Reconciling Pain Science and Biomechanics

Greg Lehman

It's finally happened. I finally attended a course presented by a Canadian! I also work with a
Canadian Occupational Therapist and from my sample size of n=2, I think it's possible that Canadians are smarter than Americans. Why is it that Canadians seem to know more about American politics than we do? I can only inadequately describe how our government operates and I know absolutely nothing about theirs.  It's like they care about what happens in the world, or something. We should do better, America.

Anyways, since I'm sure you also want to take a course instructed by a Canadian, I'm sure you want to know what course it was? "Reconciling Pain Science and Biomechanics" by Greg Lehman. Greg is a physiotherapist, chiropractor, strength and conditioning specialist, and biomechanist who also teaches a course called Running Resiliency, which is probably excellent if you run or treat runners, which I try to avoid.  (I avoid running.  I don't mind rehabbing runners).  "Reconciling Pain Science and Biomechanics" is a two day course that bridges the gap between the clinicians who focus heavily on pain neuroscience education and the psychological side of the biopsychosocial model versus practitioners who tend to focus primarily on perfection of movement patterns and anatomical tissue structural damage as potential drivers of pain.  If you're working in orthopedics or with pain management you should definitely check this one out.  The course was overall broad with big concepts that ideally could apply in multiple situations.  It also came with an extensive set of resources including his presentation and a huge number of literature papers for consideration.  So much evidence to support the discussions. 

I've previously written about pain here (and several other posts).  Greg defines pain for this course as "When all your loads/stressors exceed your ability to adapt/cope."  Pain is the balance between all the things that are harmful to you and all the things that are good to you. I often like to use the concept of inputs versus outputs with my patients, especially because people often don't recognize that pain is an output. I can't put pain into you. Pain is an output message from your brain in response to stresses that have been applied.  I can apply stresses to you so that a painful output occurs, but instead I try to find the minimum effective dose of stress to input so that your output is positive adaptation, not pain. 

Some examples of inputs: mechanical stress to tissue such as an incision or deep touch or the feeling of your rear end on the chair you're sitting on, chemical stress such as dehydration or improper nutrition, emotional stress such as those from your family or your job, light, sound, and temperature changes.  Inputs are not good or bad, they are just stresses that we have to process in our body.

Some examples of outputs: pain, emotions, sweat (loss of heat), neuromuscular adaptations such as increased strength, seeing your mental health counselor and talking it out, breathing, coping/calming strategies.

So when a person is experiencing pain, anywhere, the options for treatment could include:
1) Can you decrease some of the inputs?  Examples: Turn off the lights, focus on some breathing strategies, go for a walk, change your body position, change the temperature, increase or decrease the amount of touch on the area that hurts. 
2) Can you increase some of the outputs?  These could actually be the same as above because of things like hot versus cold where changing temperature in one way actually accommodates both, but also doing some yoga, exercise, see your therapist, take your regularly prescribed medication if you have diagnosed anxiety or depression that is being medically managed, or spend time with friends.
3) Or can you make it so that you're able to accommodate for more inputs without changing the input or output?  Again, there is overlap here.  But for many people, building up tolerance through strength training or meditation practices or learning ways to desensitize your skin can all have this sort of impact. 

It's important to also consider what is getting in the way of making some of these changes. Is the patient fearful of going for a walk because they have pain in their foot?  Are they catastrophizing or perseverating on horrible possible outcomes by participating in a certain activity so they're unwilling to try?  What are the current beliefs and expectations about their condition?  Knowledge about how the mind and body connect and work together can help decrease these roadblocks to facilitate recovery.

Greg provided some important questions to ask patients to help them return to their favorite things.  For example, "In what ways do you think you could be healthier?"  This open-ended question allows a person with headaches to consider that maybe they could better hydrate, have more nutritious meals, sleep at more optimal times, go for a walk at lunch time, maybe acknowledge some of the recent spikes in stress at their job or school... but it allows them to identify potential sources of their pain, allows them to outline what they believe is happening, and also gives you a chance to better learn about the patient. 

