Why Everything Works (and Doesn’t Work)

A Great Place to Be

I was recently at my home away from home, IFAST. Every time I go here the following occurs:

  1. I have an amazing time with amazing people.
  2. I learn a ton and realize how little I really know.
  3. Prolific discussions are had.
  4. I end up purchasing WAY too many books as soon as I get home.
Taken from outside my room after my most recent Amazon order.
Taken from outside my room after my most recent Amazon order.

As many of you know, Bill Hartman and I appreciate a PRI philosophy. When I go to IFAST, we inevitably experiment with many different things. This weekend, Bill and I were playing with how many different ways we could achieve full right shoulder internal rotation on my good friend Lance and the lovely IFAST intern Liz. Here was everything that gave these people full motion.

  • Soft tissue mobilization to the infraspinatus.
  • Manually assisted breathing.
  • Tickling the right side of the face.
  • Tapping the left hamstring.
  • Smacking the right glute max (yes, I spanked someone).
  • Having someone think about contracting their right glute max as hard as possible.
  • Having someone watch me breathe with a left sidebend.
  • Reflex locomotion.
If it will keep you neutral, why not?
If it will keep you neutral, why not?

Now of course, that does not mean you should be spanking your patients and clients with shoulder issues (but if you do make sure it is the right glute), but we have to ask why did all of these different techniques–even the weird ones– achieve the same outcome we wanted?

Why Things Work

Joseph Brence, a gentleman whose material I enjoy, recently posted a blog showing several different techniques and polling his readers if these interventions “made sense,” whatever that means to you.

While I am sure most if not all these treatments will achieve certain results, they likely are accompanied with flawed explanations. Why can we have erroneous rationale yet make positive changes?

I think that we get too caught up with what is occurring in the periphery. We can argue all day if we are breaking up scar tissue, mobilizing fascia or joints, stimulating skin, or releasing trigger points—but it does not really matter.

Forget about the periphery for now. Let’s keep things simple. Here is what we think is going on with our interventions. You ready? When I am performing treatment x, I am………………

Applying a sensory input

IASTM is a sensory input, manipulation is a sensory input, myofascial release is a sensory input, and your interaction with someone is a sensory input. All that we do—in therapy, fitness, school, socializing, everything—is a sensory input.

We apply a sensory input, the brain interprets this input, and a multi-system output is or is not elicited. This new output is itself a sensory input, which the brain interprets, thus affecting one’s perception.

Capture

This cycle explains why everything works in simplest terms. However, this process is complicated by the multiple variables that make one technique work for one person but not for another.

Take the examples above that we performed to increase shoulder mobility. What we did not account for was that Lance and Liz were very comfortable with Bill and I, thus are more likely to relax and be more receptive to the sensory input we apply.

Let’s look at ultrasound as another example. The literature is pretty clear that this modality is crap. But we have all had that patient who said ultrasound fixed them the last time and it helps so much. You try everything else to no avail, but as soon as you begrudgingly apply that ultrasound the patient rapidly feels better. The sensory input’s efficacy depends on how the brain interprets said input.

Adding the electrode makes all the difference.
Adding the electrode makes all the difference.

That is why patient interaction is so important. I can fathom someone who performs a treatment that is very much evidence supported, but does not get the outcome desired. Maybe the patient did not feel comfortable with the applied input, or maybe they did not like the clinician. These things matter and this is what makes our jobs so challenging. Everyone’s brain interprets the environment differently, thus requiring an individualized approach.

Ain't no evidence going to help this problem.
Ain’t no evidence going to help this guy’s problem.

What should be in Your Skill-set?

If we operate on the above framework, we can apply pretty much any technique to someone. But again, that does not mean that all techniques will work, and some might be more effective than others.  The short answer is that you need to provide the right intervention to the right person under the right context that has the lowest potential for harm and the largest potential for results. 

It is also desirable and beneficial to utilize sensory inputs that either the patient/client can perform on themselves (i.e. exercise) or that can facilitate this process to occur quickly. The clinician’s ultimate goal should be to render themselves unnecessary for the patient.

But you can still do cool things.
But you can still do cool things.

All that being said, there are things that I look at when I decide to implement or learn a particular technique, in no particular order:

1. Evidence-based.

If there is some substantial support in the literature for or against something, it is a piece worth considering. This does not mean we must live and die by the systematic reviews. Even things such as case studies have merit. After all, it was Pavlov’s dog, not dogs. And it was an animal study at that!

Don’t like that case? Here is another example. Suppose I have a case study which involves a healthy man in his mid-twenties being seen for shoulder pain. I apply a brand new intervention that results in his instantaneous death. Will this influence your thought process in terms of using said intervention? Perhaps a higher level study is needed to make sure that this was not just a fluke. Of course, this will not happen because this case’s outcome is relevant. The big question to be answered by evidence is can I use the literature to support my treatment rationale?

2. The patient believes it will work.

This component is huge. There is more and more research being done on thrust manipulation, but what happens if the patient does not like it? In a clinical prediction rule recently done, one of the criteria was the patient’s belief that the intervention will work. Simply put, patient perception helps maximize the placebo effect and affects the sensory input interpretation.

3. The potential for harm is low.

Hippocratic Oath baby! Do no harm first and foremost. You do not want to ignite one’s pain neurotag if you do not have to, so I try to pick things that will not hurt someone. You want to use the minimal dose necessary to achieve your desired result.

