This will be another quick video blog explaining the thoracic spine manipulation roll down technique Personally I really enjoy this technique because if done on the appropriate patient, almost immediate relief can be obtained. I will stop right now and say only those who have spinal manipulation within their scope of practice should be attempting this. You must also be very confident in knowing who to and more importantly, who NOT to do this technique with. Here are a list of some contraindications for spinal manipulation (reasons why it should not be done)
Recent spinal fracture (duh)
Bilatareal/Quadralateral numbness/tingling
Constant pain/night pain
Osteoporosis
Lack of consent (you would be surprised how many times I’v heard patient stories of a practitioner just manipulating away without even telling the patient what they are about to do)
Pain in the premanipulative hold
This is a personal contraindication…I do NOT manipulate children under 13 and adults over 65
Here are some reason why I would choose to do a Thoracic manip
Chronic loss of thoracic spine mobility…could be a stability issue though, so that should be rulled out too
Pain with inspiration
Chronic loss of shoulder mobility/ROM (please see JOSPT‘The Effects of Thoracic Spine Manipulation in Subjects with Signs of Rotator Cuff Tendinopathy for more information
Keep in mind that I am still new to the video blog entries and as such, I need to practice my camera angles/mic control. I know it’s pretty small but now I know to film horizontal with my iPhone and not vertically…I will get better, not to worry
Importance of thoracic spine extension in shoulder elevation
A great patient buy-in outcome measure I like to do pre and post manip is bilateral arm elevation. If the client is restricted with upper thoracic extension they will have difficulty getting those last few degrees of bilateral shoulder flexion because a lot of the end range shoulder flexion comes from the spine going into extension. Have the patient raise their arms over their head, note restriction and pain levels, do manip and then re-test. If this helps, the patient will notice right away and…bam, instant credibility
Explaining the technique on a spine model:
Demonstrating the technique on a real person (the film got turned off too fast and I was about to say that after the manip is done I always check patient response to see if they are feeling good.
Thank you for reading and if you have any pointers, questions or comments I’m always happy to answer
This is going to be a quick video blog demonstrating one manual therapy technique and one corresponding exercise to restore talocrural joint dorsiflexion. In my experience, many medial and anterior knee pain clients tend to have restricted ankle dorsiflexion. This limitation causes a compensation to occur at the subtalor joint creating “over-pronation” to create more range into dorsiflexion. The tibia will follow the ankle leading to tibial and then femoral internal rotation…which we all know is a factor in patellofemoral pain syndrome (PFPS).
More generally, clients complaining of a pinching sensation at the front of the ankle with such things as squats can also benefit from the mobilization and exercise I’m demonstrating in the videos. Post inversion ankle sprain clients often also become restricted with dorsiflexion and just treating the ligaments with ultrasound and stim just won’t cut it….ever! You need to get your hands on the ankle!
A great ‘buy-in’ test to see the pre and post treatment results is the knee to wall measurement. Clients are often amazed at how much more mobility they get with only a few sets of this mobilization. The effects maybe neurologically driven, mechanically driven or a combination of both…who knows. It just works and that’s what’s important to me (and my patients).
Not shown in the videos is the importance of stretching and mobilizaing both the gastroc and solues muscles to aid in any myofascial restrictions contributing to the dorsiflexion restriction. I hope these videos help your clinical outcomes!
In some physio and chiro clinic settings there is an unspoken rule that discharging a client is a negative thing. Some might say that we should never discharge because it allows the client to maintain a relationship with their therapist on an ongoing basis. While I can see some validity to this for a SMALL minority of chronic pain patients, I refuse to believe we should not discharge our clients.
When I see a new patient for the first time they usually have a specific complaint (sore back, injured shoulder, tight neck etc). They come to me because I am an expert at assessing and treating their initial complaint. They don’t come to me for friendship or any other ongoing relationship outside of the physio-patient one that develops while in the processes of helping them with their issue. Don’t get me wrong, I like to get to know my clients and figure out what their meaningful tasks are. Once their meaningful tasks have been achieved, I will ask if they have any other complaints and if not, they are told to come back only if they feel the need to. A meaningful task is anything the client is coming to you to be able to do. For example, a meaningful task for a shoulder pain client may be to unhook her bra without pain. Once this task has been achieved, they are discharged. My job is done.
