased in patients with labral pathology compared to control subjects”
45) Jennifer Pilotti writes a nice article on closed chain hip flexor strengthening
46) “A recent study investigated the use of the single leg hamstring bridge (SLHB) as a clinical test in predicting hamstring injuries in football players. The single leg hamstring bridge tests the hamstring muscles in a functional position similar to terminal swing and assesses endurance parameters rather than peak torque. This study demonstrated a significant deficit in preseason SLHB scores on the right leg of players that subsequently sustained a right-sided hamstring injury.”
47) “Patients who sustained an anterior cruciate ligament (ACL) rupture were more likely to develop secondary meniscal injury and arthritis when compared to a matched cohort. Specifically, those that were treated nonoperatively or with delayed surgery may be more likely to develop secondary meniscal injury, develop arthritis, and be in need of a total knee replacement when compared with those patients treated with early surgery.”
48) I usually focus on 3 things immediately after knee surgery: 1) edema management 2) knee extension ROM 3) quad development
49) Interesting study on the forward lunge. “Trunk and shank position have a significant influence on patellofemoral joint loading of both limbs during the forward lunge, with the trail limb generally experiencing greater total joint stress. Restricting forward translation of the lead limb shank reduces patellofemoral joint stress at the expense of increased stress in the trail limb.”
50) It’s as easy as strengthening hips. New meta-analysis shows “significant hip strength deficits exist in people with knee osteoarthritis.” These exercises are an easy way to improve hip strength in the osteoarthritis population.
51) Injuries are complex. The neurocognitive continuum is something we see all the time in the clinic. A new study measured this and correlated it with injury. “Athletes with low neurocognitive scores are more likely than their higher-scoring counterparts to demonstrate landing mechanics associated with anterior cruciate injury (ACL) risk” #Variables #DynamicSystem
52) Glute Med and ACLs – “There were significant group by phase interactions for the GMed during both SEBT and the SDT. GMed activation was lower for the ACLR group during the return phase of the posteromedial direction of the SEBT compared to the control group (P = .03). During the SDT, GMed activation was higher for the ACLR group during the ascending phase than descending phase (P<.001), while the control group showed no difference between phases (P = .707).” I like doing these inner-range holds with my ACLR patients early in their rehab (I manually position them instead of having them set up on a table or wall).
53) “A professional athlete who fails to meet functional criteria for return-to-sport or who has a low hamstring:quadriceps ratio is at greater risk for an anterior cruciate ligament graft rupture.”
54) You can tell a lot just by looking at feet. “Post hoc pairwise comparisons showed a significant difference between flexible versus stiff AHF (arch height flexibility): those with flexible AHF exhibited reduced CPEI (greater hyperpronation) while those with stiff AHF showed elevated PP. Results suggest that, in addition to AHI, the arch flexibility may affect dynamic foot function.”
55) Tell your patients with peripheral neuropathy to wear stiffer shoes. It’s the next best thing to being barefoot. #IncreasedSensoryFeedback
56) “the findings suggest that foot overpronation may affect Achilles tendon blood flow, particularly at mid-tendon, thus enhancing the possibility for injury”
57) “The findings of this study are interesting because it shows that physically active individuals with CAI are “pre-activating” muscles differently than healthy controls to try to protect the previously injured joint in preparation for landing. However, it remains unclear if participants with CAI had these activation patterns prior to developing CAI or if the activation patterns developed as a result of the injury and subsequent CAI.”
58) Training complex movements to fatigue is never a good idea. “A fatigue running protocol caused increases in forefoot push-off time in all participants, but caused increases in different foot regions based on arch height.”
59) There are 3 planes of motion to compensate in. Don’t assume. It’s not always pronation for an absent heel rocker. “Frequently a premature heel rise can force knee flexion but in this case the rise just kept going vertical and forcing them into the use of the gastrocsoleus group and thus forcing a lift of the entire body.”
60) A weak toe grip is associated with hallux valgus
61) Are you standing up? Look to your left behind you. Do you have enough cervical and thoracic rotation mobility? Do you have enough left hip internal rotation? Do you have the motor control of your rotational slings to drive the rotation? Do you have enough right foot pronation? Or are you going to have compensate with excessive left supination and sprain your ankle? Biomechanics matter.
