To me, the most important aspect of patient care is knowing who you can and cannot treat. Stratifying your patients based on who needs to be referred out, and who you can help is essential to providing the best care.
Quite simply, there are few better resources out there that outline how to do this than Scott’s ebook.
In it, he delves into what relevant questions to ask, tests to perform, and establishing a relevant diagnosis. Often underlooked, yet exceptionally important components of the clinical examination.
Again, I cannot recommend Scott’s ebook and site enough. It’s a great resource for many things PT, including many of his eclectic and unique manual therapy techniques. Definitely check this guy out.
Rehabbing a 5th Metatarsal Fracture to High Level Basketball
In this podcast, I outline a case I worked on back when I was in the NBA D League.
This kid suffered a distal 5th metatarsal fracture with only a couple minutes to spare in a game. It was a brutal injury after one of the worst games in my life that I experienced, namely because we had three guys go down in one game.
Talk about awful.
I outline my entire process and every detail of what I did to get this kid back to high level basketball. A process that started with a fracture and ended with him establishing a franchise rebounding record the last game of the season. Pretty spectacular to say the least.
I feel very fortunate to have worked with such a driven and hardworking guy, and ultimately that was what his success hinged upon. Though minor, it was an honor to be this guy’s guide back to high level performance.
In this podcast, we dive into the following topics:
This is a chapter 15 summary of the book “Movement” by Gray Cook.
The goal of movement retraining is to create authentic unconscious movement at acceptable levels. We can develop many methods to achieve our goals, but working under sound principles is paramount. Some of the principles Gray advocates include:
Focusing on how we move.
Look to movement to validate or refute your intervention.
Movement is always honest.
When designing a movement program, we must operate under the following guidelines:
Separate pain from dysfunctional movement patterns.
Starting point for movement learning is a reproducible movement baseline.
Biomechanical and physiological evaluation do not provide a complete risk screening or diagnostic tool for comprehensive movement pattern understanding.
Our biomechanical and physiological knowledge surpass what we know about fundamental movement patterns.
Movement learning and relearning follows a hierarchy fundamental to the development of perception and behavior.
Corrective exercise should not be rehearsed outputs. Instead, it should be challenging opportunities to manage mistakes on a functional level near the edge of ability.
Perception drives movement behavior and movement behavior modulates perception.
We should not put fitness on movement dysfunction.
We must develop performance and skill considering each tier in the natural progression of movement development and specialization.
Corrective exercise dosage works close to baseline at the edge of ability with a clear goal.
The routine practice of self-limiting exercises can maintain the quality of our movement perceptions and behaviors and preserve our unique adaptability that modern conveniences erode.
Some things cannot be fixed, but change what you can.
The brain that learns function can learn dysfunction.
This is a chapter 14 summary of the book “Movement” by Gray Cook.
Corrective exercise is focused on providing input to the nervous system. We are allowing the patients and clients to experience the actual predicament that lies beneath the surface of their movement pattern problem. It is okay for mistakes to be made, for these errors help accelerate motor learning. Minimal cueing should be utilized, as we want to patient to let them feel the enriching sensory experience.
Motor Program Retraining
There are several different methods in which we can achieve a desired motor output.
1) Reverse patterning – Performing a movement from the opposite direction.
2) Reactive neuromuscular training – Exaggerating mistakes so the patient/client overcorrects. Use oscillations first, followed by steady resistance.
3) Conscious Loading – Using load to hit the reset button for sequence and timing.
4) Resisted exercise – Makes patterns more stable and durable.
When you can deadlift that much, most anything is stable and durable.
This is a chapter 13 summary of the book “Movement” by Gray Cook.
Back to the Basics
Mobility deficits ought to be the first impairment corrected. Optimizing mobility creates potential for new sensory input and motor adaptation, but does not guarantee quality movement. This is where stability training comes in. In order for the brain to create stability in a region, the following ought to be present:
Structural stability: Pain-free structures without significant damage, deficiency, or deformity.
Sensory integrity: Uncompromised reception/integration of sensory input.
Motor integrity: Uncompromised activation/reinforcement of motor output.
Freedom of movement: Perform in functional range and achieve end-range.
There are 3 ways to gain mobility:
1) Passively: Self-static stretching with good breathing; manual passive mobilization.
2) Actively: Dynamic stretching, PNF.
3) Assistive: Helping with quality or quantity, aquatics, resistance.
In order to own our new mobility, we use various stability progressions to cement the new patterns. There are three tiers in which stability is trained:
1) Fundamental stability – Basic motor control, often in early postures such as supine, prone, or rolling.
2) Static stability – done when rolling is okay but stability is compromised in more advanced postures.
3) Dynamic stability – Advanced movement.
We progress in these stability frames from easy to further difficult challenges.
Assisted → active → reactive-facilitation/perturbations
Since stability is a subconscious process, we utilize postures that can challenge this ability while achieving desired motor behavior. We can also group the various postural progressions into 3 categories:
1) Fundamental – Supine, prone, rolling (requires unrestricted mobility).
2) Transitional – Postures between supine and standing such as prone on elbows, quadruped, sitting, kneeling, half-kneeling.
3) Functional: Standing variations to include symmetrical and asymmetrical stance, single leg stance.
This is a chapter 12 summary of the book “Movement” by Gray Cook.
A Whole Lotta P
When we build our corrective framework, we must take into account the 6 P’s:
1) Pain – Is there pain with movement? Staying away from pain improves motor control.
2) Purpose – What movement pattern are we targeting with corrective exercise and what problem are we addressing (i.e. mobility, stability, dynamic motor control)?
3) Posture – Which moderately challenging posture is the best starting point for corrective exercise that allows for reflexive activity?
4) Position – Which ones demonstration mobility/stability problems and compensatory behaviors?
5) Pattern – How is the dysfunctional movement pattern affected by corrective exercise?
6) Plan – How can you design a plan based on findings?
The goal when designing the correction is to stay in the middle ground of the autonomic nervous system while providing a rich sensory experience. Movement pattern dysfunction is a behavior that needs to be addressed and changed.
This is a chapter 11 summary of the book “Movement” by Gray Cook.
All exercise affects tone and tension. This influence is the basis for movement. The autonomic nervous system determines movement as threatening or not, which determines requisite tone. It is important to nudge movement towards further nonthreatening yet advanced stimuli.
Proceeding to correct under FMS protocol is determined by screen results and changed via exercise. We first correct mobility, next reinforce stability, then retrain movement patterns. Stability training in particular follows a sequence:
1) Challenge posture and position.
2) Build mid-range strength.
3) Develop end-range stability.
Movement patterns are corrected in the following hierarchy:
The SFMA corrective pathway is nonlinear unlike the FMS. The breakouts will tell you which direction to go to restore optimal movement.
The options are also increased. Often to gain mobility, you would utilize various manual therapies or other modalities. To alter stability, taping, orthotics, braces, or anything else to increase motor control may be utilized.
Movement patterns are corrected in the following hierarchy: