Friday, August 5, 2016

"Wake Up Drills" or Be Activated

The last few months in clinic have brought in some, if I can borrow the new Netflix title, "Stranger Things."  I have had at least 4 people have extremely hard falls that actually fixed chronic pain.  This was musculoskeletal pain that had been present for over 2 years.  One gentlemen had disc pain and was recommend surgery from his orthopedist.

Hard fall on a hip that took all the pain away and stated felt stronger then ever.  Another hard fall directly on a knee that shoved the hip up.  Again, took all pain away in the hip.  (knee was sore for a few weeks ) Lower back pain that went away after a hard fall down stairs onto the butt.  (I've actually had this happen 3x now in the last 7 years)  One had some serious disc pain for about a 6 month period and was in PT.  They all stated they had shot of pain, layed on the ground wondering if they broke something, slowly got up and realized the pain wasn't there.  All felt stronger after the incident immediately.

From a chiropractic stand point I don't believe there was an "out of alignment" joint.  To have that kind of need for that force would suggest a joint that was very misaligned to the point of limping or horrid movement.  One hip I can verify moved extremely well.  (I understand my bias on this and while I could be wrong I'm trying to think of other possibilities.)

For the sake of argument, if it was misaligned, I at this point in my thinking/career, wouldn't feel ethically comfortable putting the amount of force they experienced into 60+ year old hips.   Nor do I think I could actually generate that type of force.

So what happened? 

I don't really know.  If a joint moves like a joint, doesn't have abnormal tension in any of the prescribed motions what's left?  Proprioception of the joint and strength of the muscle is the only things I can come up with.  While I am a big believer in strengthening muscles/movements.  I haven't found that to be that effective with people that have had chronic pain that the joint moves well.  So for me, that eliminated this option.  That leaves proprioception of the joint.  How well the individual can find and use the joint.  This comes back to old school "muscle testing."

I've blogged before about how I don't think we are muscle testing but testing proprioceptive awareness of that movement in that position.  Movement variability even states that every successive test you are most likely not even testing the same fibers and that their is a ton of bias on the practitioners part.   But, my personal bias still thinks we should be able to lock a joint in in all planes of motion without much effort.  (not clutching the table, holding your breath, squeezing your jaw)

This question of what happened with these patients lead me to think about performance and if this could be done at a lower level.  (not having to take a huge fall to make a change.)  After much debate, I decided to take Douglass Heels Be Activated course.  I went with an open but skeptic brain.  I probably asked 5-6 people that had taken the course before their thoughts and opinions.  Really looking for a reason not to go.  All spoke highly.  What made up my mind was the number of strength coaches implementing it into their programming and all stating that the soft tissue injuries have come down.

I've found for me, the most useful tools in therapy from high class strength and conditioning coaches.  The elite use it first and it trickles down.

It was held at the Spot Athletics in Columbus, OH.  (side note...kudos Columbus, you guys have solid 3rd wave coffee scene.)  The owner JL Holdsworth a super respected guy in the strength coaching industry.  The teachers for the weekend were Cal Dietz and Chris Korfist.  Cal is the Strength coach for the University of Minnesota and has been using it with his athletes for over 3 years.  Chris is track coach and been doing it for over 6 years and has worked with Douglass for the full 6 years.  So it was great to learn from guys using it daily with real athletes.  It was equally awesome to be in a room with some pretty respected strength coaches from all over the country.

Without going into the details, it's getting muscles to fire stronger.  When JL spoke of the term "wake up" drills it clicked for me.  By the way JL, if your reading this I'm stealing that phrase!  If you believe in corrective exercises for your patients or athletes, then you can't argue with a wake up drill if it gets the muscle to fire stronger, or have better awareness, or have better proprioception in that area.  (terminology can vary)

Wake up drills make sense to me.  Can you fire the muscle/movement without a compensation pattern.  It's in the compensation pattern that many injuries can possibly be explained.  In my way of thinking it can be easily implemented into a warm up routine.  Just like many injuries can be mitigated with a great warm up, something most athletes fail at, perhaps this will be a way to increase the benefit of the warm up.

Perhaps the falls were just a jolt into the nervous system that globally stimulated the sympathetic nervous system and then a huge parasympathetic release when they realized they were ok.  Perhaps the falls literally "woke up" the muscles around the area.  A figurative defibrillator to the muscle/movement.