Greg Lehman and Me

He also discussed the importance of asking "What activities are meaningful to you?"  So, for me, I really like to play softball.  When I hurt my knee a few months ago, I was disappointed that I couldn't play for a week or two, but then I was able to return in a modified way.  If I hit well enough, I could hobble my way to first base and get myself a substitute runner for the rest of the bases.  I didn't think I would damage my knee worse by doing this, and I actually didn't have much pain when I tried that.  I spent a little more time in the dugout instead of alternating innings so I could avoid spending so much time in my catcher's squat position.  So, I was able to dose my activity so that I could do some rather than none at all, and this actually built my confidence to return back to my usual level of participation after healing and recovering. 

Which leads perfectly into "Encourage the patient to ask themselves 'Will the activity harm me? and/or 'Will I pay for this later?'"  Like with my softball example, I didn't hurt myself worse by participating and I didn't hurt more after playing. Certainly there are times when doing activities can be harmful. As a physical therapist, it is our job to recognize when that is the case and appropriately guide our patients, but modifications are often possible.  In particular, I really think it's important for our post-surgical patients who can't be playing their sport to spend time around their teammates. Be the team manager!  Learn more about your sport.  Spend that time with your friends.  It's better for mood, learning of the game, growth with teammates (and they'll get better support if they're around and showing their progress over time." 

Best Thanksgiving Food

In another example, this past weekend I attended a delicious Friendsgiving dinner at my friend's home. I've been managing some gut issues lately and had been eliminating several foods to try to identify where the problem was coming from. After a month with no wheat and two weeks without any onions or garlic, I wasn't exactly sure what would happen if I had some stuffing... but I really wanted it!  I actually did use this line of reasoning while I ate.  Will I do any permanent damage to my body by eating this? Not likely, no. Will I pay for it later? When I made the decision, I wasn't entirely sure, but I thought it was possible, which impacted my decision for quantity of stuffing that I took (dose). And yes, I felt like crap from it.  But was it worth it? That's very individual, and up for me to decide, and now I have data. Next week when I'm home for family Thanksgiving, I get to decide if I want to repeat this same thing knowing what the likely outcome will be, or not.  But I'm empowered to determine what I do to my own body, and that's something I think we can teach our patients, too. 

What else can we do as physical therapists to help our patients who are experiencing pain?  We need to help make sense of their pain using their own understanding of what's going on. A person who thinks their "back is out" can't just be told "that isn't really a thing, backs don't ''go out.'"  They'll never buy into your message if they have a belief of what's wrong and you just strong-arm them into an opposing idea.  So instead, we acknowledge their beliefs, educate them on how adaptive the human body is, and we facilitate cognitive restructuring.  An example that was suggested in the class was "I bet someone has told you that your spine is twisted," and by acknowledging their perspective, you can try to bend that belief just a little bit, "but actually your pain could be from something else, so why don't we work on getting you moving in ways you can tolerate."  You create a small hint of doubt into their beliefs and see if the patient gives you an opening and slowly you can chip away at the beliefs over time.  We can facilitate adaptability by using intentional application of specific stressors that induce adaptation for increased resiliency, and this includes with beliefs. We must meet our patients where they are at with the psychological and physical approaches, progressive loading ooth their thoughts and their tissues, which might be a really little bit of loading at the start, but sometimes that's all they can manage. We work hard to encourage their autonomy and self efficacy.  One of Greg's quotes which I really enjoyed: "Requirements for adaptability: 1) Human. 2) Not Dead."  He also made sure to include a statement about how physical therapists don't fix people.  We facilitate them.

Bob Ross

And so physical therapists need to understand barriers to recovery, which could be at the tissue healing level, or could be in the psychosocial realm, or a whole host of areas in between.  And we need to appreciate that what we do is, in fact, an art, while also being a science.  That makes Greg Lehman just like Bob Ross, I think.  He painted this one beautifully. So many happy trees.

And with that, I'll finish with another quote from the course "Limping is a helpful adaptive pattern. It is successful in keeping people moving. It decreases pain. But should we advocate for everyone to start limping?"

Thanks so much, Greg.  I hope you'll come back to the USA soon!

To Dynamic Valgus - Or Not to Dynamic Valgus? That is the Question

Ann Strother

I was recently watching a Medbridge video on knee injuries when this image appeared on the screen.  HEY!  That's Ann Strother!  Hey girl!  A UConn Women's Basketball star overlapping with two of my years there as team manager, professional basketball player in the WNBA for a few teams while I was working for the Connecticut Sun, on my list for top 10 most beautiful three-point shots, and for sure one of the kindest people on Planet Earth - I was so excited to see her on the screen - except that it was with regard to knee injuries. 

