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.

A Therapist's analysis of Jean Claude Van Damme's split

 

Watch the video and follow along. JCVD's split is not so perfect.

Using the Principles of Diagnostic Motion Evaluation, Here are the dysfunctions that I found:

1. At the very beginning of the video you will notice that his Right foot is externally rotated. We do not  know if this is a Structural or a Non-structural Dysfunction.

 If you do not know the difference between a Structural and Non-Structural Dysfunction, click here.

2. When the trucks are moving you will notice non-sequential movement in his Left mid thigh and compensatory movement in his pelvis.

This is a Structural Dysfunction because the movement of the trucks is causing Passive Range of Motion.

The exact location of this Dysfunction is in middle of his left thigh.

The motion is in the Open Chain. Although his feet are on the ground the definition of an Open Chain motion is when the Distal Structures (his legs) move about a stationary Proximal structure. (his pelvis and trunk)

To treat JCVD, you would palpate along the middle Left thigh cumferetially for a restriction in the Connective Tissue and release it using a treatment for restrictive tissues; such as mobilization or massage.

Once treated Jean Claude would have his perfect split.

If this make no sense to you then please check out my video on Diagnostic Motion Evaluation. Using this technique literally changed my career.

Just yesterday I achieve 15 degrees of motion in a knee patient by mobilizing her ankle and lower leg.

Jean Claude Van Damme, not so perfect split

69 million viewers have watched Jean Claude Van Damme's split between 2 moving trucks on you tube. If you are not one of those, I have included it above, just click on the movie to see.

I did not read all 41 thousand you tube comments, but I am curious if any one else noticed the dysfunctional motion in JCVD's epic split?

Many of you logged on to the instructional video for Diagnostic Motion Evaluation, if you understand DME then you will see that Mr. Van Damme does in fact have a dysfunction.

Test your knowledge:

Is the dysfunction on his right or left leg? where does it occur and is it a structural or non structural dysfunction?

Let me know sigproed@gmail.com

Not sure?

Click here for a review of DME, it can change your career.

Just yesterday, in less than 1 minute I gained 20 degrees of hip extension in an elderly patient by mobilizing his lower posterior IT band.

Rafael Nadal's recent injury

I hate to be right when predicting a player's injury, especially a player that I like. From my analysis of this video, I predicted in my blog last week that Rafa Nadal would become injured.

When you evaluate using the principles of Diagnostic Motion Evaluation (DME) you understand at the point at which there is non fluid motion or when there is a compensation occurring, that is the location of a dysfunction.

In observing this video of Nadal's preparation for return of serve, you will see that when he shifts his body in the direction of his forehand, there is immediate compensation of movement at his Right pelvis/ hip and knee immediately followed by the movement the Right foot.

Using DME principles I hypothesize that his thoracic dysfunction contributed to his back injury in the Australian Open and is causing stress to his Right knee. Since the compensation in his pelvis/hip occurs immediately upon movement toward his Left side and movement begins at the Trunk,  the location of his first dysfunction is in his trunk. Because the compensation occurs at the Right pelvis/hip and the shared connective tissue attachment that is most proximal to this location is at the level of Rib 6 via the attachment of the iliocostalis lumborum provides further evidence that the first place to treat Nadal would be to identify the dysfunction located at the level of Rib 6.

If you would like to learn more about Diagnostic Motion Evaluation, click here

It is important to note that there also appears to be a number of subsequent dysfunctions down the kinetic chain.
                                                 

When you observe the still photos above you will see the difference in the position of Nadal's trunk with his forehand and backhand photos. Again his first compensation occurs at the mid thoracic spine at about the level of Rib 6, this is why his back appears unlevel.

When comparing the still photos above you should notice several other locations of dysfunction. In my classes I tell students that wrinkles in clothes are an indication of movement.Where the wrinkles stop are often areas of restriction or dysfunctional tissue.

In comparing the wrinkling of the clothes in the above photos and in the video,  when Nadal is moving toward his forearm there are  fewer wrinkles at; the level of his lower back and his Right pelvis and thigh. These dysfunctions may too have contributed to his back injury and should be addressed.

Lastly, in the video and the photo above you will notice premature and excessive Right femoral (thigh) internal rotation and in the forearm photo you can even see his part of his Right knee cap. (to compare femoral internal rotation you will compare the Right leg in the forearm picture with the Left leg in the backhand picture). This would not be a problem if Nadal's Right lower leg would move into internal rotation as well, but in the video you will notice that it does not and there is immediately compensation with his Right foot moving. Therefore there also seems to be a dysfunction at the level of the Right knee. This is why I feel that his Right knee will continue to be a problem for Nadal.

