Long Term Results from Patient treatment

I always say that the hardest aspect of therapy is achieving carry over in our patients.

The challenge as see it are the following:

1. We have been taught to evaluate and treat a diagnosis and not patient functioning.
2. Virtually any person off of the street is going to present with many areas of hypertonic tissue, restrictions, decreased range of motion and neuromuscular dysfunction. We have not been how to know which of these factors are in fact causing a particular person's problem.
3. We are taught to look at the body part as isolated structures when in fact the dysfunction is not anatomically close to it.

Great results are achieved knowing exactly what is causing your patient's limitation.

Our classes are designed to teach you how to it. Here is the proof.

A few weeks ago, Targeted Evaluation and Treatment of the Pelvis, Pelvic Floor and Coccyx was hosted in NYC.

This class format involves the students evaluating and treating real patients during the final hour.

I had the opportunity to follow up with our patients 2 weeks later and here is what I learned:

100% of them reported that they continue to experience the benefits from their treatment.

72% of our patients have not required additional therapy after their visit. Of the other 28% one patient continues to receive therapy but on a different body part.

Some of the patient's reports include:

1. The ability to ascend and descend step over step rather than using only 1 foot.
2. They are without buttock and back pain.
3. Improved walking distance by double.
4. D/C of pain meds.
5. Decreased need to get up at night to urinate and improved flow of urine.

As an educator it is thrilling for me to see my student's achieve such great results!

If you are not getting carry over or great results in your patients you are probably treating the wrong thing.

Help Save Our Profession

I recently met an entrepreneur who told me that he had just purchased a PT practice. 

Sadly, my advice to him was not to have a well trained staff, but a good billing agency.

Our conversation continued about the reimbursement changes to insurance and Medicare, prospective payment in some states, and penalty for billing multiple codes.

If you are fed up and saddened by the current state of our profession, here a quick way to help to change it in less than 3 minutes. (it took me 2 minutes 37 seconds)

You and your; patients, family and friends can write your Senators and State Representative regarding the Medicare cap using the APTA legislative action portion of their web site. 

Below is the link for APTA members:

https://www.apta.org/aptalogin.aspx?redirectto=http://www.apta.org/apta/advocacy/lac.aspx?navID=10737423155

Non members of APTA and people from the community can the link to this address and advocate. 

http://capwiz.com/amerpta/issues/alert/?alertid=62327476

Our future as well as the future of every American citizen is impacted by this legislature. 

Please put these links on your facebook page and send out emails to everyone you know. 

Why treat the coccyx?

1. The coccyx serves a vital role as an attachment site for a number of muscles, tendons and ligaments of the spine and pelvic area, including the pelvic floor.
2. It is part of several spinal nerve conduction pathways.
3. It is the base of support of the urogenital system, reproductive system, digestive system.
4. It is the base of support and shares ligaments and muscular attachments with the sacrum, pelvis, spine and entire axilla skeleton. Think about a house built on a crooked foundation, if the coccyx is off everything structure above it will be off.
5. The dysfunction of this structure is pandemic.

What has been so fascinating to me is to witness after treating only the coccyx,  the changes in motion in areas that are not even close in proximity to it, such as the neck and shoulder.

Evaluation and treatment of this structure can be physically and emotionally sensitive to a patient therefore the therapist must be skilled and experienced in this technique.

In developing my On-Live seminar Targeted Evaluation and Treatment of the Pelvis, Pelvic Floor and Coccyx class, I have greater appreciation of this structure and even developed and new way to evaluate and treat it.

There are a only few spots left in our upcoming class in NYC. Click here for details.

Is hybrid learning the wave of the future?

In the latest PT in Motion (November 2013) there's an article about hybrid learning which is being taught at the DPT program of Nova Southeastern University in Tampa, Florida.

In their program hybrid learning consists of the students learning their lessons online for 3 weeks and coming into the University for 4 days of "face-to-face"hands-on learning per month.

The professor interviewed for the article confessed that she didn't agree with this type of model when they began implementing it four years ago. Now  she finds it a more beneficial way of implementing education to their students.

This model is very similar to the On-Live classes that I have developed for Signature Allied Strategies.

Part of this model is having patients with dysfunctions that are appropriate for the class come to the Live event and the participants will treat them.

At my last class, I was thrilled to see the results that my students were achieving in these patients. To me it is a direct testament that they have absorbed the material.

There is no greater satisfaction as a teacher to know that your students have learned.