The video was discussing her inverted "V" position called knee valgus which, according to several research articles (like this 2005 paper, and this 2003 paper, and this 2018 paper) may be one of many factors that increase risk of ACL injury in female athletes.  Medbridge had used this image demonstrating her continuing to exhibit this "faulty pattern" after already having had torn and rehabilitated from tearing her ACL. Ann tore her ACL during her sopomore year of high school.  Despite the injury, she was the 2002 Gatorade High School Basketball Player of the Year (her high school senior year) before heading to UConn where she was ultimately a two-time NCAA National Champion.

Kevin Durant

Anyways - seeing her on my computer made me think back to a few weeks earlier when I headed to California to see the Golden State Warriors play against the Los Angeles Lakers only for LeBron James to be out for the night.  I wrote about that here, but while watching the game, I observed that same knee posture repeatedly demonstrated by Kevin Durant of the Golden State Warriors.  See how he's standing at the free throw line about to shoot with his knees almost touching and his feet wider than his shoulders?  He does this a lot.  It's the same position.  While sitting at the game, I snapped this shot and sent it to all my favorite physical therapists and my current student in the clinic... because this knee position is repeatedly considered to be a big problem.

So... is it really a problem?  According to a lot of research, as I've previously mentioned, yes it is because of it's increased risk for injury.  But... is it a problem for Kevin Durant?  Should we be correcting this position in all of our patients who exhibit it?  Is it still a problem for Ann Strother, who I'm pretty sure is not currently playing basketball... but is still running around chasing after her two young children?  What I'm saying is - does every person who shows up in the PT clinic with this presentation need to have it "corrected" or do only some of them need to change it?  Or should we not be correcting it at all?  ACL injury prevention programs constantly work to strengthen the body to prevent exhibiting this type of movement and in PT school we're trained to squat "perfectly" without showing this pattern.  I'm constantly telling my patients to keep their knees out...but half of the time I'm wondering if it really matters. This is the movement pattern I see DAILY in my patients at Seattle Children's Hospital, most frequently in teenage girls who have knee pain, but certainly in boys and in all ages and with varying conditions.  I can tell you from experience that changing the squat position so that they don't do this inverted V is usually much less painful in many of these patients.  I can't tell you that training them to move without the V will prevent them from having an injury later on in life.

So what do we do about it?  As Robert Frost says, "Two roads diverged in a wood..." There appear to be different approaches to dealing with this presentation.  On the one hand, you can work to strengthen and reinforce a more "sturdy" pattern with the knees more straight above the feet rather than angled inward.  Glute strengthening, squatting, and training "proper" jump and landing form tend to be the typical components of a rehab program that works on this pathway.  Repeatedly trying to target a better posture and moving away from this dynamic valgus presentation is a common treatment approach. 

But Kevin Durant is paid about $30 Million per year... do you think he's going to let me change his free throw shot form?  Or anyone on his sports medicine staff for that manner?  Is he actually stable in this position?  Does he train in this position?   So the other option, that some people are now advocating for, is to train into these "suboptimal" positions on purpose.  There are recommendations to purposefully train ankle mobility and control into the position that is common for ankle sprains, particularly in those patients who have already sprained an ankle.  the thought process here seems to be that you can purposefully move into these patterns and try to develop control there so that you're less likely to injure yourself if you end up in that position.  In my search for literature on this approach, I came up empty-handed for scientific papers.  I know that when I injured my ankle years ago, putting it into the position of injury was painful and I wouldn't want to put myself there... years later I still don't purposefully do that motion... but if I play sports and accidentally end up there, I could see how I might be risking injury because I haven't trained my body to tolerate the position.  I did find some non-scientific articles that suggest doing this approach, like this one that discusses the idea of purposefully training into the movement patterns that you were injured in.  There are some people that suggest that if you don't train the injury pattern, you won't be resilient enough if life or your sport puts you into that position and you'll suffer another injury. 

And so...to dynamic valgus or not to dynamic valgus... that is the question. I'm here to tell you that I don't know the answer.  There's not enough evidence to support one way or the other - though there is definitely evidence showing that this position increases risk of injury - so the two approaches both suggest we need to be able to either avoid the position or control the position - not just ignore that position.  I think it might be a combination of both approaches.  I'm certainly not about to go give my patients who squat with dynamic valgus heavy load and have them repeatedly use that pattern - because that seems harmful, and as I've already written - we should Do No Harm.  But I'm also not afraid to consider putting people into and out of positions like this inverted V to see what they tolerate and show them that the human body can do some fascinating things.  What do you all think?