62) “Ankle plantar flexor and toe flexor muscle performance was impaired in individuals with plantar heel pain” This is a good starter toe flexor exercise (the hallux flexion variation)
63) Less ankle dorsiflexion during a squat increases valgus moment, decreases quad activation, and increased soleus activity (among other things not measured in this study). Here are 4 great ways to increase ankle dorsiflexion mobility (MWM, neurodynamics, histological stretch, pattern specific)
Some Kathy Dooley Anatomy Lessons
64) Kathy Dooley is one of the best anatomy teachers out there:
“TFL wants to be an accessory quadricep so badly, that this muscle embryonically migrated from the gluteal region to the anterior thigh. This makes the TFL a wonderful connection between the quadriceps and gluteus maximus during the propulsion phase of gait.”
A lack of hip IR is usually not a flexibility issue, it’s usually a lumbar stability or pathoanatomy problem. “the hip’s internal rotators, like TFL, gluteus medius, and gluteus minimus, which receive their major spinal innervation from L5. (Think: L5 on the side of the hip). “
Use the grip to test if the scalenes are locked long “When testing grip, the test will likely improve upon coronally stretching the OPPOSITE side, which shortens the stretched-out side in this plane. This takes the stretch tension off the compressed neurovascular bundle, resulting in better circulation and nerve conduction.”
Trouble swallowing? “When many people stress, especially when the stressor is huge and out of nowhere, they alter breathing. The gasp is a sharp inhalation, creating concentric tightness around the diaphragm. This tightness constricts the esophageal hiatus of the diaphragm, which permits passage of the esophaus and vagus nerves in and out of the thorax to the abdomen…But if vagal tone is already low, the typical indigestion the person may feel now is accompanied with a lump in the throat. This is because the vagus nerve also innervates the laryngopharynx (lower throat) and larynx (voice box).”
The cervical lumbar connector – Longissimus Capitis. “The LCap is covered on its posterior surface with the posterior layer of thoracolumbar fascia (TLF). This connection from skull to lumbar spine helps the cervical spinal musculature fire when the lumbar spine fires…This explains why you use your neck as a secondary set of core muscles, often deemed the extrinsic core.”Kathy Dooley is one of the best anatomy teachers out there:
54) So breathing is pretty important. “We have proposed that a sigh serves as a psychophysiological resetter, restoring homeostasis both physiologically and psychologically when a homeostatic balance has been compromised,”
55) Sometimes people really struggle restoring normal breathing patterns. Sometimes people get frustrated and make no progress with internal cues. Sometimes people need an easier place to start. Since we’re all very visual and very addicted to our phones, these gifs may be an ideal entry point. Big thanks to Nathan Pyle for providing a wonderful visual cue to help people coordinate their breathing patterns. And thanks to my friend, Peter Hwang, for sending them my way.
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2 responses to “Fall Hits 2016: Clinical”
What did you think about Charlie Weingroff’s thought that forcing exhalation is a bad idea?
For what it’s worth, I always thought it was strange to think of over-inhalation as stressful in itself. If over-inhalation is a stressor and also part of our stress response then it follows that our reaction to stress is more stress. This just seems scandalously maladaptive.
I don’t know enough about Charlie’s thought process or logic behind forced exhalation being bad. Like everything, I think it depends on context. Forced exhalation before a heavy deadlift is a bad idea. But I find it useful trying to teach someone with back pain how to attain a zone of apposition, facilitate the obliques, control their rib cage, and how to properly pressurize their thorax.
Over-inhalation is a problem when it goes from a short-term response to a long-term adaptation. It’s effective for short duration stress response (jumping out of the way of a cab coming at you). But it’s not effective when there is no real physical threat (sitting at a desk). Unfortunately there is a lot of scandalously maladaptive processes of the human body trying to exist in the 21st century.
For more information on the stress I would check out Sapolsky’s book, Why Zebra’s Don’t Get Ulcers and Porge’s Polyvagal Theory. For the physiological effects of breathing and hyperventilation I would check out Courtney’s thesis, Dysfunctional Breathing – It’s paramaters, measurement and relevance. Thesis RMIT University.