November Links and Review

Every week, my newsletter subscribers get links to some of the goodies that I’ve come across on the internets.

Here were the goodies that my peeps got their learn on from this past August.

If you want to get a copy of my weekend learning goodies every Friday, fill out the form below.  That way you can brag to all your friends about the cool things you’ve learned over the weekend.

Biggest Lesson of the Month

Don’t beat yourself up if you aren’t hitting perfection day in and day out. Consistent progress over time is the key.

There have been many days where I wasn’t motivated to stay on task, and faltered. The key to getting back on the proverbial horse the next day was to not beat myself up. Instead, acknowledge that these things happen, understand I’m human, and get after it the next day.

You’d be amazed at what this shift in perspective can do.

Quote of the Month

“Greatness is a lot of small things done daily” ~ MJ Demarco

MJ Demarco again takes the cake this month. This quote made me reflect a lot on just how many small, quality habits, can make an impact on life. What small things can you do to become great?

Hike of the Month

A late steal this month, but got a chance to check out Death Valley National Park.

Salt > snow. Equally as pretty, less slippery, and DEFINITELY warmer

I wasn’t really sure what to expect with this place since, ya know, it’s hot and things are kinda dead n’ stuff, but the variety in landscape was quite unbelievable. Landscape that I have never experienced before, whether salt lands or sand dunes. I’d definitely consider checking this awesome place out.

Rehabilitation

 

Here’s a little sneak preview of the free talk I’ll be putting up for you guys once I re-record it!

Blog: What Evidence Based Practice is Not

Doug Kechijian always telling it like it is. This time, my younger older brother discusses how to think about evidence based practice. How it is much more than a bomb of Pubmed citations. I also love how he touches on effective discussion on the internet.

Here is a little variation on differential tendon gliding you can try next time you see someone with a flexor tendon repair.

Blog: Should We Delay Range of Motion After a Rotator Cuff Repair Surgery?

Mike Reinold again coming on strong with this post. This time, Mike looks at a systematic review comparing early vs. delayed motion after a cuff repair, and I love his interpretation.

Training

Video: Kettlebell Swing Tutorial w/ Justice Williams (via Tony Gentilcore)

My kettlebell game is something I’m hoping to improve upon over the next year, and this was a great intro point to it. Here, Tony Gentilcore and Justice Williams provide an excellent coaching tutorial on the wonderful/brutal exercise known as the kettlebell swing.

 

Productivity

 

Article: Trick Yourself Into Writing Well by Telling Yourself to Write Badly

Lifehacker is an awesome website for many reasons, and this article is an example of that.

Many times, getting started writing is the hardest part, here, the peeps at Lifehacker give you a trick to getting started. Works wonders for those days I don’t want to write.

Making this one little tweak to how I plan email checking throughout my day has made a big difference.

Personal Development

Book: What to do When It’s Your Turn

A dear friend of mine got me this book, which has become my pre-bed reading and I love it. Seth Godin, marketer extraordinaire, writes in this book about handling fear of failure, getting the courage to start something up, and how timing is never right. These are a few of many great topics that I’ve come across, and I always fall asleep in a good mood after I read a few pages 🙂

Blog: These are the 8 Friends You Need to be Happy in Life

Social engagement is something we don’t discuss much when we are trying to reach our health and performance goals. Here, Eric Barker talks about the eight people you should have in your life. How many do you have?

Article: How Frequently Should You Take A Vacation?

This is probably the most comprehensive guide to vacationing that I have come across. It turns out, vacations are incredibly important to your health.

Don’t like vacations? Consider your increase for cardiovascular disease elevated. Read the guide to maximizing them.

Just need to make life a vacation #movesomewherewarm

Blog: How One Young Couple Repaid $87,000 of Student Loan Debt in 27 Months

If you have student loans. Read this. It’s hard work, gruesome, but paying off debt has been a rewarding experience for me. If you are lacking motivation, or can’t see the light at the end of the tunnel, here is some hope.

Blog: Struggling Against Good Decisions with Bad Results

This was just a phenomenal message that can be extrapolated not to just finances, but life. Here, Trent Hamm discusses the importance of sticking to sound principles, even if those principles don’t always result in a desirable outcome

Book: Discipline Equals Freedom Field Manual

If you need a swift kick in the ass to get back into gear, this is the book. Many of the pages are snippets from Jocko Willink’s podcast, but the message is not lost. Jocko will make you rethink everything your doing, and eliminate the excuses for you not doing. Change your life, and read this book.