Over the weekend one of the commentators predicted that Rafael Nadal would beat the record for all time Grand Slams. Unless his team resolves these dysfunctions, I foresee continued health problems and a decline in his performance in the future.

I hope that I am wrong about this.

Rafa Nadal's knee a ticking time bomb for reinjury

I always get excited when I can tell where and why a person has pathology simply by observing them move.

I was given this camera angle from the  2013 US Open that showed the back of Rafa Nadal from the baseline.

I noticed on his preparation for return of serve, when he rotates his his right femur (thigh bone) internally (toward the middle), he gets premature and excessive motion at his right knee and needs to he compensate for this lack of motion by moving his right foot (see video above). If you look at the wrinkles in his shorts (a technique that I teach in my classes) you will notice that he has more wrinkles his left shorts leg than his right. Only when he compensates at his foot does he achieve the rotation in his femur that he needs. (you may need to view the video several time and utilize the pause button to see it).  

At that point I searched the Internet to confirm that Rafa's right knee was the one that had sustained injury.

I was correct that it is in fact Nadal's right knee that has been giving him problems over the years. The abnormal forces acting on his right knee, at least from watching this video,  have not been completely addressed by his rehabilitation team. 

When we lack of movement in a particular area we make it up elsewhere.

Can you guess where the lack of motion, aka. dysfunction is? shoot me an email to sigproed@gmail.com ( I will post the answer next time)

Unless and until this dysfunction is correctly identified and rectified,  it is just a matter of time before he sustains another injury to his right knee.

It doesn't seem to be affecting his play at this year's the Australian open. 

Let's see how he does in the finals.

Snow, Rain, Ice! Fall Prevention Advice

We are now firmly into the winter season and while many of us have a reprieve from the blistering cold we must be concerned about slipping on the ice and snow. 

Falling is a potentially fatal circumstance that claims the lives of over a half a million Americans each year. 

Slipping in particular carries with it the most consequence for fatal injury as people are more likely to hit their pelvis, spine or head.

Slips are caused when our base of support, our feet, move beyond our center of gravity (out from under us). 

To assess your risk from falling as a result of a slip try the following.

Pretend to stand on the face of a clock (12 o'clock is forward, 6 back, 3 to your right and 9 o'clock to your left).  With your feet parallel and shoulder width apart, pretend that the soles of your feet are cemented to the floor as you move your body and legs toward each of the clocks directions. You will realize that the direction that is most difficult to maintain your balance is the 6 o'clock this direction. This is the direction of movement that occurs with slipping.

I experienced this phenomenon twice recently during my vacation up north. One fall occurred on flat ground the other was down four concrete steps and happened in spite of my holding on to a handrail.

Given that my balance is pretty good, I became concerned for my patients and began to think what could be done to have prevent slips and what advice would I give for falling? 

I came up with the following: 

1. Bend your knees about 10 degrees: This lowers your center of gravity and increases your weight bearing over the front of your foot. This will do 2 things, it will counteract backward momentum and allow more weight over your toes allowing you to grip onto the floor. 
2. Flex your trunk forward. This will also counteract the momentum of a slip backward and will give you move time to react in the air to better position yourself for impact. 
3. Maintain contact with the ground continuously. ie. skate over a slippery surfaces.  You have much greater balance when 2 feet are on the floor versus one.  
4. Use devices that will assist with traction such as:  crampons, a walking stick or ski poles.  These will provide traction and additional bases of support on the icy or slippery snow 
5. When going up or down stairs face the railing with your body and place both hands on it.  Go up or down the stairs sideways. This is the 3 and 9 o'clock movements and you have greater balance with sway over the sides of your body versus the 6 o'clock direction. 

Falls do happen and if you should fall remember the following:

1. Don't panic: When you panic you tense your muscles which prevent them from absorbing shock. Think of the drunk driver who walks away from a devastating crash with barely a scratch.   
2. Try to land across a broad surface and multiple body parts. This will disburse the impact of the fall through your body rather than target it at one specific spot.
3. If you are falling backward try to rotate your pelvis to land in the middle of one butt cheek. It is usually the most padded area of a person's body. 

This is where I fell in both instances. My bruises were nasty but I would take it any day over a fractured coccyx or blow to my pelvis.