It is my belief that clients respect this and in turn will refer their friends and families to me because they know I won’t swindle them into months and months of care (which there is no evidence for anyway). One of the best predictors of success with therapy is either a within session (preferable) or at least a between session change of symptoms. If after 3-4 treatments the client feels no changes at all then either therapy is not for them or the course of action needs to be altered (that is assuming the client was compliant with their home program). If their initial complaint is getting better, then I see no need in making them come back for weeks and weeks to address postural faults, over pronation, etc. These biomechanical benchmarks have been shown to have zero correlation with pain and do not correlate with injury risk either. Where my rules on this bend is with exercise. If a client demonstrates interest in an exercise program after their initial injury or pain is better then I will keep them on as long as they would like me to help motivate and teach them progressions for their exercises. If a client needs me to help them get in shape, I am more than happy to oblige.
Overall, I feel like clients are actually assured when they ask me “how many times will I have to come in?” and I say “I won’t keep you here for a single session more than you need”. They respect this and are refreshed by it…I would HATE to know my clients think I see them as dollar signs instead of real people with busy lives who have better things to do to come to physio so I can “fix” them. I always tell patients that my job is to get them independent with their condition so they won’t need to come into see me very much if at all. This might take 3 sessions or it might take 8 or 10. Anecdotally, I see very few clients over 10 times. Ten sessions with me costs $625…if I can’t get them doing their meaningful task after spending over $600 then I have not done right by my patient.
Do I have the odd patient that comes in for “maintenance” (I hate that word…we are not cars!). Sure I do, but it’s always their choice. I don’t try and scare them into coming back. If a marathon runner or assembly line worker feels like they need to get manipulated or stretched out to feel great again who am I to disagree? I also stress how important it is to get in SOONER rather than later after the onset of back pain because the sooner I can see them, the more immediate success we have with them.
How do you feel about discharging patients? Do you do it? If so why? How do the economics of running a clinic factor in on your decision?
I want to share with you a patient who I’ve seen 5 times over the past 7 weeks for right shoulder pain. He is an avid volleyball player and want’s to get back to his sport. I saw him earlier on in 2012 and diagnosed him with a SLAP tear. He was referred for an MRI which showed just what I suspected. Unfortunately conservative care could not fully abolish this patients pain and clicking in the joint. He had labral repair surgery 10 weeks ago and while in surgery, his surgeon noticed substantial anterior capsule laxity and decided to do a capsular resection and shift…meaning they cut into the anterior capsule to pull it tighter together preventing excessive humeral head anterior migration.
Initially treatment consisted of gentle PROM and scap setting stuff. He was told he could not go past 90 degrees abduction and over 10 degrees ER in neutral for the first 8 weeks (seems excessive to me). We have done lots of manual therapy work in the form of gentle PNF stretching, myofascial release (or whatever you want to call it), passive scapular mobilizations and are now starting both anterior and posterior capsule stretching. I am also starting gentle proprioceptive drills with him in supine. His exercises to date have included:
Pendulums (codmans)
AAROM into flex, abduction, ER in neutral using a golf club
Proprioceptive drills leaning the arm into a rubber ball against a wall and making figure 8′s
Scapular rows
Prone glenohumeral joint centration exercises using a 10 pound weight… think “suck the ball back into the socket”I had him doing scaption with a band but stopped this exercise due to what I was seeing in the video you can see below. Can you guess why I decided I didn’t like it for him?
Based on the one video you are about to see of this gentleman doing bilateral shoulder abduction can you tell me what you see? Based on what you see can you give me some reasons for it and what you would do about it? I would be curious to get other perspective as I have my ideas and will share them in part 2 of this post but I always like knowing what other clinicians would do.