Friday, July 15, 2016

Loading and Unloading the Body

The more I work on patients and athletes the more I kind of view therapy as learning what to load and what to unload and how to manage it.  Load can be another view of stress.  When you stress a muscle or joint you are asking it to bear the burden, "to bear the load."  When you are unloading the muscle or joint or area, you are taking away stress from the muscle or joint.  I think most pain in a muscle or joint is that to much stress/load is being applied to the muscle or joint.

I think a lot of therapy and therapist are good at unloading a joint or muscle.  I think therapy as a whole has done a very bad job of loading tissue.  I think most therapists are afraid to properly load tissue.  Without loading the body, no progress can truly be made.  Even acute injuries, if you understand the injury mechanism can be loaded for faster recovery.

An example would be a hamstring tear that occurred on a Friday, the athlete may be able to do slow dribbles on a Saturday. A few things are happening.  First, the hamstring is still involved.  There is a neural competency that is making the muscle stay active, but at such a slow speed as to not aggravate the injury.  Second, we are increasing blood flow, paramount for healing.  Third, we are beginning the slow process of keeping the skill set of sprinting ingrained.  Finally, we are giving the athlete active part in the recovery process.  This isn't passive, only relying on the therapist.  I think this may be as important as all of it combined.  Passive treatment can lead to woe is me, victim mentality.  When the athlete stays involved from the onset, an injury can be just something to overcome.

This doesn't even going into all the different workouts that may be able to be done upper body.  Perhaps even riding a bike slowly could be done right off the bat.  

Chronic problems need even more direct approach.  Lower back pain isn't about just unloading the stress from the back or hip.  It's about finding what needs to loaded to ultimately unload the lower back from that stress.  A runner that comes in with knee pain after 5 miles, most likely needs to learn to load the hip better, not unload the painful area.

Years ago Gray Cook came up with the "Joint by Joint" approach.  Essentially, alternating joints have different components of mobility and stability.  Mobile big toe, stable mid foot, mobile ankle, stable knee, mobile hip, stable lumbar, mobile thoracic, stable cervical, mobile upper cervical, stable elbow, mobile wrist.  



I think there is a general "Load and Unload" approach.  I think most people will agree that the joint by joint approach is correct it doesn't mean the hip at times won't need to be more stable in certain individuals.  I think the load/unload approach is even more general.  Just what I see that is more common.  

Muscles to unload (destress)          Muscles to Load (Stress)
abductor hallucis                               extensor hallucis
medial soleus                                    lateral gastroc/ tibialis anterior
vastus laterals                                   rectus femoris (end range)  
psoas                                                 lower ab and external obliques
adductor magnus                              glute max
semimem/semitendinosis                 biceps femoris
TFL area                                           glute med/min
lumbar erectors                                 lumbar multifidi
thoracic erectors                               latissimus dorsi 
pec sternal                                         pec clavicular
anterior delt                                      posterior delt
levator scapula                                  upper trap/lower trap
rhomboid                                          serratus anterior/ mid trap
brachialis                                          biceps 
forearm flexors                                 forearm extensors (end range)
triceps lateral/medial                        triceps long head
SCM                                                 deep cervical flexors

This is probably very similar to what you will find on what is phasic and what is tonic.  But, it's just my way of viewing what are some common patterns that I see.



The key point to understand is to figure out ways to start loading the tissue and get better at loading it, not just address the unloading of tissue.   This approach can work for all forms of scenarios.  How much load or work can a patient assimilate in one treatment?  How much load or work can you athlete handle in a workout.  What is the deload strategy?

We can view exercise as a global load on the human body and something like a desk job as unloading the human body.  This has to be brought into balance or the human body will not remain healthy.  When astronauts go to space, special measures must be taken as their bodies immediately start losing bone and muscle mass as gravity (load) is no longer upon them.  How much can we load an older individual to keep their bone mass healthy?

I often ask the question, what stretches or exercises have you done that makes you feel better or worse.  You will be surprised how often the patient has the answers, but doesn't realize it.  "I feel horrible every time I stretch my hamstrings, but I love doing lunges." Again, their giving clues as to how their body likes to loaded.  As a therapist when you start looking at the issue your patients or athletes are dealing with, start looking for a way to load them to unload them.  In my opinion this will bring longer lasting results.

