I recently did a little spot on IFAST University regarding how I approach, assess, and progress people along the physical activity continuum. Read the little intro below, and if you want to watch the video, click on the picture or the link.
As a bonus, I put together a little PDF outlining how I improve the movement variability side of physical activity. If you sign up for IFAST University, you’ll get access to it.
Without further adieu, here is the post.
The Four Step Process to Address Movement Limitations
I’m in the business of creating change, but — as you know — that stuff is HARD TO DO.
How do you simplify the process?
I like to outline things. When thoughts have a directional flow, it’s easier to keep everything straight. So I have to ask myself questions about each and every situation.
What kind of person is in front of me? And what am I going to do with him or her?
In this post, I’ll outline my process of helping people achieve their health and performance goals. We’ll discuss:The 4 areas where we can start creating change
My main area of focus: physical activity
The 4 steps physical activity
Each step from my physical therapy view
Each step from my performance coach view
My progression for mobility
The 3 active mobility tests I use
Testing for arm motion with lower body tests
Runners who get pain after they run 5 miles
Patients who get back pain after they sit for 4 hours
Athletes who can’t play the whole game without pain
…and a bunch of other short examples to relate this system to your own clients
I went to this course for a few reasons. First off, I of course support the home team. I can’t even front, Douglas Kechijian, Trevor Rappa, Greg Spatz, and I go way back, and are very much related through IFAST family and directly (Doug is my younger older brother, Trevor is my son, and Greg is my stepson #dysfunctionalfamily).
That said, there is were a couple big things I wanted to take away from this course, which I did in spades:
Mastering basic movement
In these two areas, the Resilient fellas delivered in spades. Knowing what good technique is in the basic movement patterns, how to coach, and how to regress, are all underappreciated topics that these guys teach quite well.
So should you take this course? An emphatic hell yes. I give a more indepth review as to why in the video below, so go ahead and check that out.
Once you got the verdict, check out my favorite takeaways in the course notes, and then for the love of God sign up for a course of theirs!
Click here to check out the Resilient Seminar Page
Just when I thought I was out, the clinic pulls me back in.
Though I’m glad to be back. There’s just a different vibe, different pace, and ever-constant variety of challenges that being in the clinic simply provides. This has been especially true working in a rural area. You see a much wider variety, which challenges you to broaden your skillset.
Previously, I was all about getting people in and out of the door as quickly as possible; and with very few visits. I would cut them down to once a week or every other week damn-near immediately, and try to hit that three to five visit sweet spot.
This strategy no doubt worked, and people got better, but I had noticed I’d get repeat customers. Maybe it wasn’t the area that was initially hurting them, but they still were having trouble creep up. Or maybe it was the same pain, just taking much more activity to elicit the sensation.
It became clear that I was skipping steps to try and get my visit number low, when in reality I was doing a disservice to my patients. This was the equivalent of fast food PT—give them the protein, carbohydrates, and fats, forget about the vitamins and minerals.
Was getting someone out the door in 3 visits for me or for them? The younger, big ass ego me, wanted to known as the guy who got people better faster than everyone else. Yet the pursuit became detrimental to the patient’s best interest. There were so many other ways I could impact a patient’s overall health that I simply sacrificed in place of speed.
I only got them to survive without pushing them to thrive.
I see a lot of individuals proudly proclaim how many visits it takes for them to get someone out of pain, but pain relief is only part of the equation. There are so many more qualities we can address before we consider a rehab program a success.
This stark realization has reconceptualized how I structure a weekly rehab program. I now emphasize all qualities necessary to return to whatever task the patient desires, and attempt to inspire them beyond those initial goals.
You want to know what my visit average is right now?
I stopped counting, and started treating.
Let’s look designing the rehab week to take your clients to the next level.
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.
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.
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.
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.
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.
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.
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.
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.
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.