A Little Personal It is hard to believe that I have already written my 50th post after starting this blog in February as a way to enhance both my learning and the learning of others. This blog has allowed me to interact with a variety of different individuals that I otherwise would not have. And when people who I deeply respect say they admire what I have to say (or at least my version of what other people say), I am deeply humbled. But I have had several cases in which people wondered if I do anything other than physical therapy and personal training (I do). One of my former mentors came up to me saying that she was worried about me because of how much I am into this. These interactions have made me reflect on why I am reading, working, writing, and learning as much as I can. Thus, I have come to some conclusions as to what drives me to help others. And this drive, while not the norm that some of my peers are accustomed to, is far from wrong. Others are Depending on You When you work as a health professional, some people neglect the fact that your patients and clients trust their bodies with you. They put their confidence in your knowledge and skills to show them the path to bettering themselves. When someone puts this amount of trust into me, the last thing I want to do is let them down. So I
Read MoreCourse Notes: Mobilisation of the Nervous System
I Have an Addiction It seems the more and more that I read the more and more and read the more and more addicted I become to appreciating the nervous system and all its glory. To satisfy this addiction, I took Mobilisation of the Nervous System with my good friend Bob Johnson of the NOI Group. This was the second time I have taken this course in a year’s span and got so much more value this time around. I think the reason for this enrichment has been the fact that I have taken many of their courses prior and that I prepared by reading all the NOI Group’s books. A course is meant to clarify and expand on what you have already read. So if you are not reading the coursework prior, you are not maximizing your learning experience. What made this course so much more meaningful was being surrounded by a group of like-minded and intelligent individuals. As many of you know, I learned much of my training through Bill Hartman. Myself, Bill, the brilliant Eric Oetter and Matt Nickerson, my good friend Scott, and my current intern Stephanie, all attended. When you surround yourself with folks smarter than you, the course understanding becomes much greater. This course was so much more with the above individuals, so thank you. Try to attend courses with like-minded folks. Here are the highlights of what I learned. If you would like a more in-depth explanation of these concepts, check out my
Read MoreChapter 4: Diagnosis of Specific Dysfunctions
This is a Chapter 4 summary of “Clinical Neurodynamics” by Michael Shacklock. Mechanical Interface Dysfunction In early stages of closing dysfunctions, symptoms present as aches and pains. This presentation is due to the musculoskeletal tissues being more affected than the neural tissue. As severity increases, neurological symptoms such as pins and needles, tingling, and burning are more likely to occur. The severest end of the spectrum includes numbness and weakness; indicating further compromise to the neurovascular structures. Interface dysfunctions behave with changes in posture and movement. Oftentimes cardinal signs of inflammation can be present, along with night pain/morning stiffness. Typically you will see a painful arc throughout movement. During the physical exam, patients will show an inability to move in opening or closing directions. You can also find altered pain production, soft tissue thickening, or hypermobility/instability. Neurological changes will usually be present only in severe interface dysfunction. There are four basic types of interface dysfunctions 1) Reduced closing 2) Excessive closing 3) Reduced opening 4) Excessive opening In reduced closing dysfunction, closing movements such as squeezing or cervical extension provoke symptoms. Assessment may show a protective deformity developing in the opening direction so pressure is reduced on the nervous system. Symptoms will often not be reproduced unless neurodynamic testing is combined with interface testing. Excessive closing is when, well, interfaces are closing too much. An example of this dysfunction is excessive lumbar lordosis present with low back pain that increases with standing, walking, and running. A patient’s history will often show
Read MoreChapter 3: General Neuropathodynamics
This is a Chapter 3 summary of “Clinical Neurodynamics” by Michael Shacklock. What it is General neuropathodynamics are abnormalities consistent throughout the nervous system, with specific referring to local abnormalities. These changes may lead to a neurogenic pain experience, in which pain is initiated by a primary lesion, dysfunction, or transitory perturbation in the nervous system. This definition means that dysfunction in the nervous system, it’s surrounding tissues, and innervated tissues can all be related to neurogenic pain. Definitions of Clinical Problems When discussing dysfunction, there are several descriptors: 1) Optimal/desirable: When the neuromusculoskeletal system behaves well and does not create symptoms in situations of high stress. 2) Suboptimal: Imperfect neuromusculoskeletal behavior which results in potential symptom increasing if an adequate trigger occurs. 