Wednesday, July 6, 2016

Reframing for Resiliency

Over the last several months I've been practicing the concept of reframing.  Some times I'm successful and sometimes I'm not.  Reframing is taking the situation you are dealing with and trying to look at it from a new perspective.  It doesn't change the situation.  It changes how you are going to react to it.

Create a different viewpoint.

My biggest downfall in terms of attitude is easily my viewpoint on time.  My time, or what I consider my time.  The concept that this thing or person gets this time, this task gets this amount of time and oh yea, this chunk of time is MINE.  Free to do with it whatever I want.

Life has a way of eating up that time occasionally.   Life chores, kids, owning a business, friends, family all have at moments eaten up "my time."  When it did, I would get angry, bitter, annoyed.  The gamut.  It was a weakness.

There is a quote by Henry Rollins that really got me thinking and looking at this more intently.


Time is not yours.  No one is actually promised time.  How many people have left this world to early thinking that they had more time?

Memento Mori may indeed be cliche.  But it is true.  We are all mortal.  No one is promised more time, another opportunity.  Time is a gift.  This is how I  reframed "my time" to build resiliency in myself.  I am better at what was a weakness.

I hate mowing the lawn.  It is a life chore to me.  It is not going away.  Once a week, I had to suck it up and just do it.  Again, it was something that I felt was robbing me of "my time."  How to reframe it?  It seems silly, but I threw on a weight vest and considered it aerobic work.  All of a sudden something I hated, became something I somewhat enjoyed.  Nothing changed but how I dealt with a life task, reframed.

Thanks to Stu Mcmillan, Sprint Coach at Altis, for his posts and conversation this past week about resiliency.  (Check out his instagram posts under @Fingermash, they are worth the follow)  He states that resiliency is a skill, like any other that can be trained.  It's his posts and conversation that got me thinking that reframing is a way to build a skill to to improve resiliency.

I think learning to reframe things is key.  Most people would consider resiliency to be getting up when you get knocked down.  For athletes, its bouncing back after an injury, a bad race, a unfair call.  Its reframing a disappointing performance.  It can also mean not letting a great performance deter you from the further work that needs to get done.

This past week at US Olympic trials I got to see great performances and disappointing ones.  I got to see Olympic dreams dashed because of someone elses error.  Imagine 4 years of work for a dream, gone because someone tripped you!

I have no idea if these athletes will show resiliency.  I do believe if these athletes will be successful, they must show resiliency through reframing.

The more often we practice reframing the easier and easier it will get, just like training a muscle.  The more you do it, the easier it will work.  The more it will get engrained in your psyche.

I write this in an airport waiting to catch my last flight home.  I was supposed to be home yesterday.  Storms, closed airports, crew switches and closed airports had different plans.  I'll eventually make it back to Grand Rapids, just not on the time I had planned.  I had to do some major reframing for me to not blow a gasket.  It sucked sure, but it gave me some time to read, write, listen to some podcast, and music.    Four things I enjoy.  Would I rather be home?  Yes, but that wasn't an option.

Don't begrudge the time you are in because it didn't work out, be grateful you have life time to deal with it.  

Sunday, May 29, 2016

The Modern World Versus The Long View

The definition of taking the long view is thinking about (taking action) in terms of its effects on the future instead of the present.  The long view can be also be intertwined with the concept of discipline.
Discipline to me is the ability to give up the ease of the moment for something greater in the future.
Long view recognizes what it is you could potentially be/have/do.  Discipline is allowing you to navigate each day to stay on the course.

I think about the importance of installing a long view mentality in my kids in a world that is more and more instant gratification.  I wonder how often the ability to have things instantly starts to erode patience and if it starts to chip away the ability to grind towards a goal.

Long view is so important for health.  The discipline to do the simple, boring things day in and day out.  Anything that changes health quickly is usually a drug.  Medicine is designed to work quickly.  Thankfully!  We don't want to wait 4 weeks to find out if this antibiotic is working.  But, realize, medicine (outside of some life threatening conditions)  isn't designed for long term use.