"Like A Girl"

Physical therapists observe how people move and try to guide them in ways to move more efficiently. In case you missed my previous post "What do Physical Therapists Do: Installment #1 - We Look at Mechanics" - you can review that one here for more specifics and then come back...  Go ahead, I'll wait.

Welcome back.  Today we're getting a tiny bit political.  Not White House political...good heavens no.  This is a social issue.  You may feel like I'm rambling... I felt that way, too.

I'm currently playing in an adult co-ed softball league... see photo to the left where I'm rocking  my tall socks, batting gloves, and BoSox hat.  Have to look the part... and keep my hands soft... they're my money makers!  I digress.  I was warming up with a teammate, progressing our throws into longer distances, chatting about our days, and I observed that he was throwing almost exclusively from his elbow, no rotational motion of his trunk, no follow through, not really using his legs at all.  I've only played with him a few times before, but I was concerned that he might hurt himself.  I asked him, "Who taught you how to throw?" And he said, "Why, do I throw like a girl?"

Poor guy - he never heard the end of it from me. The whole night. I'm still proud of myself for the timing and word selection of my immediate response - that he should wish he threw like any of the girls on our team. My female teammate was warming up next to him, snapping her tosses with beautiful efficiency and consistently reaching her target.  He did apologize.  I'm sure he didn't intend to use those words.  I'm sure he didn't mean to put down the entire female gender in a flippant manner.

I'm definitely not an expert on throwing mechanics, but I know a few things that could have helped him get better.  More importantly, I could have given him a few tips that might prevent him from having an injury.  None of those pointers were provided because I was too stuck on his words.  I don’t walk around making suggestions to random strangers- though sometimes I want to.  I don't go to a gym and interrupt others who are working out to change their mechanics, even if it makes me cringe.  But this is my fun time... and I really hate having to play physical therapist at the field. From a Physical Therapist's perspective, I was concerned that he could hurt himself (and his throw is inefficient if he cares about being any good at rec softball).  He's not just looking like he's going to hurt his elbow and shoulder, his back is taking a toll every time he tries to make a long throw from the outfield.  

The next morning in the clinic (I couldn't believe it!) - one of my patients, a ten year old girl, was wearing a "Like a Girl" tee shirt.  I high-fived her!  #GirlPride I asked her about her shirt.  She said girls can be superheroes.  I love working with children.  They're hilarious.  Anyways... I had just started getting over the little softball episode, when more situations like it occurred.  Maybe I was already on the lookout for them because of it - but with repeated episodes, this blog post was born.

A few days later, Breanna Stewart was named MVP of the WNBA! I was able to attend her press conference where she made an amazing speech about using her platform to promote the issues she finds important to improving the world.  The posts from the league and various media sources had the worst comments!  Terrible.  She's trying to bring awareness to important issues - like registering to vote - and someone posts a comment with a photo of an empty kitchen - like that's where she should have been instead. I'm so disgusted.

And then another episode.  I was working with a young male who told me that he wouldn't do some of the exercises I recommended for his home exercise program because they were "mom exercises."  I had asked him to deadlift a barbell that was not loaded so I could see what his form looked like and had recommended some accessory exercises to supplement the workout.  He said he may as well go to a Pilates class because that's what moms do.  And, though I tried, I failed to make any change in this perspective.  These are learned behaviors! 

During the 2018 NCAA Basketball Tournament, 16th-seeded UMBC Men's Basketball upset first-seeded Virginia.  Several people in my life - and boatloads of people on social media - said it was the first time this feat was ever accomplished. WRONG.  It was the first time in men's college basketball, but Harvard Women's Basketball had upset Stanford Women's Basketball in a 16-seed upsetting a one-seed twenty years earlier.  Women did it first in 1998.  I spent days correcting everyone, responding to posts online.  I'm not really sure why all of these things keep bothering me.  I can't explain it.  Maybe educating others is the best I can do to start bringing awareness to what people are saying, but for the sake of my niece, my cousins, my friend's daughters, my young female patients - and all the young people - boys and girls, we MUST do better.