Not only does the therapist have exposure to the material before and during the class but they are able to go back and review the online lessons after the live event is over for an additional 30 days.

The teacher is available throughout the entire process to answer questions.

Experience it Hybrid learning for yourself

Our next On-Live event is Saturday November 23rd at in NYC. Only a few slots left

Targeted evaluation and Treatment of the Pelvis, Pelvic Floor and Coccyx

I have also decided to provide FREE additional On-Live components to our  Live Seminar:
Balance and Fall Prevention Course in Teaneck Nov. 22& 24th

I truly believe that this is an amazing model and will be implemented by more companies and educational universities in the future.

If you are interested in hosting an On-Live event at your facility, contact us at sigproed@gmail.com. Please note that we are currently booked until Spring of 2014

90 year olds increased strength

After doing specific training for 12 weeks, people over the age of 90 improved their strength, power and muscle mass. This was reflected in an increase in their walking speed, a greater capacity to get out of their chairs, an improvement in their balance, a significant reduction in the incidence of falls and a significant improvement in muscle power and mass in the lower limbs. These are some of the outcomes of the study recently published in the Journal of the American Aging Association.

24 people between 91 and 96 participated in the research, eleven of them in the experimental group and 13 in the control group. Two days a week over a 12-week period they did multicomponent training: a program of various exercises designed specifically for them and which combined strength training and balance improving exercises. 

As Mikel Izquierdo explained, "the training raised their functional capacity, lowered the risk of falls, and improved muscle power. In addition to the significant increases in the physical capacity of frail elderly people, the study has shown that power training can be perfectly applied to the elderly with frailty."

I believe that what made this study unique and the results so promising is that the exercises were designed specifically for each individual.

What I practice and teach is to evaluate each individual not based upon their age or diagnosis but their functional and address each factor that is limiting them.

Should there be a Class Action Law Suit against Medicare?

This is an excerpt from a blog by Keddrick Stuart.

"I decided to try an experiment, recently.  I went to my neighborhood grocery store to buy the ingredients for French toast.  After the cashier rang up the eggs, I told him I’d only be paying 50% of the price of the bread and milk as part of my multiple product payment reduction plan. (MPPR)  I told him, I figured I covered most of the store’s utility costs in the eggs, and since I was combining up all my groceries in one trip, I shouldn’t have to pay over and over for his fixed costs."

Since its inception in April the average reimbursement by Medicare has decreased by 8%. 

Apparently more and more payers are getting on this bandwagon as according to the post, other non medicare providers have begun using the MPPR methodology.

As you know each CPT code is assigned as value, based upon:

• Work (skill and effort)
• Practice expense (equipment and facility costs directly related)
• Malpractice cost.
• Geography (location of the practice)

MPPR reasons that if you provide multiple services in one visit, the payer should not be required to pay the practice expense at full rate for every service in the visit, since the first service kind of covered their obligation. 

At what point do we as rehabilitation specialist need to say enough?

Is Vibration the Key to Balance?

Years ago, in Lancet (2003; 362: 1123–24) I remember reading about a study that was done where the researched put vibrators in peoples shoes and the participants improved their balance.

This study revealed that there was a reduction in seven of the eight sway parameters in young participants and all of the sway variables in elderly participants. Postural sway, has been determined to be the primary reason for falls in the elderly.

The mechanism as to why vibration may help with balance in the elderly is as follows:

• Vibration has documented circulatory effects, whereas applying a vibrating stimulus to a muscle belly has been shown to facilitate motor responses, even under pathological circumstances. This reflex muscle contraction is known as the tonic vibration reflex. 
• There are several ways vibration may potentiate muscular contraction. Together with enhancing the stretch reflex, vibration also stimulates somatosensory areas of the cortex, which can facilitate subsequent voluntary movement. 
• Increased muscle temperature, due to better perfusion and dampening of mechanical vibration, also may have a positive effect on force generation 

In my Balance Enhancement and Fall Prevention course I mention this research and suggest that appropriate patients purchase a vibrating pad, like the ones used on a car seat and rest their feet on the pad when they are sitting and performing exercises in standing.

There seems to be a resurgence in this idea as I was recently sent this link about a company producing vibrating shoes.

Want to improve Balance, Gait and Bunions?

