Special Test Receiving Special Attention

The Functional Movement Screen (FMS) is typically used in athletic population as a pre-participation screening tool.

It is comprised of seven individual tests of functional movements that are rated from 0 – 3 by an examiner.

The score of 0 is given if pain occurs.
The score of 1 is given if the subject is not able to perform the movement.
The score of 2 is given if the subject is able to complete the movement but compensates in some way. 

The score of 3 is given if the subject performs the movement correctly.

The individual scores for each movement are combined into a final score out of 21 points, which is thought to predict injury risk.

Researchers working with the test have suggested that scores ≤ 14 points predict individuals who are at a greater risk of injury than those with a score that is > 14 points.

They have also found that:

1. Most untrained people are above the 14 point injury risk cut off in the functional movement screen. 
2. Exercise of any kind seems to improve the functional movement screen score regardless of the type of exercise. 
3. Higher body mass index scores correlate with lower functional movement screen scores. 

Special tests like the functional movement screen are important to document our progress and G-code reporting so we can be paid for our work.

Sadly, none of these tests reveal what we can do to get our patients better.

For a review of the literature surround this special test 

What is the relationship between instability and Flexibility (ROM)?

This question was asked by a student recently concerning a patient with Lumbar instability.

When considering range of motion issues with lumbar instability you need to ask,
What's causing instability to begin with?

Unless there was a direct trauma to a patient, like a brick falling directly onto their back, typically the answer is decreased range of motion.

Even if the patient had an injury where they bent forward to tie their shoe and herniated a disc, the likelihood is that the lumbar instability was there all along due to a lack of range of motion in the thoracic spine/rib cage and/or pelvis and hips.

The mechanism of tying a shoe was just the metaphorical straw that broke the camel's back.

When we have diminished range of motion we compensate in other areas that have a lot of range of motion.

When you think about the lumbar spine, it's surrounded by the rib cage and the thoracic spine above, both of which are very stable. Below we have the hip and the pelvis also two regions that are also known to be stable.

When you have decreased range of motion in these areas it only makes sense that the lumbar spine will compensate for the lack of range by moving excessively and becoming unstable.

The next component is that you need consider is that you need to have stability in order to have mobility.

When you have instability at a joint, particularly the lumbar spine it will affect all of the muscles that act in that particular area for two reasons.

When there's instability there's irritation and inflammation.

For every cubic centimeter of inflammation a muscle shuts down by 1%.

Therefore the muscles in that area will not be working optimally.

The second way that I look at instability with regard to muscular contraction is to think about a person trying to scale a building using a rope that is not tied to a fixed point on the roof of that building. This is what a muscle is doing when it is contracting against an unstable attachment point.

A person would not be able to climb that wall efficiently because the endpoint is not stable. Muscles work and contract in a similar fashion, if one of their endpoints is not stable they will also be inefficient in their ability to contract.

What I find with the majority of my patients is that it is likely that a lack of range of motion caused the instability to begin with and then the instability will negatively effect range of motion.

This is why people with instability become "stiff".

Therefore, in addition to treating the instability you also need to address the flexibility issues above and below that lumbar spine to prevent the instability from occurring again.

If you don't take away the cause you'll never take away the effect.

Bad news for most Manual Therapists

Is has been brought to my attention that several insurance companies are no longer reimbursing for manual therapy, code 97140. Additionally I was told by a colleague of mine that the evidence-based practice is supporting therapeutic exercise and guided imagery and not manual therapy.

This would be bad news for a Manual Therapist like myself, however, my manual therapy practice utilizes a technique called the ARMS release technique. ARMS stands for active release with manual stabilization.

It incorporates mobilization (97140) and stabilization (97112) with ANY of the following:

• Therapeutic exercise:  97110
• Therapeutic activities:  97530
• Gait training:               97116

It is your choice based upon the movement that you choose to combine with mobilization and stability.

As a result I'm able to bill any of these codes, depending on what is appropriate. More importantly I can justifiably, as well as ethically, not bill for mobilization.

Billing is not the only benefit of this technique. ARMS releases dysfunctional tissue in 5 to 10 seconds when performed properly.

The patient is an active participant in the release and they are in control and will not move in a manner to cause harm to themselves.

Since movement, gait or exercise is incorporated with mobilization and stability you are getting more bang for your treatment time.

When using this technique along with diagnostic motion evaluation and dynamic static evaluation, I'm able to restore function sometimes in as little as one visit.

See some of the before and after results from one visit using these 2 powerful techniques.

Yoga versus Pilates, which is safer?

For any exercise safety depends upon how the exercise is being taught as well as the technique performed by the participant.

I believe that inherently yoga has more risk for injury due to the following reason, when performing yoga you are asked to move your body without stabilization. Because of this your body will feed into it's compensations, the areas of the body that move too much.  To attain the range of motion needed for yoga these movements will increase instability in an already unstable area.

With Pilates you are instructed to brace various muscles and lengthen as you move. This provides protection to unstable joints. 

Lengthening (traction) as well as approximation (shortening) cause irradiation into the core muscles as does rotational movement. Rotational movement is incorporated into many of Pilates exercises. Additionally, Pilates equipment provides both approximation and traction.