Words Matter.  Don't let these occurrences continue.  Speak up.  

Shoulder Care with Eric Cressey

Last weekend I jetted off to Denver for a visit with family and a continuing education course.  The family time was fantastic - a few hours of biking around Denver - far more than I'm used to doing as I'm not a fan of bike seats - some really delicious tacos - beautiful art and the backdrop of the Rocky Mountains!

The course was "Shoulder Assessment, Corrective Exercise, and Programming" presented by Eric Cressey of Cressey Sports Performance and it was hosted at Landow Performance in Centennial CO.  Loren Landow is the newly hired Strength and Conditioning Coach for the Denver Broncos and his facility is beautiful with state-of-the-art equipment and autographed jerseys all over the walls from numerous professional athletes.  His bio says he has trained WNBA athletes, too - so extra points in my book!  If you're not familiar with Eric's work, he's a Strength and Conditioning coach with facilities in Hudson, MA and Jupiter, FL and, though he is most well known for his work with professional baseball players, he also works with the general population and is considered to be an expert in the shoulder.  He's published tons of research and has a blog with articles posted starting in 2002 with regular high quality content.  I previously wrote about one of his older blog posts here.  Most importantly, Eric is a UConn grad, so I've followed his work since I first learned about him somewhere around 2005 when I was in a class with Dr. William Kraemer, one of Eric's mentors, and have been looking forward to meeting him and attending one of his seminars for a long time.

With Eric Cressey June 24, 2018

Why did I want to take this class?  Beyond wanting to hear Eric speak live and get the chance to ask him questions, I previously took a course with a strength and conditioning coach (Matthew Ibrahim) in conjunction with a physical therapist (Zak Gabor) which I wrote about here, and felt that learning from people with different backgrounds was really impactful for me.  The audience was primarily strength and conditioning coaches who work with baseball players... but there were also a handful of physical therapists, chiropractors, massage therapists, personal trainers, and baseball coaches.  People had traveled from Australia and Korea and all over the United States, some of which trained athletes from unique sports like Professional Disc Golf or MMA fighters. The variety of people present was really neat... but also, the content is applicable to so many other sports.

More importantly, I have been treating a lot of patients and athletes with shoulder injuries and recently completed Mike Reinold's shoulder seminar, but also wanted a live course to better observe how other providers evaluate and treat shoulder pathologies. Eric's approach to shoulder treatment does not look like Mike's.  They have different "favorite" screening tools and exercises that they use.  If you observe their social media, you could probably pick up on these differences and similarities.  I'd say the biggest overlap I observed was that both of them regularly use the prone low trap exercise for rotator cuff strengthening which Eric has a video for here.

When it comes to my work with the Seattle Storm, though, we also have to consider that we're working in an overhead sport with repetitive action.  Shooting a basketball is nothing like the motion of throwing a baseball, but it still requires significant mobility and stability - and very different from baseball, it requires the athlete to be reactive to opponent players slapping at their arms while they're doing it.  The arm care programs used by the Seattle Storm should not look like the arm care programs used by the Boston Red Sox - but the principles involved in developing them do match.

I learned a lot from this course which I'm still processing, but was able to immediately use some of the skills in the clinic. Here are my top 5 favorite Eric Cressey quotes and take-aways from the weekend.

1) The biggest key for the shoulder is "Keep the ball on the socket." Simple.  Having a better biomechanical understanding of the force vectors of the rotator cuff is vital. If the scapula is sitting in a depressed position, the lats may be over-active which will influence upward rotation when getting overhead.  Similarly, if the scapula is tilted anteriorly, could there be shoulder impingement with elevation or is there enough muscular balance to safely overhead press?

2) Rehab and training are the same thing!  I've previously written about physical therapists' role as strength coaches here - and this came up in the course.  Eric Cressey is not a physical therapist and he discloses this and discusses how he interacts with PTs all over the country.  So it surprised me to see the differences between what Mike Reinold and what Eric Cressey do considering this statement, but I would not expect Eric to be seeing athletes post-op day 1 following labrum repair.  So, I took this to mean that once the acute healing phase is completed, rehab and training are the same thing.  There is a need for progressive loading to tissues and a need to understand periodization, even if your PT treatment sessions are not written like a periodized training program.