One of the 3 primary senses involved in balance is proprioception. As people age, they lose proprioception, particularly in the most distal regions of their bodies, the hands and feet. Research has found that even if a proximal joint was replaced by surgery the proprioception in that joint was not as diminished as in the feet. Additionally it has be shown that individuals over the age of 80 are most affected by these deficits in distal proprioception.

In the foot, the primary location of propriception is located in the area around the hallux and therefore this location is a primary reason why individuals lack balance. Persons with hallux amputation experience a balance deficit of approximately 40%. Additionally, research has shown that the hallux is of particular importance to balance in forward and backward weight shift and walking.

When treating patients for proprioception we try to encourage the entire Hallux to be articulating with the floor in order to gain as much proprioceptive input as possible.

Elf Toe is a condition where the tip of the distal Hallux is curved up. It is caused by Hallux Ridigus which is a condition where the proximal phalux is hypomobile creating a hypermobility of the distal phalux and 1st Metetarsal phalangeal joint. This hypermobility can cause an arthritic bunion to form at the MTP joint. My 3 year old, started to develop such a bump. 

Because extension of the big toe is an important mechanism for the push-up phase of gate, with every step a patient with hallux ridigus is affected.

When treating this condition with the ARMS release technique, you would first stabilize the hypermobile distal phalanx, by doing this you will reveal the area of restriction of the proximal phalanx that is NOT in articulation with the floor. Then you will release the hypomobile proximal phalanx.

After treatment you would re-educate with functional exercise and/or taping. 

With this simple technique you will be treating not only balance, but bunion formation, as well as improving the quality and efficiency of gait.

The Science of Trips and Falls

The Wall Street Journal just published this article citing new research on how humans maintain their balance. 

What was of particular interest to me was that foot placement is the primary mechanism for maintaining side-to-side balance or sway.  Going along with that researchers found the biggest reason for falling, accounting for 41% of all falls, was due to incorrect weight shifting.

Clinically, I have found the same thing when I have evaluated and treated the foot and ankle;

• patient's improved their balance by at least 1 grade
• persons who could not perform single leg balance now could
• individuals who were chronic fallers, no longer fell

 In both the Foot and Ankle and Balance Enhancement and Fall Prevention Classes we evaluate and treat sway using a diagnostic motion evaluation called Foot Clocks. 

The article also mentions that the body has three main systems that help us stay balanced; The visual, proprioceptive and vestibular system.

The research has shown if at least two of these systems are impaired, people tend to have trouble with balance.  

As we know older individuals rely more on the visual system and report difficulty walking as well as experiencing a higher rate of falls at night secondary to the dark conditions. This problem is easily diagnosed and managed by prescribing glasses, surgery for cataracts, and improving home lighting. I believe that our health care system is doing an adequate job in addressing the visual component of balance.

Unfortunately,  the proprioceptive and vestibular systems are not routinely evaluated nor treated by health care professionals for the following reasons:

1. Little is know about these systems when compared to the visual system
2. They are expensive to diagnosis and manage
3. When we consider proprioception with regard to balance the most important structure is the foot. Health care professionals do not learn how to evaluate and treat the feet for balance and function 
4. Health care professionals rarely evaluate or treat the vestibular system unless there is a blatant dysfunction, like vertigo.  

The article mentions that improved diagnostic measures need to be incorporated by health care professionals to maintain the integrity of all 3 systems responsible for balance. 

To read the full article click the link below: 
http://online.wsj.com/article/SB10001424052702303983904579093560173066446.html?goback=%2Egde_2499430_member_276495644#%21

How the On-Live Seminar Works

For those of you who haven't heard of our amazing new method of presenting continuing education, here is how the On-Live Seminar Works. 

A student has access to all of the material online prior to the live portion of the course. We use interactive video presentation for our courses as well as downloadable pdf's. 

The student need not worry about getting a good seat or contorting themselves to see the material. Everyone has a front row seat!

The movies are shown at different angles so you are able to see everything that is going on during evaluation and treatment and if you don’t just hit rewind.

The student has access to the teacher via email to answer any questions along the way, 30 days prior and 30 days after the live class.

When the student arrives for the live portion already have a strong base of knowledge to help them. The live class is review and practice and best of all the students have access to the online material and teacher 30 days after the class.  

Having exposure to the participants prior to class allows the teacher to customize the class based upon their needs. 

Hosting facilities are provided the opportunity to bring in their appropriate patients to be treated by the therapists. 

This allows the students to apply the material on an appropriate patient population to see the techniques at work while having the supervision of the instructor when needed.