This post will be one I will add to as the list gets longer. I want to write a short post about the people I learn from in this industry. The key to being great at what you do is to never stop learning and with the advent of social media and the internet, staying current has never been so accessible. In no particular order, these are the people and websites I refer to and trust to provide me with current, thought provoking information…enjoy!
Erson Religioso III:
Having met him in person and worked with him professionally on the IFOMPT blogging team last year I can safely say that Erson is a wealth of information. His website (the manualtherapist.com) is exceptional for providing high quality instructional videos on manual therapy techniques. His eclectic approach is great because he incorporates so many different schools of thought into his teachings. He uses Mckenzie methods, Mulligan mobilizations, functional screening, Instrument assisted soft tissue work, and so much more to provide the reader with holistic ideas on how to treat patients…just look up one of his 15-20 minute videos to see what I mean!
I have the EDGE tool he created and it’s really quite awesome. If you don’t have one at least go to his website to check it out. It’s a great tool to have. Lastly, his OMPT channel provides more in depth and clear video instruction on so many orthopaedic related topics…and it’s $5/month!
Mike Reinold:
I first got introduced to Mike Reinold after reading his Current Concepts in Shoulder Rehab article back in physio school. I immediately went on to research who he was because the article was great and still provides me with solid shoulder related exercise progressions to this day. Mike is the head therapist for the Boston Redsox and is a shoulder specialist. His website (Mikereinold.com) is packed full of great articles for literally every part of the body.
I’m also a member of in Inner Circle group, where he has live video lectures and discussions posted every month on topics related to physiotherapy and strength and conditioning. It’s been a great resource for me and allows me to ask him questions about his topics in real time. He certainly makes himself accessible to his followers. He’s read my blog which I think is truly awesome because I’m sure he has 100’s of people wanting him to endorse/read their stuff. All in all, I would say he is the best physiotherapy-related writer on the social media scene.
Gray Cook:
This guy needs no introduction as I’m sure most if not everyone reading this blog has heard of him. He’s certainly a revolutionary thinker in our field and has probably done more to change the way manual medicine providers practice than anyone else has in the past 10 years. He is a proponent of creating a universal language we can use to describe and analyse faulty movement patterns. He has created a system to categorize acceptable levels of movement competency via his FMS and SFMA screening tools. Is there controversy within his methods? Yup! But at least he is creating the dialogue and forcing us to think outside the box. His book “Movement” is a must read…no questions asked.
Me and Gray Cook
Dr. Stu McGill:
Dr. McGill is a professor of spinal biomechanics at the University of Waterloo. I first got introduced to him in my first year of Physio school when I “borrowed” my first clinical instructors copy of Low Back Disorders…I guess I just forgot to give it back to him (ooops!). The book was right up my alley…all his theories on the how and why of low back pain were backed up by solid research. It’s not bullshit with Dr. McGill…he uses objective data to defend his views on back pain and proper methods to train the back….which is more than I can say for many social media gurus in our field. His second book (Ultimate Back Fitness and Performance) should be right next to ‘Movement’ as a must read title for anyone treating athletes with back pain. I am yet to hear him speak live, but it’s on the to do list for sure.
Dr. Andreo Spina:
Functional Anatomy Seminars is a great website to check out even if you haven’t taken any of his courses (like me). I want to do an FAP course but time and money allows for only so many things to get done. He is a CMCC graduate who founded Sports Performance Centres in Vaughn, Ontario and later went on to create and instruct in a series of courses based around specificity of palpation. He has a few different sub-sets of courses (FAP, FRR, and now FRC). He is also a research nut who writes very thought provoking blogs. Some call him arrogant or cocky, but being asked to teach your courses to professional baseball teams in the MLB would probably make me that way too
Dr. Craig Liebenson:
Craig is the master of blending in theories of exercise and rehab to make a point. After taking one of his courses in Toronto last year I can safely say that I have never learned more applicable skills in one weekend than I have with his course. He is passionate about bridging the gap from rehab to performance and is a tireless advocate for active care instead of pure passive care in the treatment of painful conditions. He is an engaging speaker who makes you question the way you practice…and we all need that from time to time!