3) Scapular winging is a garbage term. It does not describe what is going on with the scapula.  I document scapular winging all the time - so this will be a change I need to consider moving forward.  Is the scapula winging because it is anteriorly tilted?  Upwardly rotated?  Because there is a flat thoracic spine so the medial border is just more pronounced?  And is this inherently pathological?  Or just a finding that you're documenting.  I can't promise I'll stop using the term scapular winging entirely, but I can commit to adding at least one descriptor of the scapular position to better describe the situation moving forward.

4) Stop telling people to bring their shoulder blades down and back.  It would only be a slight exaggeration to say that Eric Cressey is begging people to stop using this cue.  Too many people use this resulting in patients pulling their elbows back with anterior humeral head translation and improper mechanics that we could be creating problems!  I asked him what cue he likes instead - and he said he manually puts people into the position he wants them to be in, using optimal muscle activation, until they can do it independently.

5) Push:Pull ratios are not accurate nor are they adequate.  It has been well ingrained into my training that for every push exercise, you should be doing at least 2, probably more like 3 pull exercises.  I've been trained to teach that focusing on the back musculature 2-3x more than the front helps combat many of the anterior shoulder issues that are seen in the clinic.  However, Eric points out two key points that make you think about this more carefully.  First, the push:pull ratio is almost always considered for front:back motion and ignores top:bottom... but both planes need to be considered.  I think John Rusin tries to deal with this by including upper body push, upper body pull, and carries into his 6 foundational movement patterns, but the balance needs to be considered for both planes.  Second: not all pushes can be considered alike.  The bench press is a push exercise that necessitates the scapulae being blocked on a bench... compared to the push up where they are moving freely on the body.  This is also an important consideration as you're not getting the benefit for scapular control through the pushing motion when doing a bench press - and Eric says he doesn't have his baseball players bench pressing.

I'd be lying if I said this even touched the surface of all the things I learned at the class... but these were big takeaways that made me think and will change how I operate to some degree.   Thanks for an awesome course, Eric!

The Importance of Breathing

Breathing Exercises Are Challenging!

This past week, the Seattle Children's Hospital Sports Physical Therapists held their quarterly in-service meeting which included a presentation by three of our PTs who recently attended a PRI - Postural Restoration Institute Seminar.  The presentation was led by Natalie Johnson, DPT, Paul Moraski, DPT, CMP, and Jeremy Kirschner, DPT, ATC, CSCS and was a great introduction to the basics of breathing.  I was really excited about the topic because I have had the PRI courses on my "to-do" continuing education list for a really long time and it was a great introduction to how breathing can impact movement.  The PRI courses are definitely going to move up on my priority list from this experience.

I have previously encountered breathing as a continuing education component when I went through my FMS (Functional Movement Screen) and SFMA (Selective Functional Movement Assessment) certifications through FMS - Functional Movement Systems.  I read Gray Cook's book "Movement" on my first orthopedic clinical affiliation during school and used the system to evaluate patients frequently back then.  While I don't use the SFMA or FMS in my evaluations very often now, I do like having them available to me as a fall back or as I'm progressing patients back to return to sports activities.  I really like using rolling techniques which comes from these systems and, when those aren't successful, breathing is the primary regression that remains.  Oh how I wish I had paid better attention during my motor control and developmental stages during PT School - but at that time, I just couldn't understand how these things were relevant.

Key concepts I took from the in-service:
1) Breathing is at the foundation of all activities.  If you're not breathing - you're not moving.  And if you're not breathing "properly" this can contribute to dysfunctions.  To work with patients that have a breathing dysfunction by training at a much higher level, you may be able to guide them to fully restored function.  However, focused training for proper breathing is sometimes necessary.
2)

photo (and additional information below) from: http://novusfitnesstraining.com/zone-of-apposition/