It is great PR for the hosting facility as their patients are getting an additional treatment from an expert in the field. 

Hosting facilities can choose to use the patient care component as an opportunity for additional revenue. 

I love teaching this way it is truly a win/win situation

Check out our Upcoming On-Live Classes

What the heck is an On-Live Seminar

I am really excited to share with you a new concept in continuing education that we have begun at Signature Allied Strategies, the On-Live seminar.

I love it for so many reasons:

• The system is cost and time effective. We are able to offer the same amount of CEU’s at 1/2 the cost. 

• Students and educators need only spend only a ¼ of the time away from family, work and friends without sacrificing CEU’s and getting burnt out from too much material in such a short time. 

• On-Live seminars offer individuals an opportunity to affordably maximize their learning experience. 

• Individuals learn at their own pace and they have at least triple exposure to the material.

• Students have access to the teacher for 2 months to answer any questions.

• Students have the opportunity to practice the material on true patients and hosting facilities can bring in their own patients for the Live component of the seminar.

The feedback from students and hosting facilities has been amazing!

Here is how it works:

A student has access to all of the material online prior to the live portion of the course.  We use interactive video presentation for our courses as well as downloadable pdf"s. The student need not worry about getting a good seat or contorting themselves   to see the material. Everyone has a front row seat. The movies are shown at different angles so you are able to see everything that is going on during evaluation and treatment and if you don’t just hit rewind.

The student has access to the teacher via email to answer any questions along the way. When the student arrives for the live portion already have a strong base of knowledge to help them.  Having exposure to the participants prior to class allows the teacher to customize the class based upon their needs. Hosting facilities are provided the opportunity to bring in their appropriate patients to be treated by the therapists.  This allows the therapist to apply the material on an appropriate patient population to see the techniques at work while having the supervision of the instructor when needed. It is great PR for the hosting facility as their patients are getting an additional treatment from an expert in the field. Hosting facilities can choose to use the patient care component as an opportunity for additional revenue. 

Lastly and really most important the material is kick ass. It is designed with the goal of making our students more success and efficient therapist. The evaluation is designed to teach students to target the areas that their patient’s need to have treated.

This system teaches evaluation and treatment as a well thought out process that elicits great results in a very short period of time.

I continue to firmly believe if you are not having great results with your patient’s you are probably treating the wrong thing.

I truly look forward to having the opportunity to work with each and every one of you!

  

If your facility is interested in hosting an On-Live event, please contact us to request information:

Our next On-Live event is in NYC October 26th

click here for details. 

People have asked "if you were given only one area of the body to treat, what would it be?"

Answers by renowned therapists, have included the psoas and coccyx.

For me it would be the feet.

A bonus for me in teaching my Balance Enhancement and Fall Prevention Class has been the knowledge and importance this anatomical structure is any standing individual.

• It is our Base of Support in standing and therefore an integral component of Balance and Fall Prevention. 

• In my clinical experience 95% of falls are contributed to from foot and ankle dysfunction.

• 84 % of 65 year olds have structural dysfunction in their feet.

• Individuals increase their chances of sustaining and injury due to a fall by 2 times if they are unable to perform 1 legged stance for 5 seconds.

• A person must have 8 degrees of ankle dorsiflexion with the knee extended and 10 degrees of motion with the flexed to be at a decreased risk for falls.

• The Hallux and toes must have 90 degrees of extension is necessary for normal push off.

• It is the foundation of our body. Misalignment at the foot will cause compensations and dysfunction up the kinetic chain.

• By improving alignment at the foot we can correct dysfunctions up the kinetic chain; knee, hip, pelvis, etc...

• Proper functioning of the foot is vital for efficient walking and any ADL's that is performed in standing. 

• Research shows that there is a significant decrease in proprioception of the feet after 80 years of age. 

• We can halt the progression of painful bunions, callouses and hammer toes as well as diminish the need for orthotics.

If you don't know about NPH, please read this

NPH stands for Normal Pressure Hydrocephalus.

Diagnosis of NPH is often difficult due to the symptoms being similar to other disorders.  In many cases the NPH is thought to be mild dementia, Alzheimer's, Parkinson's or simply old age therefore, it often goes completely unrecognized.

It is estimated that 400,000 persons in Nursing Homes have this disorder and are improperly diagnosed. 