That doesn’t mean I won’t use technique that are uncomfortable; especially if it helps me achieve my goal. This situation is where you have to educate patients that you may be sore during an activity, but safe afterwards.

You are sore, but you are safe.
You are sore, but you are safe.

4. The potential for success is high.

You want to use things that will work on patients. The ability to choose the right intervention comes with your philosophy, evidence, skill level, clinical reasoning, and a multitude of other factors.

5. The intervention works fast.

Suppose we take two manual interventions. You pick one that takes 10 minutes to perform to achieve a desired output. Mine takes me 30 seconds to achieve the same result as you. I will win every time because now I have an extra 9 minutes and 30 seconds to give the patient exercises to facilitate keeping that desired output. If something works incredibly fast and provides more opportunity for motor learning, I am going to use it.

6. The intervention gives the patient or client the power to change themselves.

This is the reason I like PRI so much. They emphasize non-manual interventions over manual. Minimal motor learning is going to occur with passive interventions, so the more active the patient can be the better.

7. I can provide rationale that the patient or client will understand regarding its efficacy.

If you cannot say why you are performing an intervention, you should not do it.

Even Jada to the muah wants your rationale.
Even Jada to the muah wants your rationale.

8. I can perform the intervention with skill and confidence.

This piece goes with maximizing patient’s expectations. If I come across as the cock of the walk with a selected technique, and I have done it enough that I can make it comfortable, that will reflect on the patient. Do all that you can to maximize placebo.

Summary

There are so many different techniques that we utilize, and we all have our biases as to which ones we like. The important thing to understand is that all the interventions we provide operate under a similar framework; sensory input to facilitate a desired output and perception. So when deciding which technique is best to apply, pick the one’s that you can perform the best, that the patient believes will work the best, and allows the patient to take care of themselves as soon as possible.

And each other.
And each other.

Chapter 15: In Conclusion

This is a chapter 15 summary of the book “Movement” by Gray Cook.

The Goal

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.
Of course I did my corrective exercise, I swear.
Of course I did my corrective exercise, I swear.

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.
  • Be safe, be satisfied, and play.
I can always tell when movement is sassified.
And I can always tell when movement is sassified.

Chapter 14: Advanced Corrective Strategies

This is a chapter 14 summary of the book “Movement” by Gray Cook.

Inputs

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.

Mistakes are good...I wouldn't be here without them.
Mistakes are good…I wouldn’t be here without them.

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.

Movement Chapter 13: Movement Pattern Corrections

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.
FREEDOM!!!! Of movement. And if the Road Warrior says we need to move free I listen.

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

I would black my face out to if someone was having me do this exercise.
I would black my face out too if someone was having me do this exercise.

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.

The only legit way to practice single leg stance.

Movement Chapter 12: Building the Corrective Framework

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.

Movement Chapter 11: Developing Corrective Strategies

This is a chapter 11 summary of the book “Movement” by Gray Cook.

Autonomics

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.

 

FMS Corrections

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:

ASLR & Shoulder mobility → rotary stability → pushup → Inline lunge → hurdle step → Deep squat

 

SFMA Corrections

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:

Cervical spine → Shoulder multi-segmental flexion & extension→ Multisegmental rotation single leg stance → Squat

Depending on how movements present, certain therapies are utilized:

DN – manual therapy and corrective exercise.

DP – Manual therapy and modalities.

FP – Modalities and manual therapy.

FN – General exercise.

Modalities? No FN way...See what I did there??? Ah hell with it.
Modalities? No FN way…See what I did there??? Ah hell with it.

Exercise Categories

There are several exercise types that can be utilized depending on one’s goal:

  • Functional: Purposeful exercise that displays carryover to other activities. Can be general (for movement patterns) or specific (for certain skills). These generally enhance physical capacity.
  • Corrective: To create a functional base, normalize tone, and allow movement freedom.
  • Conditioning: Create positive neurophysiological adaptations in structural integrity/performance over periods longer than a single exercise series.
  • Movement prep: Work on patterns needed for activity.
  • Skill training: For specific skills.

Movement Chapter 10: Understanding Corrective Strategies

This is a chapter 10 summary of the book “Movement” by Gray Cook.

Mistakes, I’ve Made a Few

When we are talking corrective exercise design, people often make 4 mistakes:

1)      Protocol approach: Exercise based on category.

Problem – 1 size fits all.

2)      Basic kinesiology: Target prime movers and some stabilizers.

Problem – fails on timing, motor control, stability, and movement.

3)      Appearance of functional approach – Use bands and resistance during functional training.

Problem – If the pattern is poor, adding challenges to it can increase compensation. There is also no pre-post testing.

4)      Prehabilitation approach – Prepackaged rehab exercises into conditioning programs as preventative measures to reduce injury risk.

Problem – Design is based on injuries common to particular activities as opposed to movement risk factors.

Several, so it seems.

There are also certain mistakes that are often made when utilizing the FMS and SFMA:

1)      Converting movement dysfunction into singular anatomical problems.

2)      Obsessing over perfection in each test instead of identifying the most significant limitation/asymmetry.

3)      Linking corrective solutions to movement problems prematurely.

The overarching rule is to address these movement deficiencies first, as we do not want to put strength or fitness on top of dysfunctional movement.

 

The Performance Pyramid

When designing an exercise program, we look for three areas to improve performance: Movement, performance, and skill.

performance pyr

It is important that program design is based on the individual’s needs and has these qualities in a hierarchal fashion. For example, if one performs excellent on functional performance capabilities but has poor foundational movement, injury risk may increase.