Honourable mentions: Dr. Harrison Vaughn of InTouch Physical Therapy Blog – very good writer and I love his ability to critically analyse popular beliefs in therapy
Dr. Jeff Cubos of jeffcubos.com- Like Dr.Liebenson, Jeff is great at putting it all together and making it interesting. I read his stuff all the time and get a lot out it…and he’s Canadian! The exercise section of his website is super useful!
Dr. Greg Lehman of Thebodymechanic.ca- Craig is what I would like to call a skeptic and his ability to question everything with such great detail is truly a gift. He articulates my concerns with so many of the common myths within rehab/training in a way that most could never do. I have profound respect for his writing and critical thinking skills and read pretty much everything he writes. Want to question the way you practice? Read his blog!
Dr. Shawn Thistle of Shawnthitsle.com- Shawn has created a website called Research Review Services. It is an ingenious idea that allows busy clinicians the time to read small digestible summaries of current research in our field. He is a great Chiropractor and someone who really ‘gets it’. The chiro profession should be proud to have him as a colleague.
This last one is not really one person but more so a collection of people that I learn from. As many of you know, I am working towards getting my FCAMPT designation through the Orthopaedic Division of the CPA. I have done quite a few manual therapy courses and have learned a lot about differential diagnosis, joint biomechanics, and neuromusculskeletal pathology. Not everything they teach is useful nor evidenced based, but I can still say I have enjoyed the courses that the Orthoapedic Division has laid out. You really do have to take the good with the bad with these courses and they really are what you make of them.
There are so many people that I learn from, but these are some of my favourite. They are game changers in the field of manual medicine and athletic development that should be part if everyone’s reading list.
Who do you learn from? Who did I miss? I’d love to know!!
Just like a house, which requires a strong foundation to stay supported, so does the glenohumeral joint of the shoulder complex. Although a thorough anatomy review is beyond the scope of this blog, I feel a few key concepts need to be reviewed. The only thing connecting the shoulder complex to the rest of the body is the scapula via the acromioclavicular joint. Some argue that the scapulothoracic complex is a joint but I will argue that is it most definitely not! It’s just a bone (the scapula) sitting on top of the ribs…no joint there. Anyways…
Since the scapula is the only thing connecting the shoulder to the rest of the body, it only stands to reason that it is the foundation from which the shoulder can function optimally. Therefore, I see very little use in training the rotator cuff muscles without first addressing scapular stability AND mobility. Too many clinicians focus on just scapular strengthening exercises without addressing scapular mobility first when they have a client with shoulder pain. For example, if levator scapula is tight, what will it do? It will downwardly rotate the scapula placing it in a disadvantageous position for glenohumeral joint mobility. If pec minor is tight (and who’s isn’t?) what will it do? It will anteriorly tip the scapula lifting the inferior angle off the ribs creating issues for lower fibers of trapezius to aid in upward rotation. Therefore strengthening lower fibers of trap without FIRST addressing pec minor tightness is less than ideal. You will never be able to achieve strength goals until the scapula is sitting flat against the ribcage with the spine of the scapula at around 15 degrees of inclination.
Furthermore, thoracic spine position is critical to scapulohumeral rhythm. An article was just published in the latest JOSPT (December addition) that dealt with the beneficial affects of thoracic spine manipulation on rotator cuff tendinopathy/pain. It only stands to reason that if the upper back is moving better, the scapula can move better, therefore allowing the rotator cuff to act as a humeral head stabilizer instead of a prime mover…which it often has to do in the case of kyphotic postures. So, hypothetically if the thoracic spine is mobile and upright, the tendons of the rotator cuff can “relax” and thus decreasing the inflammatory response due to impingement or overuse.
The beautiful thing about this model is that is applies to so many “shoulder related’ conditions. Thoracic outlet syndrome (TOS) is a function of muscle imbalances and posture. Studies are showing that cervical radiulopathy is also a function of thoracic spine and scapular positioning. Even distal conditions like carpal tunnel syndrome and tennis elbow can be traced back to shoulder positioning (not all the time, but it’s always something a prudent clinician should check).