Book: Unscripted

After you’ve been kicked down by Jocko, let MJ Demarco pull off the finisher. This guy is becoming one of my favorite authors because he is brutally honest and pulls no punches in explaining how we fall into business and work traps that not only hinder us, but minimize helping others. If you want to be an entrepreneur (and you all should, this book tells you why) then this is a must read.

My favorite part? “The goal isn’t to make money, but to provide value to others.”

Health and Wellness

 

Podcast: Dr. Ruscio – The Real Deal with Gut Microbiota

I’ve been binge listening to Robb Wolf’s podcast, and I’ve come across Dr. Ruscio a couple different times. I admire his brutal honesty and simple approach to dealing with the gut microbiome, and I hope you guys like it as well.

Want to know some of my big keys for starting my day off right? Check out this week’s quick hit.

Podcast: Dr. Richard Maurer – The Blood Code

Again, another simplified and stratified approach to functional medicine courtesy of the Robb Wolf podcast. Here, Dr. Maurer outlines his key blood markers and first-tier treatment to help individuals with their health and wellness goals.

Article: Do You Need to Refrain from Coffee to Get the Maximal Effect of Caffeine?

If you want to maximize performance, do you need to give up coffee for a bit to get the benefits? Researchers compared how caffeine affects performance in heavy, moderate, and low users.

The answer might surprise you!

The addiction is now #ebp #blessed

 

Which goodies did you find useful? Comment below and let me know what you think.

Photo Credits

Nick Kenrick

Julius Schorzman

Post 100: Sexifying Upper Quadrant Post-Op

I Wrote a Lot

It’s interesting to think how much this blog has changed since I started writing in February 2013.

We’ve gone from cliff notes of books, to cliff notes of courses, to the occasional self-musing.

 

The blog. She is my muse, my flame.
The blog. She is my muse, my flame.

While I still plan on reviewing and assimilating courses I take, my hope is to expand and reflect upon whatever is in my brain a smidge more.

It makes sense to start this trend with post 100.

And today, postoperative care is piquing my interest.

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Yes, post-op intervention is a guilty pleasure of mine. And it’s not because it’s easy.

Far from easy.

Post op treatment gives you a license to create under various constraints. Meaning you have to dig a little deeper to achieve desired goals.

I think it can be way sexier, and effective, than your typical post-op protocol BS. So let’s create some successful post-op fun.

In post op, not sure if it was ever there.
In post op, not sure if it was ever there.

The First Constraint

Before we even talk about specific patients, we have to first look at the largest constraint yet: available tools.

At my current digs, I don’t have much of anything in terms of heavy weights. So here is what I have at my disposal that I can implement:

  • 1-on-1 care for 60 minutes
  • Kettlebells: 10, 15, 25 pounds
  • Therabands and theratubes of various sizes
  • Cook bands of various resistances
  • PRI trial orthotics (mouth splints, arch supports, reading glasses, yada)
  • Steps
  • Tape
  • IPAD
  • 3D stretch cage (aka very expensive equipment to tie therabands to)
  • Access to higher level brain centers
  • Heart of gold

We keep things simple at EV.

All day every day at EV
All day every day at EV

Early Stages

This is every clinician’s favorite rehabilitation stage, namely because it is incredibly boring.

That is, boring if said clinician has absolutely zero temporal wobble.

You can be amazed at what the patient can actually be do at this stage to expedite the rehab process once movement constraints are lifted.

The most common upper quadrant restriction involves no movement of the involved extremity.

The goals during this stage ought to include:

  • Promote a safe healing environment – reduce fear, pain, swelling, etc.
  • Restore local mobility
  • Restore system variability
  • Remap affected regions in the somatosensory homunculus
  • Challenge the aerobic system

Let’s take a patient I am seeing post-rotator cuff repair on his right arm. He cannot move his arm for 6 weeks.

Top priority of course is restoring range of motion, so session bulk was spent on pain-free manual therapy and passive range of motion. For home he gets elbow/wrist ROM and nerve glides.

But there is no way in hell I am doing that for 60 minutes.

In the outfit I would say it in...
In the outfit I would say it in…

There are many other things that this fellow can work on aside from basic range. Let’s address the other qualities.

Restore System Variability

In PRI-land, this gentleman was a PEC/RBC/RTMCC. We began to address this protective pattern day 1 after surgery.

Reduce sympathetic tone, reduce threat perception, promote a safe healing environment. Everybody is happy.