NPH patients usually exhibit:

• Gait disturbance (difficulty walking)
• Dementia or forgetfulness
• Urinary incontinence (bladder control)

*Note that not all symptoms are always apparent or present at the same time.

Here is a link to a video of a person's gait with NPH.

NPH is treatable with the implant of a surgical shunt.  These patients do not improve with Physical Therapy intervention.  

In my over 15 years of practice, I can recall 3 patients who presented with these symptoms and were not diagnosed.  Two have passed and the other is my Grandfather.  Currently, I am in the process of learning more about this disease and getting him to the correct doctor. 

The following website has information and a link to doctor's who specialize in this area:

www.lifenph.com

Modifying Lunging exercises

Lunging is a functional exercise as it is a vital action for properly retrieving items off of the floor and for people themselves, being able to get up off of the floor after a fall.

I confess that I do not prescribe this exercise to patient's and I didn't know why until I visited a hotel gym the other day and was watching someone perform lunging exercises.

The way a traditional lunge is taught places excessive pressure on their lower back.

This occurs due to the relationship between the hips, pelvis, sacrum and lumbar spine.

When a human extends their hip past 30 degrees of extension, they should begin to have movement into extension at their lumbar spine. The majority of people, however begin to extend their lumbar spine well before (I have tested people who begin to extend their spines at as little as 2 degrees of hip extension).

A traditional lunge requires about 60 degrees of hip extension thus mandating the lumbar spine to move into extension.

The goal of patients with lower back pathology and those who are at risk for lower back pathology (everyone) is to stabilize their spine's and increase motion in the lower quadrant rather than feed into a pathological motion of premature extension of the lumbar spine.

In my experience Lumbar extension is the most common overused compensation for a lack of hip extension and pelvic motion in younger people.

I would suggest rather that keeping the shoulders back and trunk upright during a lunge, that a person hinge at their their hips forward at least 30 degrees and keep the spine in neutral alignment during both the forward and backward lunge. (As shown in the picture above)

Additionally I suggest that a person bring their opposite arm (with respect to the leg) forward and backward. (Not shown in the picture above)

Why Novak Djokovic is Falling All Over the Court

If you follow Men's tennis you are aware that Novak Djokovic falls more than any other player on tour.


At this year's Wimbledon he tried to overcome this by adding treads to the sides of his sneakers. As a result, the All England Club asked Djokovic to change his Adidas shoes after his quarterfinal win over Tomas Berdych because the nubs on his shoes gave him an unfair advantage. The Grand Slam Handbook states that grass court shoes “with pimples or studs around the outside of the toes shall not be permitted.”

From that point forward he was slipping and sliding and hitting the turf with more frequency than his previous matches and this may have cost him the title.

When you look at Djokovic's impressive record you will note that he has far greater success on hard court (4 Grand Slams) versus Grass or Clay (1 Grand Slam against an injured Rafa Nadal) where there is less traction. 

Falling occurs when a person's center of gravity (located at sacral level 2) moves beyond their base of support (the feet). This occurs in In Djokovic's case when his looses base of support a portion of his foot comes off of the ground. 

From what I could see in pictures, it looks like Djokovic's left foot is the one with greater dysfunction and will present with a premature loss in base of support.

To test this on Djokovic's foot I would perform an evaluation that I call foot clocks.

Foot Clocks can be tested in multiple directions, in Novak's case I would test the 6 o'clock motion as he often falls when he is in a anterior/posterior position of the feet. The 6 o'clock position tests plantar flexion in the closed chain. People who lack range in this direction will often fall when they slip.

Click the following link for a video demonstration of this evaluation showing dysfunction.

This is easily treated with mobilization once it is determined where in the range of motion base of support is lost. It would behoove Djokovic's team to evaluate and likely treat the mechanical dysfunctions of his foot so he won't have to compensate with illegal footwear and can spend more time hitting the ball and less time hitting the ground.

In any sport including tennis, a fraction more balance and speed on one movement could be enough to make the difference between victory and defeat.

If anyone out there has the opportunity to evaluate Mr. Djokovic, throw me an email and let me know if I was right, physicaltherapy@hotmail.com

Why I think Pilates is effective

I had mentioned in my last entry about my lower back patient finding benefit with Pilates exercise (please note that this patient was performing supervised exercise using Pilates equipment).

 As a result a question was raised:

"What is it about the Pilates method that makes it beneficial for some Orthopedic patients?"

My theory is that the springs and the command/manual contact provided by the instructor provide both traction and approximation. Traction and approximation are theorized to provide irradiation into the core.