Conditions such as rotator cuff or long head of biceps tendonosis, upper limb nerve entrapments, and even labral tears can usually be traced back to scapular positioning. But what can we do about this? How do we train the scapula more optimally? Here is the key: STOP doing external rotation exercises for the rotator cuff to fix scapular positioning I see it all the time and it drives me nuts.
Now I will outline a summery of what I feel needs to be done to addresses many shoulder- related issues:
We all know that we should balance our pushes and pulls, especially with regards to our bench pressing and rowing, right? But what if it’s not so simple a relationship?
In essence, what we’re looking at here is balancing our ability to protract and retract the scapulae. Bench pressing is a horizontal pushing movement that you’d think normally produces protraction (forward movement of the scapula around the ribcage) and trains the muscle that cause protraction, a.k.a. the serratus anterior. The logical opposing movement would be a row of some sort. Balanced, right? Wrong.
Question: What’s the most effective scapular position to maximize bench press performance?
Answer: Retraction and depression
Question: What scapular position is achieved in the contracted phase of a rowing movement?
Answer: Retraction and depression
Balanced? Nope.
Get it? What looks good on the outside, feeds an imbalance on the inside. Serratus anterior becomes ineffective as a protractor, stabilizer, and upward rotator. Then there’s an added bonus. But first a quick anatomy lesson.
Next time you’re cutting on a cadaver (What? Doesn’t everyone?), check out the serratus anterior and the rhomboid. What you’ll find is that because of the fascia that covers everything in the body, they’re essentially the same muscle with the scapula kinda stuck in the middle.
So if the serratus anterior isn’t fully effective at producing an upward rotation force and the rhomboid (a downward rotator) is getting trained with both pushes and pulls, then guess who wins the tug-o-war with the scapula.
Correct! The rhomboids and downward rotation. This means you’re more likely to experience shoulder impingement. (thank you Mike Roberson for that great example!)
It becomes clear that one of the best ways to train the shoulder is…the PUSH-UP!!! This classic exercise is fantastic at activating and strengthening the serratus anterior as an upward rotator of the scapula. It also acts to counteract the forces of pec minor by flattening the scapula against the rib cage (fighting that anterior tilt a tight pec minor exerts on the scapula).
Lear and Gross determined that push-ups performed with the feet on an elevated surface significantly increased the activation of the serratus anterior compared to traditional push-up variations. If it’s been a while since you performed traditional push-ups, it would be a good idea to start with basic variations, but elevating the feet is a viable progression if your primary goal is improved serratus function.
(J Orthop Sports Phys Ther. 1998 Sep;28(3):146-57.)
Another clutch exercise for optimal shoulder health is the Face-Pull. This exercise works to strengthen the scapular retractors…but the beauty of this exercise is that is does so with the scapula pre-set in an upwardly rotated position. We must be careful here..too much posterior deltoid activity is no good…we want pure scapular retraction occurring with minimal humeral head elevation.
Another not so popular exercise that is often forgotten for shoulder health in the Standing Straight-arm pulldown. I love this exercise because it is dead easy to preform and coaching for it is a breeze. Very little that can go wrong here. This exercise is fantastic because it teaches the latissmus dorsi muscle to work to depress the humeral head in the glenoid without activating the deltoid. This will prevent excessive humeral head elevation with overhead reaching…a common source of pain in shoulder pathology patients.
Besides exercise, I will ALWAYS employ manual therapy to help with scapular positioning. Here is what I do:
Pec Minor soft tissue release (I would say ART but I’m not allowed…it’s like $2500 for a weekend ART course…are they serious?!?!) I digress… I pin the muscle just at its origin on the coricoid processes and passively or actively flex the arm in the plain of the scapula to release this muscle. I then do manual stretching to aid in loosening it up.