If it acts quick, it isn't sustainable.  If it's not sustainable, it's not a great choice when it comes to the long view.  Restricted calories and drinking nothing but 2 shakes a day may indeed lose you that 20 pounds you are looking for.  But, that isn't sustainable and when it ends there is usually a very strong rebound effect.

We are told that eating fiber is great for us, but there isn't that instant gratification that come from doing it.  The difference may not show up for months and months down the road.  That is where discipline comes in to do it day in and day out.

This leads to the final piece of the puzzle, trust.  You have to trust the process.  Trust that the long view is worth it.  If trust isn't there, discipline will wain.  Instant gratification will start to win.  Trust can come from repeated failures that what you have done didn't work.  It can come from seeing what someone else has done and following the steps.  It can come from seeing others failures and successes.  The trust has to be real.

I see people every day that have either kept themselves active or inactive in clinic.  The difference in their quality of life when they get to their 60's and 70's is mind blowing.  My last visit to ALTIS I started thinking about this when I was watching the sprinters working on the acceleration for the 100m.

The 100m is a technical race.  There is a very important phase called acceleration coming out of the blocks.  It takes discipline to gradually build into the speed to accelerate smoothly to have energy for top end speed later in the race.  The athlete must trust the process and not rush it.  You don't get a medal for being first at 50 meters.  You have to have the long view of running your race to win at the end.

 I often ask myself the question, will the me that is exactly one year older from me currently, be glad that I started doing this every day today?  If the answer is yes, I have a long view goal.  Take the long view with your health.  Don't fall for the modern world myth that health can be achieved quickly.  Discipline day in and day out.  Trust that the journey is indeed better that way

Wednesday, May 11, 2016

Random Monthly Thoughts and Recaps

Things To Watch:

I really enjoyed the documentary Barkley Marathons.  It's about a very odd 100 mile inspired by a prison break.  There has been 10 finishers in 25 years.  You get to meet the odd and interesting man that puts on the race and the equally impressive and interesting people that feel drawn to compete in it.  Available on Netflix.

I have a fascination with the world of medicinal mushrooms.  The more I read or watch on it, the more I get interested in it.  I've enjoyed the products from Four Sigmatic foods and they are putting out some really cool youtube interviews.  Very informative.



Things to Read:

Probably the newest voice I've been reading is Scott Adams.  He is the creator of the comic Dilbert and has a really interesting blog.   Through his blog, I bought his book.  How to Fail at Almost Everything and Still Win Big.   I'm really enjoying it.



Things to Do:
I've made a variation of this windmill a staple in my every day training.  It really makes the hips/lower back play nice together.  Will Chung showed me a variation of this, but this is a solid tutorial.



Things I'm Thinking about:

I know (believe) at the root of all injury is a cause.  There is no such thing as bad luck.  The last time I was in AZ working with some Olympic Sprinters through the organization ALTIS, one of the sprinters I was working with pulled her hamstring.  Everything seemed to look well for a competition and yet, she still was injured racing.  I can't stop thinking about why...is there an answer?  Is there something that could have been seen that I didn't see.

Whats the significance of mono vs biarticular muscles.  Should they be trained differently?  Perhaps biarticular only trained isometrically.  Mono articular trained for endurance?  Frans Bosch has me thinking perhaps?

Lessons to be learned:

The things or attitude that brought you success in one arena may be a hindrance in another.  One very awesome patient is a lawyer that is also a runner.  The tenacity and hard work and just the mindset that I'll do whatever it takes to do well and succeed is often recipe for injury when it comes to a training plan.  Rest was seen as weakness almost.  Push, push, push till you get the result you want.  The problem is that training doesn't respond like that.  A different mindset is needed if recovery from injury is to happen.

Things I'm Playing Around With:

I'm trying to get in 60-75 grams of fiber per day from 8-12 real pieces of fruit and vegetables.  I've never actually eaten them consistently.  Going to do this for a few months and get my blood work redone to see how it looks.





Friday, April 22, 2016

Clinical Neurodynamics: Lumbar Foramen Mechanics and Implications for Nerve Root Health

If you read my last blog post you know that I recently attended the Clinical Neurodynamics course with Michael Shacklock.  One of the most interesting bits of discussion was his research and findings with lumbar foramen biomechanics and it's relationship to the lumbar nerve root.  I've asked permission from him to write this blog post as this is part of the course and he has graciously permitted this.