 

Program Design

When implementing corrective exercise, it is important to provide the correct stimulus amount. We want the individual challenged, but not struggling for dear life.

  • Too easy – >30 reps with good quality.
  • Challenging, but possible – 8-15 reps with good quality and no stress breathing. There is a decline in quality secondary to fatigue towards the end of rep ranges.
  • Too difficult – Sloppy from the beginning and only worsens.

Rarely does increasing difficulty equate to increasing resistance. Oftentimes you may advance the exercise position, decrease the base of support, or add more movement complexity.

You may have to remove some activities that feed into dysfunction from one’s current programming, lest you wish to not change the movement pattern. Often how quickly one changes his or her ability to move depends on how diligent one is with corrective exercise.

Realize that corrective exercise should only be supplemental and temporary to what one is doing. It is supposed to be corrective in nature, not preventative.  Moreover, movement scores can decrease with hard training, so continual reassessment is important.

I do active leg lowering and wall ankle dorsiflexion while I'm taking NO Xplode bro.
I do active leg lowering and wall ankle dorsiflexion while I’m taking NO Xplode bro.

The corrective exercise pathway should proceed as follows:

1)      Exercise selection is driven by screen and assessment.

2)      A thought out framework gives you the best possible choices.

3)      Retest, note positive or negative changes, and then use results to modify next session.

4)      Reassess once an obvious change is noted to see what the next priority is.

Ain’t no need to question the Authority

Movement Chapter 9: Analyzing the Movements in Screens and Assessments

This is a chapter 9 summary of the book “Movement” by Gray Cook.

While I have broken up these sections into patterns, much of what Gray talks about does not involve the patterns themselves, but are still good points to know. Ergo, much like the book itself, this post may seem a little disjointed 🙂

The Deep Squat

One’s inability to squat is not considered a single problem. Instead, a disconnect is present between the body and the brain in the squatting pattern. Our brain sees things in patterns, and the squatting pattern essentially gets smudged. Before performing the squat as an exercise, we must first groove an optimal movement pattern.

Preferably while listening to someone groovy like Marvin Gaye

One interesting point regarding the squat is that as an exercise it is often a top-down based movement. However, when we learn to squat in development, the movement occurs bottom-up. So one way to train the squat is by starting from the bottom of the squat and working to standing. This method ensures full mobility to perform a full deep squat.

To relate the SFMA to the squat pattern, Gray is very clear about not training the squat if one cannot touch his or her toes.

Hurdle Step and Single Leg Stance

These two movements simultaneously test mobility and stability of both legs. Oftentimes in these patterns you will see a high-threshold strategy (HTS), in which a hyper-protective core response occurs. Research demonstrates that this stabilization strategy can cause poor motor control to occur. These tests also are basic precursors for stepping, running, and climbing.

In this section Gray also mentions that he does not recommend assessing static postures; namely because posture is dynamic and changing.

Inline Lunge

The inline lunge is more a test of control and efficiency as opposed to strength.  Because we talk about control, we must discuss stability. It is important to note that stabilizers do not necessarily need to be strengthened, as these muscles will never be able to overpower prime movers. Instead, these muscles should be trained for endurance, timing, or quicker action.

 

Shoulder Mobility Reaching Test

These tests assess reciprocal arm patterns and thoracic spine mobility. The movement is challenging because opposing movements end up borrowing mobility and stability from other segments, thus potentially impairing these qualities.

Thoracic extension is necessary to perform this pattern. However, oftentimes people will compensate with thoracic flexion. This compensatory pattern can rob the scapulae of ground to help stabilize the movement.

 

Active Straight Leg Raise

There are several necessary components to perform this movement optimally:

  • Adequate down leg extension (otherwise substitution with anterior pelvic tilt and lordosis occurs).
  • Adequate mobility and flexibility of the elevated leg.
  • Pelvic stability prior to and during the movement.

Another interesting tidbit from this section was that research has demonstrated that one’s ability to perform a sit and reach correlated with arterial flexibility.

 

Core Stuff

The pushup, rotary stability, and rolling patterns all assess core functioning. In particular, the pushup looks at reflexive core action, rotary unilateral and diagonal patterns, and rolling the ability to separate upper and lower quadrants.

It’s all in the reflexes.

Movement Chapter 8: SFMA Assessment Breakout Descriptions and Flowcharts

This is a chapter 8 summary of the book “Movement” by Gray Cook.

What to Look For

The SFMA breakouts are utilized to determine if one’s movement deficiencies have a mobility or stability origin. There are further possibilities in each of these categories.

It Could Be a Mobility Problem

There are two subsets of mobility problems that include tissue extensibility dysfunction (TED) and joint mobility dysfunction (JMD). From here, we can break it down even further in each subset.

Here are some potential TEDs

  • Active/passive muscle insufficiency
  • Limited neurodynamics (they said neural tension; come on Gray!)
  • Fascial tension
  • Muscle shortening
  • Hypertrophy
  • Trigger points
  • Scarring/fibrosis

And here are some potential JMDs

  • Osteoarthritis/arthrosis
  • Single-joint muscle spasm/guarding
  • Fusion
  • Subluxation
  • Adhesive capsulitis
  • Dislocation
This is the only TED that I deal with.

It could be a Stability Problem

These issues are also known as stability or motor control dysfunction (SMCD). Most conventional therapies would treat these complaints by strengthening the stabilizers, but this is problematic. When something works reflexively, how can we train something volitionally and expect changes? To train these muscles we must focus on proprioceptive and timing-based training.