Traction decreases pain and elicits proximal stability

Approximation increases muscle recruitment and proprioception into the joint.

Many of the Pilates exercise incorporate rotation, particularly of hips. When you look at the kinesiology of muscles that are know to be core muscles, their action is rotation.

Lastly Plilates classes are one hour in length and in my experience the number of patient's that spend a dedicated hour on stability exercises are few.

Similar to any other profession there are excellent instructors and not so excellent instructors, it is vital that any person particularly a patient find a qualified instructor.








I

Difference between Stability and Muscle Guarding

 

A colleague recently stated that when people are in pain there is muscle guarding and hypertonicity of muscles and would this not make a patient stable? I do not feel that this guarding stabilizes an individual's joint effectively as the muscles that are guarding are not the muscle that are designed for stabilization.

I believe that this guarding is a result of a compensation for a lack of stabilization.

It is from the principle of Stability/Mobility that I developed the ARMS (Active Release with Manual Stability) release technique. The success that I have achieved using this technique in my practice, reinforces my belief that hypertonic, guarding muscles are compensating for a lack of stability elsewhere.

I was trying to mobilize the connective tissue around a sacrum so that it could move in the direction of nutation. I had tried all of the techniques that I had learned for release without success.

The words of my Orthopedics teacher in PT school "you need to have stability in order to have mobility" entered in my mind. I then provided a prolonged hold type of stabilization to the patient's abdomen and the hypertonic tissue immediately released.

Yesterday I attended a private Pilates session with a patient who I referred there. He expressed that when he was performing a certain exercise, he felt that the spasms an tightness in his back release.

To answer my colleagues question, I think that a person with muscle guarding does not gain adequate stabilization from this guarding, and teaching them stabilization exercises and techniques may in fact help to decrease their painful muscle guarding.

Can your patient's feet even articulate with the floor?

Of course.

You don't often see anyone standing or walking with their foot off of the floor, but how many people can achieve this task without compensation?

The other day in clinic I decided to passively evaluate my patient's feet and ankles moving them into a neutral position to see if their foot could articulate with the floor without compensation.

None of my patient's, age range 18-84 could achieve this motion without mobilization.

Restoring it helped to elicit an improvement in posture as well as function.

Compensations up the kinetic chain for a lack of neutral dorsiflexion in standing include the following:

• Genu recurvatum
• Anterior innominate rotation
• Knee flexion in standing (think of your elderly patients)
• Elevation of the rib cage a sternum
• Forward head rounded shoulders posture
• Thoracic kyphosis
• Rotation of the tib/fib
• Rotation of the femur

To evaluate place the patient in prone or supine and passively move the toes, metatarsals (where most the structural restrictions are), mid tarsals and ankle joint to see if the patient can achieve a neutral position in all.

As you do this look up the kinetic chain as you do this to see if there is movement including, rotation of the lower leg or femur and/or hyperextension or flexion of the knee.

In my classes I always say that I could make the world a better place, physically if I could restore dorsiflexion in my patients.

 See what happens to yours when you take a close look.

Comment on: Improve your Posture Improve your Breath

One of my axioms of Rehab is Alignment Dictates Function. 

This statement is substantiated by the musculoskeletal  principle of the Length Tension Ratio which states that  a muscle will contract with greatest vigor when it is at a particular length. 

Ultimately, my goal in all of my patients is to restore proper alignment as best possible for that individual.

I believe the Alignment Dictates Function principle when dealing with the viscera. The human body is essentially made up of tubes and if there is a kink in the tube, just like a garden hose, things will not flow. 

Recently I read a post called Breathing Right Down to your Bones that illustrates the Alignment Dictates Function principle with breathing.
 http://www.huffingtonpost.com/carla-ardito/breathing-exercises_b_3269076.html

If you have a pulse oximeter available to you, put it on and test your O2 saturation assuming your patient's posture.

Notice some changes?

As therapists we cannot put more calcium in an osteoporotic bone, heal a broken bone,  or undo damaged lung tissue or change a person's age. Alignment/posture is one of the few things that we can change through the use of manual techniques, taping, bracing, and positioning in our patients.

Another one of the axioms that I ascribe to when it come to therapy is taken from the Serenity Prayer;

grant me the serenity 

to accept the things I cannot change; 

courage to change the things I can;

and wisdom to know the difference

The myth of Core Stability

My linkedin account is a buzz about a post written on the Evidence Based Practice Group stating that Core Muscle training shows little affect on lower back pain. 

