This is a chapter 2 summary of the book “Movement” by Gray Cook. Funky Muscles There are anatomically two basic types of muscles; shunt and spurt. Shunt muscles compress and produce structural integrity because the distal attachment is far from the moving joint. Spurt muscles produce movement because the distal attachment is close to the axis of rotation. While these two muscle types are present, they can vary depending on the function performed. For example, if we perform a movement in the closed chain, the spurt and shunt roles become reversed. Focusing on a single muscle group causes us to lack understanding of the supporting matrix behind superficial muscle action. Muscle function depends on body position and joint in action. We can see this point illustrated in Lombard’s paradox, which involves the coactivation of hamstrings and quadriceps when performing a sit to stand. These muscles are antagonistic to one another at their respective joints, yet movement is produced. The resultant effect is the quads and hamstrings becoming global stabilizers. Muscle activity is task specific, therefore Gray purports four types of muscles: 1) Global Stabilizers: Multi-joint muscles contracting to produce stability and static proprioceptive feedback. 2) Global Movers: Multi-joint muscles that produce movement and dynamic proprioceptive feedback. 3) Local Stabilizers: Deep segmental muscles (1-3 segments) that produce stability and static proprioceptive feedback. 4) Local Movers: Single joint muscle that produce movement and dynamic proprioception. These different muscle types require different training modalities. The example given is stabilizer muscles. These muscles cannot
Read MoreMovement Chapter 1: Introduction to Screening and Assessment
This is a chapter 1 summary of the book “Movement” by Gray Cook. Intro This chapter’s central point, and for that matter the whole book, is that movement needs to standardized just like all other therapeutic and performance measures. Movement is fundamental to who we are. Despite movement being at our center, we continually classify patients and clients by body region. Unfortunately through this reductionism, much is lost. We cannot measure parts and expect that to give us an adequate picture of the whole. Screening Before we begin training, it is advocated that movement be screened to facilitate an optimal training environment. The screen will determine movement as one of the following three areas: 1) Acceptable 2) Unacceptable 3) Painful Movement is screened for many reasons. Gray often states that the number one risk factor for injury is previous injury. A movement screen helps find potential risk factors for re-injury. Moreover, if movement is dysfunctional, then all things built on that dysfunction could predispose one to more risk. The screen also helps separate pain from movement dysfunction. It is widely known that when one undergoes a pain experience, motor control is altered. Because motor control is altered, we may not get the desired training effect secondary to pain. Pain screening gives us an avenue for further assessment a la the Selective Functional Movement Assessment (SFMA). Movement screening is the first step away from quantitative analysis to movement quality; from reductionism to holism. Once we have a basic movement map we
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 MoreCourse Notes: The Elite Speed Seminar
I just finished up the Elite Speed Seminar at what has become my home away from home, Indianapolis Fitness and Sports Training. The presenters were Lee Taft and Nick Winkelman, and I learned a great deal in an area that I am weak in. Here are the notes and quotes. Multi-Directional Speed Tools That Make Change – Lee Taft Lee talked about 5 qualities to train that separate great from good athletes. Performing well under urgency, as sympathetic states change how we move. Reactivity – These are reacting to finite reactions, such as a gun going off in a sprint. Random reaction – This uses the stretch-shortening cycle more frequently by foot repositioning. Think a shortstop. Tactics – Reacting to fakes and deception. Mistake Recovery – Training to recover from worst case scenarios. Here were Lee’s recommendations for program design. Skill acquisition – The ability to control desired movements. This portion can be trained by either skill components (3-4 exercises), skill itself (1-3 exercises), or linking skills (shuffle to sprint). Force application – Performing the desired movement patterns with increased force or resistance. Random reactive training – Challenge movements under a random setting, but make sure the above 2 components are rock solid first. Here were Lee’s recommendations to progress to reactive training Acceleration → deceleration → Change of direction →One direction reaction → Multi-direction reaction. Some great cues that Lee used Stay in the tunnel. Arms long and strong. Tear the paper – Get in the athletic position, load the big toes, and try to rip
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 MoreDNS B Course Notes
Whew, I recently finished (and still trying to process) the B level DNS course from the folks at The Prague School. Instructors were Martina Jeszkova and Dr. David Jeurhing. There were a lot of things covered during this 4 day course and I definitely learned a few things. Here are the highlights. Developmental Principles The focal point of DNS is the concept of joint centration, a static and dynamic maximal joint surface approximation. When joint surfaces achieve optimal bony congruency, the muscles surrounding the joint achieve optimal activation and highest mechanical advantage. The reverse is also true. If muscles coactivate properly, then joint centration occurs. Conversely, if optimal joint centration is not achieved then muscle imbalances occur. The reverse is also true. This change becomes very problematic, as decentration at one joint effects centration at all the other joints. This may lead to decreased performance at best and at worst increased wear on joint surfaces. Take lower crossed syndrome (or open scissors if you are a DNS fan) for example. Let’s say we had a problem with our lower back. In order to cope with this trouble, we increase lumbar lordosis and decentrate the lumbar spine. See how it affects the surrounding structures. The pelvis anteriorly tilts, which affects length tension relationships to glutes, hamstrings, and hip flexors. Thoracic kyphosis increases as well, affecting the shoulder girdle and cervical muscles. Basically, play with one body region or joint position and see how it affects the others, and you can develop