There are several examples of SMCD problems.

  • Motor control dysfunction.
  • High threshold strategy.
  • Local muscle dysfunction/asymmetry.
  • Mechanical breathing dysfunction.
  • Prime mover or global muscle compensation behavior or asymmetry.
  • Poor static stability, alignment, postural control, asymmetry, and structural integrity.
  • Poor dynamic stability, alignment, postural control, asymmetry, and structural integrity.

Relatedness

Mobility and stability can influence one another. If I were to lose mobility at one segment, motor control can be distorted at nearby segments. Conversely, if I lack motor control, abnormal mobility may occur to compensate. However, the progression remains the same—restore mobility, then improve stability.

Honorable Mentions

Though the following testing protocols did not make the SFMA, they should still be tested per Gray:

  • Neurological exam.
  • Muscle strength.
  • Joint stability/mobility
  • Tissue tension testing (so…painful…to…write)
  • Identify neuromuscular trigger points
  • Impairment measurements

SFMA Rules

Here are some basic rules to implement when utilizing the SFMA that I picked up from there course.

1)      No warm up.

2)      If it looks like a dog and smells like a dog – it’s a dog.

3)      Be picky. Not bad = not good.

4)      No shoes.

5)      Monkey see, monkey do…perform the movement.

Sometimes it can go too far though...story of my life.
Sometimes it can go too far though…story of my life.

The SFMA generally also follows these basic ideas of testing, which can help assist you through the breakouts

  • Bilateral vs. unilateral
  • Loaded vs. unloaded
  • Active vs. passive

You will notice that the breakouts are a little different than what is presented in the book. These are the official breakouts from the current (6/2013) SFMA course.

Active Cervical Flexion

1. Start with supine cervical flexion (looking for chin to chest)

  •  FN: SMCD
  • DN, DP, FP: Move on

2. Passive supine cervical flexion (chin to chest)

  • FN: SMCD
  • DN, DP, FP: Move on

3. Active supine OA flexion test (20 degrees)

  • FN Bilaterally: If passive cervical flexion was DP/DN – TED/JMD; if FP – potential SMCD.
  • DN: OA flexion JMD/TED &/or possible cervical flexion JMD/TED
  • DP/FP: Stop; treat with modalities over exercise.

Active Cervical Extension

1. Supine cervical extension

  • FN: SMCD
  • DN: JMD/TED
  • FP/DP: Stop; treat with modalities over exercise.

Cevical Rotation-Lateral Bend

1. Active supine cervical rotation test (80 degrees)

  • FN: SMCD
  • DN/DP/FP: Move on

2. Passive supine cervical rotation test (80 degrees)

  • FN: SMCD
  • DN/DP/FP: Move on

3. C1-C2 cervical rotation test

  • FN: If test 2 was DP/DN, treat as lower cervical JMD/TED; if FP, could be an SMCD.
  • DN: C1-C2 JMD/TED &/or possible lower cervical spine JMD/TED.
  • DP/FP: Stop.

Upper Extremity Pattern 1 (MRE)

1. Active prone upper extremity pattern one (touch inferior angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown below.
  • DN/DP/FP: Move on.

If the supine reciprocal upper extremity pattern test is…

  • FN: Mid-range SMCD; check spine extension breakout.
  • DP/FP: Stop the breakout.
  • DN: SMCD end-range SMCD. Check the spinal breakout.

2. Passive prone upper extremity pattern one (touch inferior angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown above.
  • DN/DP/FP: Move on.

3. Active prone shoulder 90/90 IR test (60 degrees &/or total arc of 150 degrees)

  • FN: Move on to shoulder extension (#5).
  • DN/DP/FP: Move on to #4.

4. Passive prone shoulder IR (60 degrees &/or total arc of 150 deg)

  • FN: Shoulder IR SMCD; note this and move on.
  • DN: Shoulder IR JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

5. Active prone shoulder extension test (50 degrees)

  • FN: Move on to elbow flexion (#7)
  • DN/DP/FP: Move on.

6. Passive prone shoulder extension (50 degrees)

  • FN: Shoulder extension SMCD; note this and move on.
  • DN: Shoulder extension JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

7. Active prone elbow flexion test (thumb to shoulder)

  • FN: Move on to active lumbar locked extension (#9).
  • DN/DP/FP: Move on.

8. Passive prone elbow flexion test (thumb to shoulder)

  • FN: Elbow flexion SMCD; note this and move on.
  • DN: Elbow flexion JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

9. Active lumbar locked extension (50 degrees).

  • FN: If no findings so far, combined pattern one JMD/TED.
  • DP/FP: Treat pain.
  • DN: Move on.

10. Passive lumbar locked extension (50 degrees)

  • FN: T-spine SMCD.
  • DN: T-spine JMD/TED.
  • DP/FP: Treat pain.

Upper Extremity Pattern 2 (LRF)

1. Active prone upper extremity pattern two (touch superior medial angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown in the previous section.
  • DN/DP/FP: Move on.

2. Passive prone upper extremity pattern two (touch superior medial angle)

  • FN: Move to supine reciprocal upper extremity pattern test shown in the previous section.
  • DN/DP/FP: Move on.

If the supine reciprocal upper extremity pattern test is…

  • FN: Mid-range SMCD; check spine extension breakout.
  • DP/FP: Stop the breakout.
  • DN: SMCD end-range SMCD. Check the spinal breakout.