Levator scapula/Upper trap stretching and soft tissue release
Passive side lying scapular mobs into elevation, depression, upward and downward rotation
Thoracic spine manipulation to aid in upper back mobility
(Not exactly how I do it, but you get the idea…you want more of a superior directed force as opposed to a straight anterior to posterior force)
So how do you make a rotator cuff happy?
1) Address upper back posture.
2) Maintain optimal balance of the muscles around the scapulae and the shoulder joint.
3) Then addresses rotator cuff muscle strength AND endurance (which is an entire post in itself!)
This year over 10, 000 new readers found my blog from over 80 different countries. To some this may seem like a small number, but to me it is an epic accomplishment I’m so happy that people are enjoying the content and I look forward to being more active with my blogging in 2013. It’s something I love to do and will try to write more relevant content week after week. Thanks for all the support!
Here’s an excerpt:
600 people reached the top of Mt. Everest in 2012. This blog got about 10,000 views in 2012. If every person who reached the top of Mt. Everest viewed this blog, it would have taken 17 years to get that many views.
I wanted to share a quick story about a new patient I had at my clinic a few weeks back. This 34 year old male came in as a new patient with a complaint of some “minor knee pain” after falling at work. He walked into my treatment room with what seemed like good control of his knee. I didn’t see a limp nor was his gait antalgic in the least. I figured it was a muscle strain or something of that nature. I get him on the bed to do stability testing and this is what I find:
At fist I thought it was an ACL tear but upon further investigation it was a PCL tear. I didn’t show it in the video, but his sag sign was very positive.
I then did another stability test and this is what I found:
This maybe a little harder to see but he also have extreme laxity of his MCL!!
So let’s review: This patients calmly walks into my clinic with very little pain after falling at work and hearing a pop. He looks stable in gait yet these orthopaedic tests tell us a very different picture…not sure I’m able to explain this clinically
I had him go back to his GP to get an MRI to confirm my diagnosis and it was in fact shown to be a full PCL and MCL tear. His surgeon does not want to do surgery as the PCL has a very poor recovery rate as her his words ( I didn’t know that at the time).
Any suggestions on how to treat this? Just curious to see what others might do?
Over this past weekend I had the opportunity to see Dr. Craig Liebenson present a course at SPC in Toronto. In this blog I will write a review of the course with some interesting take home points.
For those that don’t know, Craig is a chiropractor from Los Angeles. He is what I would call a revolutionary chiropractor as he has taken concepts from so many discipline and formed his approaches based on the work of physicians physiotherapists, strength coaches, etc. He is well known for his ability to make us look at the body as a unit and not as separate parts that need to be fixed in isolation. He is a master at corrective exercise prescription and he understands movement better than pretty much anyone else I have ever heard speak. He is a strong advocate for bridging the gap from rehab to fitness…meaning manual therapy and modalities are great, but we must also teach our clients to move right to empower them to be able to heal their own pain. HERE is the link to his personal website where he literally gives away tons of information and printable exercise sheets for patients. It is refreshing to know that he doesn’t charge for everything, and he doesn’t seem like he is in it for the money at all.
Craig started the day on a rather interesting “rant”. He told us we are in the midst of a rehab renaissance and if we fall behind, we will be lost. He encouraged us to see Pr Stu McGill, Grey Cook, and take DNS, kettlebell FMS, and SFMA courses to make us complete practitioners. Personally, I found this strange at the onset as he never said “good work” for taking a weekend and spending hard earned money to take his course. Instead he almost made us feel bad for not taking other courses. Towards the end of the weekend he rectified this by thanking us all and saying how much he appreciates us in Toronto for having him back for a third time.
After his initial rant he went on to discuss societies failure. We as a society have become super sedentary and it’s reeking havoc on our health. He brought up an interesting slide that looked like this:
Obesity, High BP, and sedentarism
GP’s- medication, imaging
Ortho Docs- Injections and surgery
Gold standard: Manual therapy and Exercise
Essentially, we has physiotherapists, chiropractors and personal trainers (minus the manual therapy) are well positioned to educate the world about how devastating inactivity is. Dr. Liebenson told us we must be at the front lines of batteling this. I agree with him 100%!
