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. Getting Mobility 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. Getting Stability 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)
Read MoreCategory: All Things Rehab
Lessons from a Student: The Interaction
The Inspiration Over the past few weeks I have felt called to write about an often uncovered yet extremely important component of the therapeutic process: Patient interaction. We had an instance in which I came back into the clinic from my lunch break and my intern was supposed to have a patient evaluation. Instead, she opted to have me take this particular patient. This patient was a lovely 17 year old lady who was being seen for bilateral foot pain. This was her second bout of therapy, and her and her mother was very dissatisfied with their last physical therapy experience just a few months (and 17 visits) prior. She was not a happy camper and wanted a second opinion. After hearing stories from my coworkers, I expected the worst. We progress through the evaluation, and my student observes nothing but smiles throughout from the patient and her mom. Jokes were cracked, movement was looked at, and edumacation happened. At this point, after a little explain pain and kinetic chain discussion, these women were sold. We leave the treatment room and I said “that wasn’t so bad yes?” My student replies “that’s because they are in love with you.” But really, that essentially is what you have to do with the patient interaction. You can have the greatest hands, the greatest exercise plan, and evidence up the wazoo; but if your patient hates your guts you will fail. I heard this from Patrick Ward that 80% of your success with
Read MoreMovement Chapter 7: SFMA Introduction and Top-Tier Tests
This is a chapter 7 summary of the book “Movement” by Gray Cook. Intro The SFMA’s goal is to assess functional capabilities. This system is based on Cyriax differentiation and grading principles. Instead of describing things as strong, weak, painful, or painless; the following descriptors are utilized: Functional nonpainful (FN): Unlimited movement and able to complete a breath cycle at end-range. Called the dead end. Functional painful (FP): Called the marker, reassessed. Dysfunctional nonpainful (DN): Limited, restricted, impaired mobility, stability, or symmetry. Labored breathing with movement also implicates this choice. Called the pathway, where treatment occurs. Dysfunctional painful (DP): Called the logical beehive because we do not know if pain is causing poor movement or vice versa. It is an unreliable place to work unless acute situations. SFMA corrective and manual therapy lie in treating the FP’s and DN’s. The order at which things are treated also matters, so the order listed below for the top tier tests is also typically where treatments should hierarchically begin. Cervical spine patterns (CSP) Upper extremity patterns (UEP) Multi-segmental flexion (MSF) Multi-segmental extension (MSE) Multi-segmental rotation (MSR) Single leg stance (SLS) Overhead deep squat (ODS) We then operate the SFMA in the following fashion:
Read MoreMovement Chapter 4: Movement Screening
This is a chapter 4 summary of the book “Movement” by Gray Cook. What Be the Goal? Movement screening’s goal is to manage risk by finding limitations and asymmetries via two strategies; 1) Movement-pattern problems: Decreased mobility and stability in basic movements. 2) Athletic-performance problems: Decreased fitness. The FMS razor, akin to Occam’s razor, is to determine a minimum movement pattern quality before movement quantity and capacity are targeted. Movement patterns are lost by the following mechanisms: Muscular imbalance. Habitual asymmetrical movements. Improper training methods. Incomplete recovery from injury. Ideally, the FMS would be part of the basic tests performed when one is looking to participate in sport. Prior to any athletic engagement, a medical exam is performed to clear someone to participate. This exam is often followed by performance and skills tests. Gray feels that the FMS belongs between these two tests, as there is an obvious gap from basic medical screening to high performance. It is not to say that we must only train movement patterns. Rather, all the above qualities can be trained in parallel. The real goal is to manage minimums at each level and make sure improving one does not sacrifice quality at the others.