3) Normal: Function of neuromusculoskeletal system is within normal values. 4) Abnormal: Neuromusculoskeletal system is outside of the normal range. 5) Relevant: When pathodynamics are linked to the clinical problem. 6) Irrelevant: When pathodynamics are not linked to the clinical problem. You will oftentimes have multiple of these components in a clinical situation. Mechanical Interface Dysfunction These dysfunctions deal with abnormal or undesirable forces on the nervous system. There are two main categories with their own subcategories. 1) Closing dysfunctions – Altered closing mechanisms of the movement complex. Can be reduced (protective response) or excessive (hypermobility/instability). 2) Opening dysfunctions – Altered opening mechanisms of the movement complex. Can be reduced which creates impaired pressure reduction, or excessive leading to tissue traction. Pathoanatomical Dysfunction This type of dysfunction is
Read MoreChapter 2: Specific Neurodynamics
This is a Chapter 2 summary of “Clinical Neurodynamics” by Michael Shacklock. Intro Specific neurodynamics include local effects of body movements on the nervous system. So today we will go through each body region discussing these. The Spine Here are some interesting tidbits regarding the spine and neurodynamics. When we flex the spine, the spinal canal elongates by about 9 cm. Neck flexion creates significant tension to the lumbosacral nerve roots. Neural structures slide relative to the bony interface differently depending on the location and the movement used. Flexion increases tension, but reduces compression. Extension adds compression, but reduces tension. Lateral flexion increases tension on the convex/contralateral side of the spine. This situation occurs by interface and neural tissue elongation and increased distance between the spine and periphery. Rotation closes on the ipsilateral side and opens on the contralateral side. The spinal cord tends to move towards various specific segments. These areas are termed zones of convergence, and these areas include C5-6 and L4-5. For example, tissues above C5-6 will slide toward this zone, as will tissues below this segment. The midpoint at which tissues diverge is at T6. At this point, tissues below T6 will converge towards L4-5, and tissues above T-6 will converge to C5-6. Gravity can also play a role in neurodynamics. For example, if you perform a SLR in sidelying, the downward side usually has less mobility. This difference occurs because the neural contents are convex on the downward side and convex on the upper side,
Read MoreChapter 1: General Neurodynamics
This is a Chapter 1 summary of “Clinical Neurodynamics” by Michael Shacklock. Concepts When we first started working with the nervous system, oftentimes we called pathological processes adverse neural tension. The problem with this name was that it left out nervous system physiology; it was mere mechanical concepts. Hence, we call the movement and physiology of the nervous system neurodynamics. General neurodynamics account for whole body fundamental mechanisms, regardless of region. Specific neurodynamics, on the other hand, applies to particular body regions to account for local anatomical and biomechanical idiosyncrasies. The System There are three parts to the neurodynamic structure: 1) The mechanical interface 2) The neural structures 3) The innervated tissues The mechanical interface is that which is near the nervous system. It consists of materials such as tendon, muscle, bone, intervertebral discs, ligaments, fascia, and blood vessels. The neural structures are those which make up the nervous system. These structures include the connective tissues that forms the meninges (pia, arachnoid, and dura mater) and peripheral nervous system (mesoneurium, epineurium, epineurium, and endoneurium). The nervous system has mechanical functions of tension, movement, and compression. It also has physiological functions to include intraneural blood flow, impulse conduction, axonal transport, inflammation, and mechanosensitivity. The innervated tissues are simply any tissues that are innervated by the nervous system. They provide causal mechanisms for patient complaints, and are able to create nerve motion. When we have neural problems, sometimes the best treatment is to these structures. You must treat everything affected. Mechanical Functions
Read MoreWhy 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: I have an amazing time with amazing people. I learn a ton and realize how little I really know. Prolific discussions are had. I end up purchasing WAY too many books as soon as I get home. 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. 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
Read MoreChapter 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. 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
Read MoreChapter 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. 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.
Read MoreMovement 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. 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 MoreMovement 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.
Read MoreMovement 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. Exercise Categories There are several exercise types that can be utilized depending on one’s goal:
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