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:
Read MoreMovement 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. 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. 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
Read MoreMovement 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. 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
Read MoreMovement 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 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.
Read MoreLessons from a Student: The Interaction
The Inspiration Over the past few weeks I have felt called to write about an often uncovered yet extremely important component of the therapeutic process: Patient interaction. We had an instance in which I came back into the clinic from my lunch break and my intern was supposed to have a patient evaluation. Instead, she opted to have me take this particular patient. This patient was a lovely 17 year old lady who was being seen for bilateral foot pain. This was her second bout of therapy, and her and her mother was very dissatisfied with their last physical therapy experience just a few months (and 17 visits) prior. She was not a happy camper and wanted a second opinion. After hearing stories from my coworkers, I expected the worst. We progress through the evaluation, and my student observes nothing but smiles throughout from the patient and her mom. Jokes were cracked, movement was looked at, and edumacation happened. At this point, after a little explain pain and kinetic chain discussion, these women were sold. We leave the treatment room and I said “that wasn’t so bad yes?” My student replies “that’s because they are in love with you.” But really, that essentially is what you have to do with the patient interaction. You can have the greatest hands, the greatest exercise plan, and evidence up the wazoo; but if your patient hates your guts you will fail. I heard this from Patrick Ward that 80% of your success with
Read MoreMovement Chapter 7: SFMA Introduction and Top-Tier Tests
This is a chapter 7 summary of the book “Movement” by Gray Cook. Intro The SFMA’s goal is to assess functional capabilities. This system is based on Cyriax differentiation and grading principles. Instead of describing things as strong, weak, painful, or painless; the following descriptors are utilized: Functional nonpainful (FN): Unlimited movement and able to complete a breath cycle at end-range. Called the dead end. Functional painful (FP): Called the marker, reassessed. Dysfunctional nonpainful (DN): Limited, restricted, impaired mobility, stability, or symmetry. Labored breathing with movement also implicates this choice. Called the pathway, where treatment occurs. Dysfunctional painful (DP): Called the logical beehive because we do not know if pain is causing poor movement or vice versa. It is an unreliable place to work unless acute situations. SFMA corrective and manual therapy lie in treating the FP’s and DN’s. The order at which things are treated also matters, so the order listed below for the top tier tests is also typically where treatments should hierarchically begin. Cervical spine patterns (CSP) Upper extremity patterns (UEP) Multi-segmental flexion (MSF) Multi-segmental extension (MSE) Multi-segmental rotation (MSR) Single leg stance (SLS) Overhead deep squat (ODS) We then operate the SFMA in the following fashion:
Read MoreMovement Chapter 6: Functional Movement Screen Descriptions
This is a chapter 6 summary of the book “Movement” by Gray Cook. Screening Keys The FMS is not considered a training or competition tool; it simply ranks movements. Here are the keys to a successful screen. First off, know the following bony landmarks Tibial tuberosity ASIS Lateral and medial malleoli Most distal wrist crease Knee joint line 3 repetitions are performed for each movement, and it is important to stand far away so the whole movement can be seen. When testing both sides, take the lowest score if an asymmetry is present. Here are the movements (videos courtesy of Smart Group Training). The Deep Squat Purpose: Full-body coordinated mobility and stability; linking the hips and the shoulders. Here is how it is done. Hurdle Step Purpose: Evaluate stepping and stride mechanics. Here is how it is done. Inline Lunge Purpose: Test deceleration and left/right function utilizing contralateral upper extremity patterns and ipsilateral lower extremity patterns. Here is how it is done. Shoulder Mobility Purpose: Evaluate scapulothoracic rhythm, thoracic spine and rib mobility. Here is how it is done. ASLR Purpose: Tests hip flexion, hip extension, and core function. Here is how it is done. Trunk Stability Pushup Purpose: Tests reflexive core stability. Here is how it is done. Rotary Stability Purpose: Check multi-planar pelvic, core, and shoulder girdle stability. Also looks at reflexive stability and transverse plane weight shifting. Here is how it is done. FMS Conclusions The FMS is designed to give a corrective pathway that may involve
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