3. Active prone shoulder 90/90 ER test (90 degrees &/or total arc of 150 degrees)

  • FN: Move on to shoulder flexion/abduction (#5).
  • DN/DP/FP: Move on to #4.

4. Passive prone shoulder ER (90 degrees &/or total arc of 150 deg)

  • FN: Shoulder ER SMCD; note this and move on.
  • DN: Shoulder ER JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

5. Active prone shoulder flexion/abduction test (170 degrees)

  • FN: Move on to elbow flexion (#7)
  • DN/DP/FP: Move on.

6. Passive prone shoulder flexion/abduction test (170 degrees)

  • FN: Flexion/abduction SMCD; note this and move on.
  • DN: Flexion/abduction JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

7. Active prone elbow flexion test (thumb to shoulder)

  • FN: Move on to active lumbar locked extension (#9).
  • DN/DP/FP: Move on.

8. Passive prone elbow flexion test (thumb to shoulder)

  • FN: Elbow flexion SMCD; note this and move on.
  • DN: Elbow flexion JMD/TED; note this and move on.
  • DP/FP: Treat pain and move on.

9. Active lumbar locked extension (50 degrees).

  • FN: If no findings so far, combined pattern two JMD/TED.
  • DP/FP: Treat pain.
  • DN: Move on.

10. Passive lumbar locked extension (50 degrees)

  • FN: T-spine SMCD.
  • DN: T-spine JMD/TED.
  • DP/FP: Treat pain.

Multi-Segmental Flexion (MSF)

1. Single leg forward bend (touch toes)

  • FN/DN/DP/FP: Move on.

2. Long sitting (touch toes; 80 degree sacral angle).

  • FN: Move to rolling breakout.
  • DN/DP/FP: Move on.

3. Active SLR (70 degrees)

  • FN: Move on.
  • DN/FP/DP: Move on to passive SLR (#5)

4. Prone rocking (full rock back position)

  • FN: Move on to rolling breakouts.
  • FP/DP: Stop the breakout and treat the pain.
  • DN: Spinal flexion JMD/TED. Treat this first then reassess. Breakout can be stopped for now.

5. Passive SLR (80 degrees)

  • FN: Move on to rolling breakouts.
  • DN/DP/FP: Move on.

7. Supine Knee to chest (knees touch chest)

  • FN: Posterior chain TED &/or active hip flexion SMCD.
  • FP/DP: Stop the breakout and treat the pain.
  • DN: Hip JMD &/or posterior chain TED.

Multi-Segmental Extension (MSE)

SPINE BREAKOUT

1. Backward Bend (ASIS in front of toes, scapula pass heels, uniform curve).

  • FN: Stop the breakout; go to upper body extension flowchart.
  • DN/FP/DP: move on.

2. Single leg backward bend  (ASIS in front of toes, scapula pass heels, uniform curve).

  • FN: SMCD or anterior core TED; go to upper body extension flowchart.
  • DN/FP/DP: Move on.

3. Press up

  • FN: May have SMCD; but check other breakouts. Stop the spinal breakout.
  • DN/FP/DP: Move on.

4. Lumbar locked (IR) active rotation/extension (50 degrees)

  • FN: Move on to Prone on elbow unilateral extension (#6)
  • DN/FP/DP: Move on.

5. Lumbar locked (IR) passive rotation/extension (50 degrees)

  • FN: Thorax extension SMCD; check upper/lower extension breakouts.
  • DN: JMD/TED; check upper/lower extension flowcharts.
  • DP/FP: Stop and treat pain.

6. Prone on elbow unilateral extension (30 degrees)

  • FN: SMCD or anterior torso TED; check upper/lower extension breakouts.
  • DN: Move on.
  • FP/DP: Stop and treat pain.

7.  Prone on elbow unilateral extension (30 degrees)

  • FN: SMCD or anterior torso TED; check upper/lower extension breakouts.
  • DN: TED/JMD.
  • DP/FP: Stop and treat pain.

LOWER BODY BREAKOUT

1. FABER Test (2 fist distance)

  • FN: Move on.
  • DN/DP/FP: Hip/SI JMD/TED or SMCD (only if stabilized FABER changed mobility). Note this and move on.

2. Modified Thomas Test (flat to mat)

  • FN: Move on.
  • FN w/ knee straight: Lower anterior chain TED. Treat.
  • FN w/ hip abducted: Lower lateral chain TED. Treat.
  • FN w/ hip abducted & knee straight: Lower anterolateral chain TED. Treat.
  • DN: Hip extension JMD/TED &/or core SMCD. Treat.
  • DP/FP: Stop and treat pain.

3. Prone active hip extension (10 degrees or >)

  • FN: Move on to rolling breakouts.
  • DN/DP/FP: Move on.

4. Prone passive hip extension (10 degrees or >)

  • FN: Move on to rolling breakouts.
  • DN: Hip extension JMD/TED.
  • DP/FP: Stop and treat pain.

UPPER BODY BREAKOUT

1. Unilateral shoulder backward bend

  • FN: Double check press up on spine extension breakout as well as cervical spine.
  • DN/FP/DP: Move on.

2. Supine lat stretch hips flexed (arms to table)

  • FN: Move on to rolling breakouts.
  • DN/DP/FP: Move on.

3. Supine lat stretch hips extended (arms to table)

  • FN: Lat/posterior chain TED &/or possible hip extension dysfunction; check lower body flowchart.
  • Flexion improves but not full: Same as above. Note these changes and move on.
  • DN/DP/FP: Move on.