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 MoreExplain Pain Section 2: The Alarm System
This is a summary of section 2 of “Explain Pain” by David Butler and Lorimer Moseley. Alarm Signals Our body’s alarm system alerts us to danger or potential danger. This alarm system is composed of sensors throughout the body, the eyes, nose, and ears. It is these sensors that are our first line of defense against harm. If one sensor fails the others take over. Most of these sensors are located in the brain and respond to various stimuli. Some to mechanical movement, some to temperature change; the sensors in the brain particularly respond to chemical activity. What is important to know with sensors is that they have a very short life expectancy of a few days. This cycling means our body’s sensitivity is constantly changing. It is with these life cycles that there is hope for those with chronic pain. Moreover, the rate at which sensors are made is normally stable but can change very quickly in regards to a particular stimulus. So if we take for example one with persistent pain, the rate at which pain sensitivity occurs can be changed. Nociception We lack pain receptors in our bodies. Instead, the various tissues have special neurons that respond to different stimuli. These receptors are called nociceptors, which translates into “danger receptors.” Nociception is occurring all the time, but only sometimes will it end in pain. Nociception is neither necessary nor sufficient for pain. The sensors correspond to particular neurons. In order for these neurons to become excited and
Read MoreThe Sensitive Nervous System Chapter XV: Clinical Aspects of Neurodynamics
This is a summary of chapter XV of “The Sensitive Nervous System” by David Butler. Intro In this chapter we discuss many specific neurodynamic pathologies and implementing the nervous system into treatment approach. Conservative Nervous System Decompression Here is a general step-by-step approach to decreasing threat throughout the nervous system. 1) Decrease tissue sensitivity by removing relevant stimuli and decreasing CNS threshold. 2) Improve container tissue health. 3) Improve the nerve tract’s ability to absorb traction forces. 4) Assess and improve the nerve to container relationship. 5) Assess/modify any adverse ergonomic or environmental factors. Carpal Tunnel Syndrome Tests to perform. ULNT1 & reverse. ULNT2 (median) & reverse. Compression (can add ULNT). Phalens and reverse Phalens. Phalens + ULNT. Treatment There are several options to treat carpal tunnel syndrome. Mobilizing not only the median nerve, but radial and ulnar is beneficial because the nerves are closely connected. Movement is critical because nerve inflammation and swelling does not leave the carpal tunnel easily. This problem is because there are minimal lymphatic channels in the tunnel. Nerve Root Complex Nerve root issues often have corresponding postural adaptations. Cervical – forward head posture. Lumbar – Flat lumbar spine with knees flexed, positioned toward the injured sign. In acute instance, it may be okay to let the patient rest in these antalgic postures until AIGS settle. Other presentations indicative of nerve root complex pathology include numbness/tingling down the extremities. Other possibilities include coldness, shooting, tiredness. Pain rarely goes into the extremities. Double Crush Double crush
Read MoreThe Sensitive Nervous System Chapter XIV: Management Strategies: Integration of Neurodynamics
This is a summary of chapter XIV of “The Sensitive Nervous System” by David Butler. The Big Picture Evidence Based Approach Here is the step by step patient care process that Butler advocates. 1) Identify red flags and manage accordingly. 2) Educate on the whole problem to include tissue health status, the nervous system’s role, and test results. 3) Provide prognosis and make realistic goals. 4) Promote self-care, control, and motivation. 5) Decrease unnecessary fear and manage catastrophization. 6) Get patients moving as early as possible. 7) Help patients identify success and sense of mastery of a problem. 8) Perform a skilled exam. 9) Acknowledge that biopsychosocial inputs combine with the nervous system to produce pain and disability. 10) Use any measures possible to reduce pain. 11) Minimize number of treatments and contacts with all medical personnel. 12) Chronic pain may need a multidisciplinary approach. 13) Manage physical function and dysfunction. 14) Assess and assist in improving general fitness. 15) Assess how injury affects creative outlets and assist the patient with regaining creativity and discovering new creative outlets. Incorporating Neurodynamics There are several ways to incorporate neurodynamics into the patient’s plan of care which will be outlined below. Reassessment. Explanation. Passive mobilization. Active mobilization. Posture and ergonomics. Reassessment There are many evaluation protocols that warrant constant reassessment after applying an intervention. Be it a comparable sign or audit, neurodynamic tests can be utilized well within these systems. A word of caution with instant reassessment, as quick changes could merely be
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