We talked about the postural conspiracy and how poor kyphotic postures are causing lower back, neck, shoulder pain along with headaches and so much more.
Back and neck pain..check!
Bruegger’s exercise
We reviewed the joint by joint approach and we talked about the importance of micro-breaks for our office worker patients. To break the code and get people moving better, we can’t have them go back to sitting in a hunched position for hours at a time. This defeats the goals of corrective exercise. HERE is an exercise sheet I give to ALL my desk worker clients, regardless of their initial complaint. Throughout the weekend Craig had us doing Cat-Camels, Reach the ceiling, and bruegger’s exercises to keep us limber…he is a man that definitely practices what he preaches.
We discussed the overhead athlete and how shoulder impingement might be due to a contralateral hip internal rotation deficit. If a pitcher can’t post on his lead leg when pitching due to a lack of hip IR, he will ultimately have to use more force through the throwing arm to get the acceleration he needs. This over time can lead to a tight capsule and impingement. Moral of the story: we must look at each client as a whole and not just treat the site of pain.
Breathing was also big. Long story short: we must breath through our belly and not our accessory muscles of respirations (pec minor, scalenes, upper traps) as this can cause chronic neck pain/tension.
Dynamic knee valgus was also discussed as a leading cause of ACL injuries in women (nothing new there).
Exercises to mobilize the thoracic spine such as the T4-8 sphinx, foam roller extension, and child’s pose positions open books were all discussed as ways to self-correct the kyphotic postures our desk jobs put us in….I should probably do some sphinx exercises right about now! We talked about squat training and how to from a goblet squat to a sumo squat and then to a potato sack squat with a kettle bell to train for a weighted squat with a bar…this was an excellent progression as I am always looking for better ways to teach my motor moron patients better progressions to squats with.
There was so much talked about on this course that is it very hard to summarize everything. I will say that the biggest take home for me was HOW we get our patients to buy in to the corrective exercise framework of rehab. I asked this question on the course….I wanted to know how we convince a back pain client who wants to get passive care to buy into an exercise based approach. This is how we should integrate this into our practice:
1) Find out what hurts (movement, ROM, specific exercises, ADLs…whatever!)
2) Find out what movements the patient is bad at that do NOT hurt (non-painful dysfunction)
3) Pick an exercise that helps correct #2 , which should also help with #1. You can pick ANY exercise you want, as long as it helps with the patient’s initial complaint. If you know the principles of movement, the method doesn’t matter as much. Just get the patient feeling better and moving better and they should feel better. If by doing the chosen exercise for teh non-painful dysfunction helps with the clients initial complaint, they are MUCH more likely to buy in.
(With all that said, I still think it will be impossible to get some of my patients to exercise…they just have ZERO interest in active care which is both depressing and frustrating as they are essentially denying them self a pain free existence due to laziness)
NOTE: Being able to tease out the non-painful dysfunction and then figure out which exercise to give that will help that dysfunction and simultaneously decrease their pain is hard. It takes practice and is the art of what we as manual medicine providers do. We must learn as much as we can about why we hurt and how the kinetic chain can become compromised. Once we know that, it becomes easy (as Craig said).
We left the course with this amazing quote by Karel Lewitt:
I am always aware of how many things which I taught in my long past have since been proved wrong. The most important attitude is therefore to be constantly aware that what you are doing and teaching now you will have to modify and correct in view of new facts. Thus you must keep an open mind for new knowledge, even if it sometimes shows that what you believed and taught before was wrong
Here is a small clip just to see what it looked like at the course. Enjoy:
Thursday was my second day at the conference and it was my favourite of the 3 I was in attendance for. To start the morning off we had Gray Cook talk about how we look at movement screening, testing, and assessing movement patterns. I wrote a full blog post on his talk that can be seen HERE .