The author of the comment references a paper called the myth of core stability: The Myth of Core Stability.www.cpdo.net/myth_of_core_stability.doc

There seems to be a lot of misconception by the author surrounding this topic

Myth #1: Core muscles are only found the in the abdomen: Core muscles are deep 1 joint muscles whose primary function is to stabilize a joint to allow its moving muscles to work.Think about the relationship between the supraspinatus and the shoulder. If the supraspinatusis torn the shoulder cannot flex, yet our kinesiology books do not list the supraspinatus as a flexor of the shoulder.  

Myth #2: The abdominal core consists only of the Transversus Abdominus (TA): The author references only the TA when refuting this topic. The abdominal core also consists of fibers of the multifidus, psoas, pelvic floor, obliques, and likely more to be discovered. 

Myth 3: Patients should go around bracing their core in a constant state of contraction. 

The core should function automatically prior to motion. The following is a true story and an example of how the Abdominal core is supposed to function. I was walking down Park Avenue with my rollerblades in one hand and a cup of coffee in another. There was construction being done on a building on the corner of 35th street. There was scaffolding and noise. At the very same time a younger male was walking toward Park Ave up 35th street and neither of us saw the other person coming. We collided and he went flying off of me, my coffee didn't even spill.

He turned to me and asked "Why did you push me?"

I replied: "How could I have pushed you?, my hands are full and I didn't even see you coming". 

I went on to explain that I was a PT and it was my abdominal core bracing that caused him to ricochet off of me. It was a great comeback as he had no reply and ended our confrontation.

The take home being that the Core should fire automatically in a person and if it is not firing it needs to be facilitated and trained to do so rather than consciously be taught. 

What do A-Rod and Lady Gaga Have in Common?

The Answer: They are both still recovering from labral tear surgery they underwent this past winter. 

The labrum is made of cartilage that lines the rim of the acetabulum of the ilium and provides shock absorption, stability, and nutrition to the joint, similar to the labrum of the shoulder. 

This injury is usually caused by abnormal and repeated internal rotation and or flexion of the hip and it is not coincidence that it has impacted hockey goalies Jean-Sebastien Giguere and Vesa Toskala. The tear can occur over time or by a sudden traumatic event. 

Other famous names who have suffered the same fate; Figure Skater Michelle Kwan and Golfer Gregg Norman. 

Why has this injury become so popular? It was often misdiagnosed as a groin pull and advances in MRI technology have helped to diagnose the problem. Symptoms include clicking and locking of the hip. 

It is not always a surgical problem and can be managed by Physical Therapy. 

How can PT help?

A therapist needs to asses the kinematics of the hip with its relationship to the innominate (1 side of the pelvis), sacrum and the spine will need to be addressed as well as the ability of force to be attenuated and dispersed by the lower extremities. 

Only 3 minutes of Exercise Need per Week?!

Really good news for those who don't have the time or desire to exercise!

Research in Exercise labs in the UK and North America have found that people only need 3 minutes of exercise per week to improve 2 important measures of health; the VO2 max and insulin sensitivity.

VO2 max is the maximum amount of oxygen that the body can use at the highest exertion of exercise. It is measured in milliliters of oxygen used in one minute per kilogram body weight and is considered to be the gold standard measurement for aerobic and cardiorespiratory fitness.

Insulin sensitivity is a test to determine how quickly the body can eliminate sugars from the blood. A decreased ability to eliminate sugars from the blood is caused insulin resistance and can lead to Type II diabetes.

The exercise is called High Intensity Training (HIT) it is broken down into 3 bouts of 20 seconds of max exercise with a period of rest in between,  and performed 3 times a week.  

Labs in the UK, US and Canada have shown that performing HIT has the same cardiovascular benefits as 3 hours of exercise per week.

Studies found that improvements in insulin sensitivity can be documented in as little as 2 weeks and improvements in VO2 max occurred in 6-8 weeks. 

The hypothesis is that maximum exercise for only 60 per session breaks down glycogen stores in the muscle and tricks muscle into thinking that it needs to get more glucose from blood. Additionally maximum exertion of exercise recruits 70 % of muscles versus moderate walking or jogging which recruits 20-30%. 

For obvious reasons a person should obtain clearance from their doctor before performing this type of exercise.   