Read MoreMovement Chapter 3: Understanding Movement
This is a chapter 3 summary of the book “Movement” by Gray Cook. You Down with SOP? Unlike many other areas, movement does not have a standard operating procedure and is thus very subjective. Since movement is the foundation for all activity, it is important that we develop some type of standard for good movement. Changing Compensations Movement compensations are often unconscious, thereby making these patterns difficult to be cued away. It may be the case that less threatening movements and corrective exercise could be utilized to change undesired patterns. When designing exercise, it is important to make them challenging as opposed to difficult. Difficulty implies struggling, whereas challenges are what test one’s abilities. Anyone can make something difficult, but not all can challenge. Function of the FMS and SFMA The goals of the functional movement systems are as follows: 1) Demonstrate if movement patterns produce pain within accepted ranges of movement. 2) Identify those without pain that are at high injury risk. 3) Identify specific exercises and activities to avoid until achieving the required movement competency. 4) Identify the best corrective exercise to restore movement competency. 5) Create a baseline of standardized movement patterns for future reference. The difference between the FMS and SFMA is that the FMS assesses risk whereas the SFMA diagnoses movement problems. The FMS operates in the following manner: 1) Rates and ranks nonpainful movements based on limits and asymmetries. 2) Identifies pain. 3) Identifies lowest ranking or most asymmetrical patterns; most primitive pattern if
Read MoreLessons from a Student: The Brain
Oh It’s On Believe it or not, I currently have someone interning with me for the next 12 weeks which is has led me to thinking about many things: 1) People trust me with the youth of America? 2) I have to justify what I am doing now? 3) I hope I can teach her something. It has been a great and even nostalgic experience thus far. I remember just a couple years ago being in this young lady’s shoes having the same successes, failures, and questions she has now. I think working with me may have been quite a difference from the scholastic framework that she was accustomed to. This difference is because our common theme for the week was wait for it…………………………………….The Brain. Most schools, especially in the orthopedic realm, teach about developing physical therapy diagnoses and treating various pathologies. However, we had a couple different cases in which we didn’t necessarily nail down a pathology yet got fantastic results. Case 1 The first patient we saw was a lovely middle-aged woman who was classic for the biopsychoscial treatment model I espouse. She comes into seeing us with chronic low back pain over the past 3 years, has had several TIAs, been diagnosed with an eating disorder, and generally lives a stressful life. Our comparable sign for the day was flexion which was at 50% range and painful (or DP for you functional movement folks out there). We discuss what we think is going on and the first
Read MoreExplain Pain Section 6: Management Essentials
This is a summary of section 6 of “Explain Pain” by David Butler and Lorimer Moseley. Management 101 The most important thing you can understand is that no one has the answer for all pains. Pain is entirely individualistic, hence requiring different answers. There are several strategies which one can undertake to triumph over pain. Tool 1: Education Knowing how pain works is one of the most important components to overcoming pain. Instead of no pain, no gain, the authors like to use “know pain, or no gain.” Understanding pain is essential for squashing fear of pain, which leads best toward the road to recovery. Here are some important concepts to be known about explaining pain. Anyone can understand pain physiology. Learning about pain physiology reduces pain’s threat value. Combining pain education with movement approaches will increase physical capacity, reduce pain, and improve quality of life. Tool 2: Hurt ≠ Harm It is important to understand that when someone feels pain it does not equate with damage. The same can be said with recurring pains. These pain types are often ways to prevent you from making the same mistake twice. If your brain sees similar cues that were present with a previous injury, the brain may make you experience pain as a way to check on you and make sure you are okay. Just because hurt does not mean harm does not mean you can get crazy though. Because the nervous system is trying to protect you, it will take
Read MoreExplain Pain Section 5: Modern Management Models
This is a summary of section 5 of “Explain Pain” by David Butler and Lorimer Moseley. So Many Clinicians There are several people who would like to help someone in pain, with each person offering a different explanation and solution for someone’s pain. Research has shown these conflicting explanations can often make things worse. The one who has the most power over pain is the person who is in pain. Here are some general guidelines for someone dealing with pain. Make sure any injury or disease which requires immediate medical attention is dealt with. All ongoing pain states require a medical examination. Make sure any prescribed help makes sense and adds to your understanding of the problem. Get all your questions answered. Avoid total dependence on any practitioner. Make sure your goals are understood by you and the clinician. The clinician’s ultimate job is to assist you in mastering your situation. Models of Engagement There are 5 interchangeable models which enable both the patient and the clinician to identify the processes underlying pain. The orchestra model – Pain is a multi-component process that manifests itself in the brain and goes through many pathways. There are many players involved in the pain experience, hence the orchestra, with the brain as the maestro. The Onion Skin Model – Helps describe all the factors that go into the pain experience; including nociception, attitudes and beliefs, suffering, pain escape behaviors, and social environment. Fear-based models – Fear of pain and reinjury are major forces