Since I knew he would be living in a recliner for the forseeable future, we kept things simple by blowing up a balloon.

One week later our guy came in as a LAIC/RBC with decreased left hip internal rotation, so we shifted our emphasis towards improving right apical expansion while shifting into his left hip.

With this strategy, we were able to maximize system variability within the confines of his restrictions. Gaining apical expansion on the right side was a nice way for the patient to relax the shoulder tissues while keeping the repair intact.

Remap Affected Regions

Use it or lose it reigns king in post-op land. But how can we get this gentleman to use his arm while respecting the passive-only barrier?

Here is where I love graded motor imagery the most. The shoulder’s motor pathways can still run while the repair stays intact.

So day one, we assessed our guy’s left/right discrimination using the NOI Recognise app.

He ended up blowing this stage out of the park, so once we went through all the different challenges this program allows we went straight to explicit motor imagery.

Most of my imagery is explicit...
Most of my imagery is explicit…

I asked our guy to visualize what his shoulder looked like without the brace first. Once he was able to do this, I had him imagine moving his arm in various movement planes, to progress to envisioning ADL performance with his affected extremity.

In the clinic, I would teach him push/pull movement on his left arm while he imagined performing those actions on his right.

Once he mastered imagery, we began to implement mirror box therapy.

We first started out by just watching him move his “right” arm in the mirror, which he said was very freaky.

Grab a mirror box...and perhaps some Chardonnay.
Grab a mirror box…and perhaps some Chardonnay.

Despite the freakiness, it blew him away how much this technique reduced his pain and stiffness.

Once he could do basic movements no problem, we had him work on push/pull movements using his left hand while watching his “right”arm.

His most challenging piece? Open loop arm movements. This task was a beast for his mind:

Combining GMI with working the non-affected extremity tremendously expedited re-learning basic movements on his affected extremity as we progressed later into postoperative care.

Challenge the Aerobic System

 Our guy is in his 50’s and a blue collar worker, so we aren’t getting super wild and crazy here.

Day one we emphasized nice easy walking 20-30 minutes per day to increase circulation and promote healing.

Clinic-wise, we taught him squatting, deadlifting, pressing, and rowing. To emphasize the aerobic system, we kept things at tempo pace to emphasize slow-twitch hypertrophy and aerobic development.

Tempo lifting

  • 2-4 sets of 10-12 reps
  • Pace 3 second eccentric—no pause—3 second concentric. I tell patients to say this mantra slowly – Screw…you…Zac (eccentric) Screw…you…Zac (concentric). This mantra also helps boost the immune system because patients find it funny. Two points for me!
  • 30-40 seconds rests between sets.

Later Rehab Stages

 The later rehab stages look somewhat similar to typical fare, though I do not emphasize isolated strengthening so much.

Once the active assist/active unresisted phase is allowed, we switch to that stuff. Shoulder remapping becomes a greater active process, so most of GMI is stopped. Let’s get him moving.

Fortunately he does.
Fortunately he does.

Our program also shifts toward him using his right extremity to aide in variability restoration. He has limited flexion, so I like a doorway lat stretch:

[side note: amazing that most comments I’ve heard on this vid involve my glutes and not the technique. Upon reflection of most of my life, this probably is not as surprising]

I also like him doing unresisted reaching:

We still emphasize challenging the aerobic system and the unaffected extremities, but this usually accounts for about 20% of the session at this time.

Once we can start resistance training the extremity, we keep things simple. I like push/pull movements and static/dynamic motor control exercises. So we teach our guys armbars, get-ups, carries, crawling, etc.

I don’t use a whole lot of isolated cuff work during the rehab process. The cuff doesn’t really work as a prime mover, so unless the goal is cuff hypertrophy (aka gettin’ Swolebodan Milosevic), I don’t do it.

 

Do some homework if you don't know who he is
Do some homework if you don’t know who he is

In the cases that I have scrapped cuff isolation exercises, I still saw manual muscle testing improve just the same. So let’s teach the cuff to be a cuff.

We finish the rehab process by making it look a lot more like fitness. By the end, the hope is to have system variability restored, local mobility in the clear, and strength up to snuff. Teach your guys and gals the basic movements and emphasize patient-specific functional activities, and you are in the clear.

Final Thoughts

 That’s where I am right now with upper quadrant post-operative care. There is a lot that these folks can be doing, and my challenge to you is to make those early stages of rehab some of the most exciting for the patient.

Now go and create!

Even if it's something like this.
Even if it’s something like this.