4. Lumbar locked (ER) Unilateral extension (50 degrees)

  • FN: Scapular/humero-glenoid SMCD.
  • DN/DP/FP: Move on.

5. Lumbar locked (IR) active rotation/extension (50 degrees)

  • FN: Shoulder girdle JMD/TED.
  • DN/DP/FP: Move on.

6. Lumbar locked (IR) passive rotation/extension

  • FN: Thoracic SMCD.
  • DN: Thoracic JMD/TED.
  • FP/DP: Treat the pain.

Multi-Segmental Rotation (MSR)

SPINE BREAKOUT

1. Seated rotation (50 degrees)

  • FN: Go to hip rotation breakout
  • DN/DP/FP: Move on.

2. Lumbar locked (ER) unilateral extension (50 degrees)

  • FN: Move on to prone on elbows unilateral rotation (#5)
  • DN/DP/FP: Move on.
  • DN/DP/FP switches sides: Move on to to rolling breakouts.

3. Lumbar locked (IR) active rotation (50 degrees)

  • FN: Shoulder girdle TED/JMD.
  • DN/DP/FP: Move on.

4. Lumbar locked (IR) passive rotation (50 degrees)

  • FN: Move on to rolling pattern breakouts.
  • DN: Thoracic JMD/TED.
  • FP/DP: Stop and treat pain.

5. Prone on elbows unilateral rotation (30 degrees)

  • FN: Move on to rolling pattern breakouts.
  • DN: Move on.
  • FP/DP: Stop and treat pain.

6. Passive prone on elbows unilateral rotation (30 degrees)

  • FN: Lumbar SMCD.
  • DN: Lumbar TED/JMD.
  • DP/FP: Stop and treat pain.

HIP ROTATION BREAKOUT

1. Seated active hip ER/IR (>40 degrees/>30 degrees)

  • FN: Move on to prone active hip ER/IR (#3)
  • DN/FP/DP: Move on.

2. Seated passive hip ER/IR (>40 degrees/>30 degrees)

  • FN: Move on.
  • DP/FP: Stop and treat pain.
  • DN: Hip JMD/TED. Make note of this and move on.

3. Prone active hip ER/IR  (>40 degrees/>30 degrees)

  • FN: If seated passive rotation was DN, stop and treat. If not, move on to rolling pattern breakouts.
  • DN/FP/DP: Move on.

4. Prone passive hip ER/IR (>40 degrees/>30 degrees)

  • FN: If seated passive rotation was DN, stop and treat. If not, move on to rolling pattern breakouts.
  • DN: Hip JMD/TED. Go to tibial roation and lower body extension breakouts
  • DP/FP: Stop and treat pain.

TIBIAL ROTATION BREAKOUT

1. Seated active Tibial ER/IR

  • FN: Double check lower body extension flowchart.
  • DN/DP/FP: Move on.

2. Seated Passive Tibial ER/IR

  • FN: Tibial rotation SMCD.
  • DN: Tibial rotation JMD/TED.
  • DP/FP: Stop and treat pain.

Single Leg Stance

VESTIBULAR AND CORE BREAKOUT

1. CTSIB (Static)

  • FN: Move on.
  • DN/DP/FP: Potential static vestibular dysfunction. Refer out/treat. Can move on to Half-kneeling narrow base (#3)

2. CTSIB (Dynamic)

  • FN: Move on.
  • DN/DP/FP: Potential Dynamic vestibular dysfunction. Refer out/treat. Move on in breakout.

3. Half-Kneeling narrow base

  • FN: Go to ankle breakout.
  • DN/DP/FP: Move on.

4. Rolling breakouts

  • FN: Move on.
  • DN: SMCD. Go to ankle flowchart.
  • DP/FP: Treat pain; go to ankle flowchart.

5. Quadruped Diagonals

  • FN: SMCD; go to ankle flowchart.
  • DP/FP: Treat pain; go to ankle flowchart.
  • DN: SMCD or shoulder flexion/hip extension are DN; go to ankle flowchart.

ANKLE BREAKOUTS

1. Heel walks

  • FN: Move on to toe walks (#3)
  • DN/DP/FP: Move on.

2. Prone passive dorsiflexion (20-30 degrees)

  • FN: Dorsiflexion SMCD; note and move on.
  • DN: Dorsiflexion TED/JMD; note and move on.
  • DP/FP: Treat pain and move on.

3. Toe walks

  • FN: Move on to seated ankle inversion/eversion (#5)
  • DN/DP/FP: Move on.

4. Prone passive plantarflexion (30-40 degrees)

  • FN: Plantarflexion SMCD; note and move on.
  • DN: Plantarflexion JMD/TED; note and move on.
  • DP/FP: Treat pain and  move on.

5. Seated active ankle inversion/eversion

  • FN: If no above impairments, then there is a proprioceptive deficits. Otherwise treat above impairments.
  • DN/DP/FP: Move on.

6. Seated passive ankle inversion/eversion

  • FN: SMCD.
  • DN: JMD/TED.

Overhead Deep Squat

1. Interlocked fingers behind neck deep squat

  • FN: Recheck extension breakouts
  • DN/DP/FP: Move on.

2. Assisted squat

  • FN: Core SMCD. Make sure MSE is clear.
  • DN/DP/FP: Move on.