Read MoreExplain Pain Section 4: Altered Central Nervous System Alarms
This is a summary of section 4 of “Explain Pain” by David Butler and Lorimer Moseley. CNS Alarms While much of talk in rehab deals with tissue injury and tissue pain, realize that the brain always makes the final decision as to whether or not you should feel pain. No brain, no pain. This sentiment does not mean that pain is not real. All pain is real. However, pain is a construct that the brain creates in order to ensure your survival. Spinal Cord Alarms When an injury occurs and the DRG receives impulses from peripheral structures or the brain, the spinal cord neurons must adapt to better uptake all these signals. In essence, the DRG becomes better at sending danger messages up to the brain. This change leads to short term increases in sensitivity to excitatory chemicals. Those stimuli that didn’t hurt before now do (allodynia) and those that used to hurt now hurt more (hyperalgesia). In persistent pain, this change continues occurring to the point where neurons that do not carry danger messages start growing into space where danger messages are taking place. Now innocuous stimuli such as grazing the skin begin hurting. The pain may be normal, but the underlying processes become abnormal. When these spinal cord alarm systems become unhealthy, the brain no longer receives an accurate message of what is going on. The alarms become magnified and distorted. The brain is told there is more damage in the tissues than is actually present. What is good is
Read MoreExplain Pain Section 3: The Damaged and Deconditioned Body
This is a summary of section 2 of “Explain Pain” by David Butler and Lorimer Moseley. Tissue Injury 101 When a body is damaged, pain is often the best guide to promote optimal healing. Sometimes it is good for us to rest, other times it is better to move. A similar healing process occurs for all tissue injuries. First, inflammation floods the injured area with immune and rebuilding cells. This reason is why inflammation is a good thing in early injury stages. A scar forms once the inflammatory process is over. The tissue then remodels to attempt to become as good as the original. Blood supply and tissue requirements determine how fast the healing process occurs. For example, ligaments heal much slower than skin because the former has a lower blood supply than the latter. This may also be a reason why aerobic exercise may speed up the healing process. If present, pain usually diminishes as the tissues heal. However, pain may persist if the nervous system still feels under threat. Acid and Inflammation The alarm sensors described here constantly work and often get us to move. Movement keeps our system flushed. When we don’t move or a physical obstruction is present (e.g. sitting), acid and by-products build up in the body tissues. Oftentimes we will start to feel aches and pains when we stay in a prolonged position, which is our body’s way of saying “get up and move.” Much like the alarm system, inflammation is a primitive way for our
Read MoreCourse Notes: Graded Motor Imagery
I recently attended another great course through the NOI Group called “Graded Motor Imagery” (GMI) taught by Bob Johnson. These guys are the industry leaders in all things pain so please check them out. It was great connecting with Bob and learning what I think will be an excellent adjunct to what I am currently doing. So here is the run down on GMI. Overview GMI is a three-pronged sequential process of establishing early, nonpainful motor programming. Johnson calls this synaptic exercise to limit negative peripheral pain expression. GMI is a 3 step process: 1) Laterality reconstruction (Implicit Motor Imagery). 2) Motor imagery (Explicit Motor Imagery). 3) Mirror Therapy. The Neuromatrix Paradigm & Pain States Before delving into the neuromatrix, we first must define pain. Pain is a multiple system output or expression by an individual-specific pain neuromatrix that activates when the brain concludes that body tissues are in danger and action is required. The neuromatrix, like I talk about in this post here, is the nervous system’s coding space and network. It is first and foremost affected by genetics, sculpted by experience, and constantly evolving. It is the entity that makes us who we are—the self. The neurosignature, or neurotag, is an output’s representation in the brain. For example, regions in the brain will activate in response to produce the pain output. This sequence is the neurosignature. Some common activated areas when pain is expressed include both primary and secondary somatosensory cortices, insula cortex, anterior cingulgate cortex, thalamus, basal
Read MoreThe Sensitive Nervous System Chapter XI: Neurodynamic Testing for the Spine and Lower Limb
This is a summary of Chapter XI of “The Sensitive Nervous System” by David Butler. Intro For today’s chapter, I have decided that the best way to learn these tests is to show you. I will write in any pertinent details you need for a good test performance. The Straight Leg Raise (SLR) SLR hacks. Add sensitizers (dorsiflexion, plantarflexion, etc) to determine nervous system involvement. Add cervical flexion or visual input to enhance responses. Be mindful of symptoms before and after pain responses. If this test is positive post-operation, it will likely be inflammatory in nature. You can preload the system further with cervical flexion or sidebending the trunk away from the test side. Here are some other ways to perform the SLR with sensitizers first. (I apologize for the way the camera shot in advance). For tibial nerve-bias. For fibular nerve bias. For sural nerve bias. Passive Neck Flexion (PNF) Here is how to perform the test. PNF Hacks. Add SLR to further bias the test. Be mindful of Lhermitte’s sign, which is an electric shock down the arms or spine. This is a must-refer sign as there is potential spinal cord damage. Slump Test Here is how to perform the slump. Slump Knee Bend In the book itself, Butler uses the prone knee bend as his base test. However, NOI does not teach this motion as much and now favors the slump knee bend. This movement allows for much more differentiation to be had. And the saphenous nerve
Read More