The Zone of Apposition (ZOA) describes the positioning of the rib cage and how it influences the function of the diaphragm which directly impacts breathing.  This also directly relates to posture, as the skeleton on the right side has a loss of ZOA due to the bottom of the rib cage flaring and influencing the available excursion of the diaphragm.  While I have joined the bandwagon of "there is no bad posture, only positions that are sustained for too long or that you can't get out of," I still feel that there are optimal postures for various activities.  For example, a basketball player who attempts to dunk but has increased thoracic kyphosis limiting shoulder elevation and anterior weight shift while squatting that limits the stretch-shortening cycle of the posterior chain while jumping will have difficulty getting the ball over the rim unless they're 8 feet tall.  The current trend of saying there is no perfect posture relates more to static positioning throughout the day than postures for activity.
3) There are commonly seen breathing fault patterns.  Three that were described at the in-service were:
- an anterior internal chain dysfunction which presents with quad dominance and decreased extension through the hip that is more often a unilateral pattern.
- a brachial chain dysfunction more related to the upper body presenting with accessory musculature facilitating breathing and rib flare with shoulder flexion.
- a posterior external chain dysfunction which often presents as a forward head with increased thoracic kyphosis and lumbar lordosis and anterior pelvic tilt and more often a bilateral pattern.
4) Basic breathing techniques to improve apical expansion generally require focused training of the left internal obliques and improved ability to breathe into the right upper lungs region.  In the picture at the top of this post, I'm siting in a position that allows for the right side of my rib cage to open up and increase my ability to breathe into the right side of my lunges while I'm using my left arm to reach forward and increase activation of my left interior obliques while simultaneously using left hip adduction that integrates the pelvis and the lower portion of the internal obliques.

Overall, an awesome learning opportunity and good reminder of the importance of breathing.  I know that I have far more to learn on this topic and hope to get to a PRI Course at some point.  Feel free to check out the link with the Zone of Apposition photo because that blog had really interesting information about breathing - among several other topics!

Running Mechanics Assessment for Physical Therapists

Two days ago - I wrote that Physical Therapists should be looking at mechanics - triggered by a patient coming in needing their running mechanics assessed after a physical therapist said they didn't do this work.  I had every intention of writing my own blog post on some of the key things to look for to assess running - but then Mike Reinold posted a write up  this morning based on Chris Johnson's running training - and they're experts.  So rather than re-invent the wheel - Here's Mike's post from today entitled: "A Simple Approach to Running Mechanics for Clinicians." (Seriously this could not have been more timely!)

Quick Summary:  Chris and Mike are recommending you look at the Four S's: Sound, Strike, Step Rate, and Speed. While this is not exactly the same method that I assess running form - I'm thrilled to see how they do it, and I can't wait to update some of the techniques I've been using.  I'm big on listening to the sound that my patients make - with running, walking, jump-landing, and plyometric activities - so this was not new to me.  I've never seen an app to use for cadence - only learned about using a metronome which I have done on a few occasions.

Ultimately - check Mike's post to learn some simple things you can look at in a runner experiencing pain to try to fix their form.  If you can't fix it so they're pain-free, find someone who's an expert such as Mike and his crew in Boston or Chris who is here in Seattle.

Happy Holidays!

What Do Physical Therapists Do? Installment #1: We Look at Mechanics

Recent scenario evaluating a high school-aged patient: let's call him Bobby and pretend that he's referred with a diagnosis of shin splints. (We can get into "Shin Splints" not being an actual medical diagnosis on a different blog post).  The conversation went something like this:

Abby: Hey, what brings you in today?

Bobby: I'm here for biomechanics testing.  I want to get back to running ASAP.

Abby: That's awesome that you like to run. 

Bobby: I run track and cross country but my leg hurt a whole lot at the end of the last season.  I saw the doctor and he shut me down from running while I did 2 months of physical therapy elsewhere.  When I went back to the doctor, he said he needs the physical therapist to clear my biomechanics so I can return to running.  My physical therapist said they don't do that, so my doctor gave me a referral to come here instead. 

Abby: Wait.  WHAT????

Bobby: Can you test me so the doctor will know I can get back to running?  I feel a lot better.

SO MANY THOUGHTS running through my head.  Primarily - what did your previous physical therapist do if they didn't look at your biomechanics?  Is that really what happened? 

This person came to me after having physical therapy for several weeks because they had experienced pain while running.  He had done all of his prescribed exercises and was now pain free with walking outside of the boot, but returned to the referring doctor for clearance. At no point during the rehab process had he ever been on a treadmill, tried to participate in a return to running program, or been to the track. 

What did I do?  I proceeded to conduct a complete initial evaluation of this patient - no different from any other initial evaluation I would normally do for an injury to that body region. I am a full body-focused physical therapist, so I never examine an ankle injury without looking at the lumbar spine and the hips in addition to the ankles followed by full body motions and balance. 