I believe that the machines used in Pilates are more protective and beneficial than the Pilates mat work, especially for a novice. 

My feeling as a clinician is that people should choose to do the exercise that they enjoy. 

Here are several modifications that can be incorporated into yoga to make it safer and more beneficial.

1. When performing standing poses, push your feet into the floor and rotate them either out or in isometrically (without movement of the legs). Choose the direction that feels most comfortable
2. When performing poses where your hands are on the floor, keep shoulder blades down and rotate your hands either outward or inward isometrically (without movement of the arms). Choose the direction that feels most comfortable.
3. When you lift your arms keep your shoulder blades down as if to place your shoulder blades into your back pockets. 
4. Lengthen your body and limbs when moving through your poses. 
5. Maintain normal breathing. 
6. Move through your poses slowly and deliberately.

History of the ARMS Release Technique

During my career I trained extensively to become  a good manual therapist and was having success with most of my patients.  A downside to becoming more proficient in my palpation and technique was that I created immense pain with my releases. One patient, who requires no medication for his dental work or colonoscopy, suggested I work for the government in Guantanamo Bay.  It wasn’t until I failed to help 2 patients using the techniques that I had been taught by the that I made a breakthrough and created the ARMS Release Technique.  
The first case was on a patient's sacrum that would not nutate. I knew that I was on the correct structure using the correct hand placement, but it would not release in spite of using every release technique that I had been taught.

At that moment of frustration, I heard my Orthopedics professor from PT school saying “You need to have stability in order to have mobility”. In this case my goal was mobility; maybe this sacum would not move because it lacked stability.  I knew that all core muscle are diagonally oriented as are rotators so I provided a diagonal hand placement technique and combined it with traction to the abdominal wall.

The patient’s sacrum melted underneath my fingers.  It was now completely mobile and required no further mobilization.

The second patient had a navicular bone that would not budge.  Again I tried all the techniques that I had learned without a release.   I decided to try my stabilization to the talus.  Since this is such a small surface area, I choose to use 1 finger to apply my diagonal force.

Again the restriction melted underneath my fingers.

From these clinical experiences I hypothesize that some patient’s present with restrictions as a compensation for an instability elsewhere.

This is now my release treatment of choice as I have consistently found that I gain a release of any restricted tissue, without significant pain in less than 10 seconds using this technique.

As a bonus, I am also performing neuromuscular re-education, exercise and/or therapeutic activities, while releasing.

ARMS provide you with way more bang for your valuable time and effort.

When you are unable to help your patient

When this happens in my practice I become very  frustrated. 

First I try everything that I've been taught to do. Then I spend countless hours trying to figure out a treatment that I haven't been taught to do that may help. 

When I am out of ideas I do the following:

- I am honest with my patient 
- I apologize for not being able to resolve their problem 
- I refer them to someone who I think can 

Many years ago I had to have this conversation with a particular patient who I felt needed an internal coccyx mobilization.  At the time did not know how to perform one so I explained to the patient that I did not know how to perform a particular treatment that might be of benefit to her and provided her with the contact information a therapist who could help.  I explained that I felt that we had reached a plateau in our treatment and I didn't feel that I could progress her any further at this time. 

Years later I ran into her again and when she saw me she smiled and happily stated "You were the only one who ever admitted that they couldn't help me". In other words, she respected my honesty. 

Some good  things happened; 
I learned how to perform an internal coccyx mobilization and after I learned this technique, I gave her a call and explained that I had been taught some new things since we had last worked together and would she be willing to let me try to help her again.  

As a result she became one of  my best sources of patient referral.

Treating Function and NOT Range of Motion

This is blog that I wrote a while back. I wished that I had posted it last week as I had just been referred a challenging patient.

I have now wasted the better part of 3 visits trying to increase the Range of Motion of 1 joint rather than addressing function. 

I stress in my class to focus on what the patient cannot do functionally to guide your evaluation and treatment by asking “What activity or activities do you have difficulty performing”.

This strategy is beneficial for the following reasons:

1. We now have functional goals which are vital for insurance reimbursement

2. We now can break the activity down into its components and determine where the dysfunction is and what type of dysfunction exists.

3. As a result we will be able to provide the appropriate treatment to restore function.

I was recently given such a case study and asked to evaluate and treat the following functional limitations.

1. Patient is unable to negotiate stairs
2. Patient is unable to balance on one foot to don clothes

Significant patient history is the following:

1. Total toe replacement over 5 years ago on the R.
2. Trendelenberg gait on the right

When we observe this patient we notice the following:

1. Bilateral pronated feet
2. Right hallux extension, approximately 3 degrees in neutral
3. Diminished push off phase of gait.

My evaluation will be as follows: 

1. For negotiating stairs I will evaluate:

1. ROM of dorsiflexion with the knee bent in stepping (going up and going down)
2. Pelvic Depression with the leading leg on descending stairs
3. Hamstring Contraction

2. For Single leg Balance I will evaluate:

4. PROM of the hallux to neutral
5. AROM of the hallux in flexion
6. Observing where motion occurs (motion = instability) Single leg balance

I will practice what I preach next visit.