This information was featured in a  fascinating documentary called "The truth about exercise with Michael Mosley",  clips of the show can be seen on http://www.bbc.co.uk/programmes/b01cywtq

The 86 year old gymnast

Johanna Quaas is an active gymnast from Germany who is amazing viewers on you tube with her strength and flexibility given that she is 86 years of age. 

She is what I consider to be one of the "elite elderly" who has manage to maintain her physical functioning rather than declining with age. Others members of this group include; Regis Philban (81), Clois Leachman (87), and Barbara Walters (83).  In the fitness industry we could consider the late Jack La Lanne who allegedly participated in his daily 2 hour work out the day before his death at age 96 and Joseph Pilates examples or elite elderly as well.

So is age really just a number? 

What makes the elite elderly different?

In researching their bios common characteristics include the following:

1. Proper nutrition and diet
2. Active lifestyle and exercise

In the case of Johanna her ability to maintain he level of gymnastic skill is is based upon a important principle that I believe to be true;

"If you don't move it, you lose it".

If you perform a task/functional activity consistently (at lease 1 time/week) throughout your life, you will never loose the ability to do it. 

One functional activity that older people lose is the ability to get up off of the floor from a position of supine and feel that it should be practiced at least 3 times a week by anyone over 50. Ideally one would alternate the leading leg when getting up. I like this skill as it involves many mini tasks that contribute to a person being able walk, balance and maintain independence. 

These tasks include:

1. Dorsiflexion of the ankle
2. Hip Extension
3. Quad/hamstring strength and control
4. Rolling/Abdominal Core activiation
5. Toe extension

I believe that if every person over the age of 50 did this one simple task every day, falling and consequences of falls would be diminished greatly.  

Becoming a member of the "Elite Elderly" is not easy but with some practice indeed possible. When one considers the alternative, it is definitely worth the effort. 

Alternative concept to improving Range of Motion

How often have we considered that our patient may be limited in their range of motion because they lack stability?

When I was in PT many years ago, I was taught that a person needs to have stability in order to have mobility. This is a well established rehabilitation concept and an often utilized principle with regard to positioning in the neurological patient population.

Stability within our system comes from our core muscles. They are the deep 1 joint muscles that are found in every joint and they must fire in order to allow our moving muscles to work. A good example of the this is the relationship of the rotator cuff  and shoulder flexion. If the rotator cuff is torn, the shoulder joint cannot flex.

If I had been given $100 every time that I gained range of motion with a patient only to find that it was lost on the next visit, I would be very wealthy.

The reason for this can be 2 fold:

• I didn't addressed or assessed the stability component of the joint that I was working on.  
• The patient became inflamed between visits and there was core muscle shut down. Remember for every cubic centimeter a muscle shuts down by 1 %. 

If you find yourself having difficulty gaining or maintaining range in your patient consider addressing the stability of that joint.

The Barrier to Good Posture

"STAND UP STRAIGHT"! 

If I had a dollar every time I heard that phase in a Rehab facility, I would be very wealthy. 

Don't you think our patients would like to have good posture if they could?

So why don't they?  

We are a manifestation of our compensations, meaning that when our body is not in alignment it will compensate to achieve function. 

I also believe that people become "Disabled" when their bodies run out of compensations. 

There are 2 main reflexes that dictate postural alignment in the human body. The body will contort itself by any means possible to achieve the following. 

1. Keeping the eyes on the horizon to facilitate the righting reflex and optimize vestibular function. A prime example of this is compensations due to a scoloitic curve. 

2. Weight bearing of the body over the hallux and medial foot. Examples of compensations include: rotation of the femur or tibia, medial shift of the talus, flat feet, genu recurvatum, genu valgum, anterior innominate rotation, and knee bending in standing. 

Diane Lee uses the term driver to describe the reason that there is a postural abnormality, the driving force behind the postural abnormality.

I feel the best way to determine is to place the bony structure in neutral and do the following: 

1. Observe compensations that occur as a result of this change. 
2. Ask our patients where they feel a resistance to allowing for movement to occur within the system. 
3. Feel through our tactile sense where there is a restriction to movement. 

I term this type of evaluation Diagnostic Static Evaluation. 

The ultimate way to achieve carryover and maximum functioning in your patient is to give your patient the best possible alignment in their system. 

The key to achieving this is to unlock the driver and treat the compensations. 

If you don't the patient will never physically be able to "STAND UP STRAIGHT"!