After a break with exhibitors, I attended a specialist master class pertaining to complex cases presentations. The presenters all described a real case which served as a great clinical lecture with real take home messages for me. Dr Trudy Rebbeck from Sydney Australia talked about a very interesting case of 15 year old football player who suffered concussion like symptoms after being aggressively tackled in a game. Any movement of the neck produced numbness and weakness in the arms and legs (yikes!). He was sent for an MRI which was “negative”. After a course of therapy including DNF exercises, gradual return to play re-training and balance training he was cleared to go back to his sport. The one detail that astounded me was after the initial MRI was cleared, the Physiotherapist (Dr. Trudy Rebbeck) wanted to see it because his symptoms just didn’t make sense to her. After she reviewed it and asked another radiologist to look at it, they clearly found out that this young boy had incomplete fusion of the arch of the atlas and small tears in the alar ligament. The condition is called Spina Bifida Atlnato and was completely missed by the first radiologist.
Moral of the story: We must exercise clinical judgement and we can’t believe everything is fine with our patients even when they are cleared medically.
There were other case presentations that dealt with similar situations. The overall theme of this class was to think holistically at the body and always to think outside of the box when treating any one specific joint. I.E anterior shoulder pain might be an issue with the rotator cuff, LHB tendon, cervical spine, thoracic spine, serratus anterior or lower trap weakness…the list is long and we have to differentiate to get a a true clinical diagnosis.
After that class the conference gathered back in the main room to witness Robert Elvey get the Geoff Maitland award for clinical excellence throughout his 40+ year career as a physiotherapist. He has been dumbed the father of modern neurodynamic therapy and has taught 1000′s of clinicians the art and science of OMPT all over the world. He was not in attendance to receive the award due to health matters, but his acceptance speech read by a friend and colleague of his was excellent. Congratulations to Robert Elvey on this distinction.
The last presentation of the day was called ‘Manipulation in the Thoracic Ring’ by Dianne and Linda-Joy lee. Unfornately I arrived just as they started and was forced to stand for the 2+ hour lecture with about 30-40 other people in the back. I could not write any notes down as I had no space to do so. Even with that in mind, I still highly enjoyed their talk. If you’re a physio in Canada, chances are you have heard of the lee’s. Diane lee is synonymous with the pelvis and they have been vital in their work of the theoretical model of thorax biomechanics. In a very large summery of what they said, their 30+ years of clinical experience has lead them to believe that many common orthopaedic conditions can be traced back to the thorax. It is their contention that the ribs can shift to the right or left… envision the rib-vertebra-rib-sternum complex as one complete ring. Therefore we have 10 complete rings from rib 1 to rib 10 (last 2 ribs are floating and don’t constitutive a true ring). They believe that subtle shifts in these rings can alter our positioning, creating muscle imbalance, join compression, and really many different problems. They used videos to demonstrate their ring re-positioning techniques on their patients with what seemed like miraculous results. The lee’s really made this concept look like the missing link that integrates all forms of therapy into one conceptual model. They showed video of a rower with a long history of LBP with rowing and long periods of sitting. In their video they showed the rower long sitting (like a rower position) and we saw his lower lumbar spine shift sideways with each rowing movement. L.J Lee then placed her hands along the side of the thoracic wall (which 2 ribs i can’t recall) and ‘repositioned’ the rings and told the patient to do another rowing motion. After her force was applied, the rower had no more pain in his lower back. All in all I left this presentation with so many questions as I always am skeptical of techniques that are advertised as cure-all’s. I’m not saying they out right said their form of treatment can cure everything, but they did have an almost mystic-like tone to their presentation. To learn more about their very interesting model, click HERE
In summary: This day and really this whole conference has been about the connection between research and clinical experience. We must use research to guide our practice, but we can’t let it be everything. Like the Lee’s said: RCT’s will never encompass or be able to examine the therapeutic relationship we have with our patients…and this is a very valid point indeed. This conference has also really been about thinking about the regional inderdependence of the body and to view it in a holistic way. Surprisingly, I didn’t hear as much as a I thought about specific manual therapy treatment. I heard more about functional movement assessment, integrated systems model (Lee’s), and the biopsychosocial model of pain.