3. Half-kneeling dorsiflexion (20-30 degrees)

  • FN/FP/DP: Move on.
  • DN: TED/JMD; check MSE/SLS breakouts, note and move on.

4. Supine knees to chest holding shins

  • FN: If dorsiflexion normal, then SMCD; If dorsiflexion was DN, then knees/hips/core are normal; if dorsiflexion was DP/FP, then treat dorsiflexion. Chec MSE.
  • DN/DP/FP: Move on.

5. Supine knees to chest holding thighs

  • FN: Knee JMD/TED. Check MSE.
  • FP/DP: Stop and treat pain.
  • DN: Hip JMD/TED. Check MSF for hips an MSE.

Segmental Rolling

1. Prone to supine upper body rolling

  • FN/DN: Move on.
  • DP/FP: Go back to chart that tested rolling.

2. Prone to supine lower body rolling

  • FN/DN: Move on.
  • DP/FP: Go back to chart that tested rolling.

3. Supine to prone rolling with upper body

  • FN/DN: Move on.
  • DP/FP: Go back to chart that tested rolling.

4. Supine to prone rolling with lower body

  • FN: Likely a weight-bearing or higher level SMCD if all patterns were FN; return to the chart that tested rolling.
  • DN: Likely a fundamental SMCD in any of the above patterns.
  • DP/FP: Go back to chart that tested rolling.

Conclusions

Phew, that 2000+ words later and we have a lot of stuff. Digest this information, and give these breakouts a try.

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.

Truf.
Truf.

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 patients depends on if they like you. A recent RCT supports this notion as well. You have to get your patient to fall in love with you and your approach, in a nonsexual manner of course.

While I am neither aware nor sure if possible there exists any evidence regarding the best way to interact with a patient, I am going to run through how I approach the patient experience. I don’t know if my way is the most successful or even the best way, but I generally get good patient satisfaction reviews so deal with it.

The Goal

Here is what an excellent patient interaction achieves:

1)      Reduced threat perception.

2)      Establishes a bond and rapport.

3)      Maximizes placebo effect.

4)      Makes rehab fun.

If you read The Polyvagal Theory, Stephen Porges discusses neuroception, which is basically how your nervous system responds to situations after evaluating all given sensory input. If your autonomic nervous system perceives someone or something as threatening you will either fight, flight, or freeze. The goal then, is to make the patient feel safe when working with you. This shift allows for decreased sympathetic response and increased prosocial behavior, both necessary and influential when working with pain states.

The patient interaction is also a great way to get the placebo effect. I know the placebo effect often is thought of as deceitful and providing ineffective treatment, but that is far from the truth. All the placebo effect does is maximize the belief and perception that a treatment will work. In fact, the belief that something will work is part of a recent CPR developed for cervical spine manipulation in neck pain. In On Intelligence, perception and behavior are one and the same. So by optimizing one’s perception, we can optimize one’s motor behaviors.

Theatricality and deception are powerful agents to the uninitiated.

Moreover, I think it is important to have fun with what you do, and make the physical therapy experience a pleasant and rewarding time for all involved. Think of how we are perceived; “PT stands for pain and torture,” or “I hate physical therapy.” Adding humor and performing fun activities can make PT a more fruitful time.

Seeing how my student has been progressing is a good example of this. When she first started out, much of the focus was geared toward getting all the relevant information, making sure she was performing all the tests, manual therapy, and exercises well. One thing that was really lacking was the patient interaction.  After stepping in a few times when she struggled, you could see some of her patients just open up and smile during our short stint together. After explaining the above to her, my intern is now asking patients about their life stories, weekend plans, and empathizing with their problems. She is even stealing some of my jokes, which is okay because half of my material is not original.

Be like the rehab version of Carlos Mencia.

The Greeting

The first impression is very meaningful and sets the tone for the patient interaction. When I meet a patient for the first time, I will call them by name and have them walk to me. I get several pieces of information from this introduction:

1)      Their sitting posture.

2)      Their facial expression when you make eye contact.

3)      How they get out of the chair.

4)      Their gait pattern and speed.

These pieces help me understand how well and willing the patient moves, as well as their general demeanor. Depending on if I see someone hop right up with a huge smile on their face versus someone who is slouched in their seat and slowly trudges over towards me, my interaction with them often changes. With the former, I will be more upbeat, with the latter, I will be mellow. The more you can mirror the patient, the greater bond you can develop.

The Handshake

This small gesture reveals so much about your patient. The firmness and way they shake your hand can tell you a lot about their personality. There are several different handshakes you may experience:

Which you should use depends on how you wish to be perceived. If I see someone who seems to need more guidance, I may use a more dominant type of handshake. If I see someone who needs reassurance, I may use a more submissive handshake. Regardless of how you shake one’s hand, make sure you use firm pressure and warm eye contact.

The Subjective

The subjective examination is very important, but not for the reasons you think. I know my mentors in my residency will kill me, but I personally do not feel the subjective examination really steers me in a particular treatment direction. Rather, I see the following as the subjective exam’s goals:

1)      Find out how you may help them.

2)      Establish rapport.

3)      Understand the patient and their story.

4)      Make the patient feel understood.

5)      Rule out red flags.

You obviously want to find out what brings them to you, but for me the objective tells me where to go. The subjective examination is more for the patient than you, so let’s talk about how to maximize that interaction.