For the longest time we assumed the foramen in the lumbar spine was doing what the disc did.  This is no longer the case.  The therapy approach Mckenzie has a large component of extension to drive the disc forward.  This has been shown in MRI to be true.  But for the disc to be driven forward, the posterior annulus must essentially spread or get larger to help drive the nucleus forward.  So as this spreads, the foramen actually gets smaller.



So, going forward also does the exact opposite.  As the spine bends into flexion the discs nucleus is pushed back.  The annulus gets smaller.  The foramen increases in size.  A larger foramen is created.  With the larger foramen comes 5 positive and tested outcomes.

1.  The foramen area increases between 15-40%
2.  Pressure on the nerve decreases 30-40%
3.  Size of the nerve root increases.  (from the reduction of the pressure)
4.  Electrophysiology of the nerve improves.  Strength of the contraction is better.
5.  Pain has decreased.    

Essentially the lumbar nerve roots and lumbar discs have opposite biomechanics.  This doesn't mean the Mckenzie approach is wrong.  It just means different techniques for different times  It shows how some approaches such as PRI with their flexion based activities in my opinion give relief to some peoples back pain.

It reinforces to me some very important concepts like Functional Range Conditionings approach to having segmental control of the lumbar spine.  How can you ultimately take pressure of a nerve root if you can't flex the lumbar spine segmentally?




They are showing that the same spine in a standing MRI with disc bulges go away essentially to the point you can't tell the disc has a bulge when the individual goes into flexion.  This doesn't mean flex a disc patient that is in pain.  What it does mean is perhaps the person that has fear based apprehensions to flexion because of a prognosis of disc bulge can be reeducated.

Again, there are some really important points to take away on how to use different movements at different times.  Assess what you want to happen and use movement to help facilitate the right healing environment the body needs at the time.

Thanks again to Michael Shacklock for letting me share this.  I can't recommend Clinical Neurodynamics enough for health practitioners out there.

Tuesday, April 5, 2016

Clinical Neurodynamics Course Review

The last 4-5 years I've pretty much realized what I want from a seminar.  I want to learn something.  I want to be able to go back to my clinic and use the information right away.  I want it to spark some type of further learning.  I'm pretty happy when I get 2 out of 3.

I recently took Clinical Neurodynamics Upper and Lower with Michael Shacklock.  This course fulfilled 3 out of 3 in my wants.  I had read the book years ago and found it to be quite interesting and had tried to incorporate some of the info into my evaluation process when I deemed it necessary.  This is a very well taught course.  He has a great teaching style and I became much better at evaluating normal vs abnormal neural tension.  There is no substitute with having the author himself give you hands on on how to do a test.  There are very subtle nuances to really do the neural tests optimally.  This is something that is hard to get from a book.  The learning of how to regress/progress each neural test for treatment is invaluable in my opinion.    

I've found that great courses are able to be incorporated with whatever technique or approach you use in practice.  In fact, as I was sitting their listening I was able to see how several techniques I have an interest in are actually saying or doing some similar thought process without knowing it.  So in a way, it helped my philosophy on my approach to practice.  

It's interesting how martial arts and stuff like Scott Sonnens IntuFLow or Pavels Mobility looks very similar to some neurodynamic upper body techniques.  

This was the first I've heard of how disc and nerve root have opposite mechanics.  This was fascinating to me.  Extension of the spine opens up disc, but closes on the nerve root and vice versa.  Perhaps this is why some Flexion based PRI exercises have helped many back pain patients.  I will be devoting a separate blog post on the lumbar foramen biomechanics, so stay tuned!

Realizing that lumbar nerve roots can have 7mm of movement when both legs are involved in a straight leg raise makes you see how an L5 ELDOA technique can be so useful.  

It had me realizing my lack of blood flow physiology knowledge.  Understanding all that takes place with venous and nerve interplay and how that affects swelling and performance.  There is a dose response to blood flow on a healthy nerve.  The research is there.  Getting edema off a nerve and increased oxygen will result in less fibroblast activity.  Better tissue quality.  

I was surprised I was the only Chiropractor there.  It seems this is just up a chiropractors wheel house.  This guy lives and works in Australia so you don't get a ton of shots learning from him in the states.  That is a shame.  

I would highly recommend this seminar to anyone that was thinking about it.