Bobby's parent: Wait - why are you looking at his back?  And his hips? We already did physical therapy and his leg is what hurts.  And what difference does it make that it hurts his knees when he squats... he doesn't want to squat or lift weights, we're here to get back to running. When is the biomechanics portion of this session?
Abby: Let's do that right now!

Alright... I already know from my examination that there's no way I'm clearing someone for return to running based on intolerance to a double leg squat that doesn't even hit a 90* knee flexion position.  Running is basically repeated single leg squats so if you can't double leg squat, there's got to be a problem with at least one leg in single leg squatting - but, I still need to see how the running looks because I'm going to give them a new home exercise program and need as much information as possible.  Also - the patient came with a specific request - so I'm listening to their demands and being thorough.  The more time spent in evaluation - the more effective the treatment can be later. 

This is the moment when I cut the previous physical therapist some slack and think that they knew this person should not be permitted to return to run but both the patient and parent are pushing for it and so they're sending him back to the doctor.  Who am I to judge another physical therapist I don't even know based on a patient sitting in front of me?  I fear that we, as a profession, are often guilty of blaming our colleagues without considering the whole scenario.  I'm nowhere near an expert - and I also don't have any clue what this kid looked like before 8 weeks of physical therapy.

So I put him on the treadmill and had him run.  Fortunately, it didn't hurt... but it also didn't look good.  I recorded it so I could play it back to him and his parent.  Of course there are really excellent pieces of equipment available and there are physical therapists who are highly specialized experts who work with elite-level runners.  I am not one of those therapists and I don't have any special equipement.  I know the basics of what running should look like and when I watch someone running, I can make modifications to form based on the errors they demonstrate and help them progress back to running when appropriate.

At bare minimum, all physical therapists working in outpatient orthopedics and/or sports medicine facility have the responsibility to learn how to observe and correct basic mechanics of a squat, hinge, and running pattern in order to help their patients.  I'm willing to look the other way if you can't break down throwing mechanics and specialized sport activities like gymnastics moves and ballet positions.  But the squat, hip hinge, and running patterns are essential to far too many athletes and the general population.  There are tons of courses and materials on how to do it - or you should find a colleague who can help you out.  Again - I'm no expert.  I don't spend much time studying running mechanics because the basics are pretty easy to spot once you take the time to learn those. 

I don't know if the other physical therapist ever actually said they didn't do biomechanics assessments.  Perhaps the therapist was a new grad who wasn't comfortable clearing an athlete for return to activity - as this is often a responsibility left to the physician that barred them from participation in the first place.  Regardless - because this has happened multiple times (and potentially has even happened with patients I have seen that then went to a different physical therapist... I would never even know!) - my new reoccurring segment of "What Do Physical Therapists Do" has been launched with Installment #1: We look at Mechanics. In a future post, perhaps I'll even outline some of the common faults to look for - so stay tuned for that!

Take Home Messages:
1) If you are a physical therapist - it is your job to be assessing your patients mechanics - in numerous ways - to make sure they are properly moving. 
2) If you don't know how to assess running form, there are several courses available: on Medbridge or in person, so you can learn the basics.  Truly - the basics help clear up problems in a large number of people.
3) If the basics don't fix your patients' issues, find a physical therapist nearby who focuses on running mechanics and refer.  But you should know that it is a physical therapist's job to be "the movement specialist" and as such - we need to better inform the public of what exactly we do.  You could also record your patient running (with permission - from the back and the side) and get the consensus of your clinic colleagues so you can collaborate and improve your assessment skills. Or re-evaluate the patient using a body-wide system like the SFMA to see if you're missing something.  Or send them back to the doctor to make sure an underlying pathology is not present.
4) Take the time to listen to the patient and target their treatment to the goals they have stated.  I can't always put a patient on a treadmill and watch them run at an evaluation because sometimes that isn't appropriate - but if they're going to return to sports, they're definitely going to do it at some point.
5) Find Physical Therapist colleagues who focus their energies on different areas of expertise and develop relationships with your referring doctors.  For example - I know exactly who to call when I'm looking at an athlete with pelvic floor dysfunction. And I know which doctors I can call and say - hey - I just looked at Bobby - and here's why I don't recommend he return to running at this time.

Let's fulfill the role we are intended for and serve as The Movement Specialists.

(Disclaimer: No identifying or specific patient information is being released here - as this would be breaking the law.  Names are changed, injury is different, and lots and lots of patients want to run.)