The Setup

How you face the patient can make or break your interaction. Remember the goal is to reduce threat perception and make them feel comfortable with you. To maximize this goal, you want to eliminate as many barriers as possible. So you probably do not want to face the patient like this…

qAdYbetfk_P-eN9NPa96aOJyTuUPKC8_DMvm6LpKYzc
No focus; barrier

Or This

_6zqczBAzFtjybMHOAULjXxqv6pOEtkbWEHoYsrJTZQ
Focus, but barrier of leg and clipboard.

Or this

BW90UgG_6zoz5LWhUnDebd7o8-IoVy_93uWlVRw8k0Q
Focus, but table is a barrier and too far away.

Or this

bEU-zFcKxhiWg-A13BDdcWtZ6NXH6kZkOhuyvF_3aGk
Not even in the same room…barrier.

And definitely not this

Too up in the business.
Too up in the business.

Rather, I like this orientation

More ideal...minus my slouching posture.
More ideal…minus my slouching posture.

Here you are staying close to the patient while simultaneously respecting their privacy because you are not directly facing them.

Now I know what you are saying, “But Zac, you are using a computer, clearly that is going to kill rapport and act as a barrier.” I would agree to some extent, there are two things here that you ought to notice:

1)      The computer is not directly in front of the patient, thus is not a barrier.

2)      I maintain quite a bit of eye contact while typing.

Now granted some people may still feel uneasy about me typing in front of them, so I will usually ask if I sense that this is problematic. But you can still develop some semblance of intimacy with the patient by playing with 5 different variables.

The 5 Intimacy Variables

In order to develop an intimate experience with the patient, we can add/subtract 5 different ways to create a bond with someone:

1)      Proximity

2)      Eye contact

3)      Touch

4)      Direction

5)      Saying the person’s name

The more of the above variables you utilize when you interact with someone, the more of an intimate encounter you may experience.  You want to use neither too many nor too few variables when interacting with someone. Too many will make you seem creepy (and potentially send the wrong message) and too few will make you seem distant. I generally shoot for 2-3 at a time.

So if we take the above setup example, I am keeping a close proximity toward the patient and maintaining eye contact, however I am not directly facing the patient. I may modulate the interaction throughout by saying the patient’s name or providing a light touch of the arm. So here I can utilize my 2-3 variables at a time.

The Objective

While the objective’s goal is to guide your treatment plan, it can also be a great time to further build rapport. Perhaps the best way to establish that you care is by providing a thorough examination.

How many people have been to a 5 minute physician visits compared to one who may spend up to 30 minutes taking a look at you? Which physician is better liked? The fact of the matter is, people want and expect a thorough examination, so give it to them.

This is where I feel like something such as the SFMA can come in handy.  People may have gone to other clinicians who just looked at the affected region, but this clinician is looking at everything, he/she must be different. So when I am performing an assessment, I generally perform something closer to the SFMA top tier and then do my own type of breakouts from that. What can I say, I’m a rebel.

A clinical Badass, one might say.

Throughout the examination, I will sprinkle compliments or ask about things like their plans for the rest of the day, anything I can do to further establish rapport.

The Education

So you finished the subjective and objective, and you likely have the information that you need to treat. The post-evaluation education is the spot in which you can really win or lose people. David Butler suggests that there four questions that the patient would like answered:

1)      What is wrong with me?

2)      How long will it take to get better?

3)      What can I do to make it better?

4)      What can you do to make it better?

I will usually educate the patients to some degree on pain physiology, followed by whatever objective impairments I find that can improve upon one’s complaints.  In order to maintain low threat perception, I will rarely break out models or use terms such as “motion x is crushing body part y” or “you have weak area z” or “your spine is unstable,” even if these components may be somewhat true.  Reason why comes back to reducing threat perception. Seeing models of bulging discs or using some semblance of the above language tends to just freak people out and moreover is often inaccurate. People just need to know that it is safe to move, when it is safe to move, and move well when they do.

I will finish my education by asking the patient an incredibly important question. Drum roll………………………………

Do you have any questions?

Especially the case with pain neurobiology, if the patient does not understand where you are coming from, they will not be able to fully buy in to your methodology and plan. So make sure any questions the patient has are answered to the best of your ability.

 

The Ending

I always finish my interaction with patients with the following phrases

1)      “Do you have any questions, comments, concerns, or complaints?”

2)      “Is there anything else I can do for you or that I did not cover?”

I ask these questions to again establish an open communication and rapport. I want to make sure that the patient is completely satisfied with the experience that I have provided them. Moreover, finishing the session with the same ending every time they come in provides the patient with some consistency and helps establish your brand; in my case, the Zac Cupples brand.

With extra placebo-enhancing effects...works best when not plugged in.
With extra placebo-enhancing effects…works best when not plugged in. For sale soon on www.zaccupples.com

Conclusion

So there you have it, the above methodology is how I approach a patient interaction. I have based many of these methods on what I have read regarding people interaction, so the below resources might be good to check out. If you can get your social capabilities to a high standard, the rest will take care of itself.

“The Definitive Book of Body Language” by Allen Pease

“How to Win Friends and Influence People” by Dale Carnegie

“Made to Stick” by The Heath brothers

“Influencer” by Joseph Grenny et al

“Social Intelligence” by Daniel Goleman

“Just Listen” by Mark Goulston & Keith Ferrazzi

“Never Eat Alone” by Keith Ferrazzi

“The Power of Self Confidence” by Brian Tracy

James Bond – Seriously, the way he interacts with people is gold, especially if you kill bad guys and woo women like I do in my spare time.

Cupples, Zac Cupples