The Best Exercise?

I recently read an article online about the top exercises that you should do. I find it interesting to see what "experts" are saying about this topic even though, for one reason or another I often wind up disagreeing with what they recommend.

There are some exercises that I believe to be better than others particularly for various diagnosis, yet when we consider that individuals have; different skill levels, needs,  and most importantly bodies there is simply no "Best Exercise" for everybody.

There are some guidelines that can be given when recommending exercise to individuals

1. Do No Harm: Safety First. If the exercise is unsafe for an individual it should not be done. There are cases where a patient will want to continue with an exercise or activity that prevents their healing or because of their alignment is causing harm over time. In these cases, I usually explain why I think that the exercise should not be done and ask that they discontinue for a finite period of time to allow healing.

2. Compliance: This one of our greatest challenges with many of our patients. Unless it violates guideline 1, when I am asked  "What is the best Exercise?" my simplest answer is "The one that you are going to do". Ideally people will enjoy their exercise, realistically this is not always the case. Additionally, some people simply cannot devote an hour of their day that is dedicated only to exercise. I am one of them.  For me 20 minutes is very doable. I make up the rest of my exercise time with what I call purposeful exercise, meaning I will exercise to get somewhere that I need to go anyway rather than driving.  The exercise program in order to get done, needs to fit in with their schedule and be regarded as important enough to do.

3. Specificity of Training: This is an Exercise Principle that is violated over and over again. If you want to get better at do a particular skill or activity (ADL) you should do that skill or activity. If it violates principle 1,  then you should exercise the muscles that are involved in that skill, by mimicking the range of motion involved and the type of muscle contraction utilized to perform the activity.

5. Make Life your Exercise: One of my professors stated that "The human body is the only machine that gets better with work". I would modify that by saying "An aligned human body is the only machine that gets better with work". If the body is in its appropriate alignment every activity that one performs with good body mechanics in their daily life now becomes an exercise. Transfers and bending to pick something off of the floor are squats, reaching to retrieve an item from the refrigerator and vacuuming now become a modified lunge.

With so many choices when it comes to exercise, using the guideline above, there is simply no reason why an individual cannot discover their own "Best Exercise".

Simple Technique to Calming a child with autism

Treating children with autism is especially challenging. Getting a good subjective history from the patient is practically impossible therefore, Therapists must rely on observation and information from the parents and other caretakers.

I was at a social event with a family whose child is on the spectrum. She is high functioning and can become easily upset like most people with autism. On this occasion she became upset and went into the other room to calm down. This is not my area of expertise, but I had an idea on how to help her out and decided it was worth a try.

I also know that some people with Autistic Spectrum disorder feel comfortable with compression. I recall Temple Grandin's, squeeze machine that she constructed and used when she found herself becoming upset. For those of you not familiar with Temple, she is a writer, professor, expert in the cattle industry and also happens to have autism.  Although this child has tried weighted vests and blankets, they have done little to help. I am aware that her self soothing technique is climbing and were it an Olympic sport she would be a shoe in for the gold. (I actually witnessed her climb a door way once). Although compression to her trunk had been attempted, I know that compression to her wrists and hands had never been tried with  her before. My thought was to try to teach her position of manual stability on her wrist as climbing in particular requires significant stability at the wrist and hand.

I explained to her that I had a trick for feeling better that I wanted to teach her and asked if I could touch her wrist and show her. She allowed me to apply my force, which by design is gradual and non threatening and tried it herself. After a minute she was able to rejoin the party and did not have another episode of being upset for the rest of the evening.

Coincidence, I don't know. but worth further investigation for sure.

New Twist to a old exercise

In the past squats have gotten a bad rap. Some claim that is bad for the knees. Others state that it is too difficult for the older population. I say it is one of the most functional activities known to man. In cultures where people don't spend hours of their day in a desk or in front of a TV, squatting is their sitting. 

Before their were toilets there was squatting and current research is demonstrating that it is the most idea position to be in when you have to go. 

We are born with the ability to squat, look at any child play before the age of 4 or 5 and their mode to play on the floor or pick something up is squatting. 

Why do we stop squatting? We loose the ability simply because we do not continue to use it after the age of 4 or 5 when essentially we are put in chairs for at last 7 hours a day for the next 13 or more years. 

Most of the exercises that I prescribe and teach, including the squat incorporate core muscle contraction with movements that are functional to life and protective of our joints and other soft tissues.

Core muscles are located in every joint, not just the abs. They are small, 1 joint muscles, that are oriented in a diagonal fashion, sometimes they are a part of a larger muscle and example of this is the Vastus Medius Oblique which is a subsection of the Vastus Medius Muscle and it is a core muscle of the knee. The function of Core muscles is to provide stability to the joint and allow our moving muscles to work properly. Joint disease and degeneration is usually caused by core muscles not working properly and the inflammatory process causes core muscles to become dysfunctional. 

As I previously mentioned, all core muscles are oriented in a diagonal fashion and therefore their action is rotation. Many health and fitness professionals will falsely train these muscles by performing rotational exercises. This contradicts the fitness principle of specificity of training which states that in order to improve a muscle's function or a particular activity one should train by performing that muscle's function or activity.  The job of the core muscle however, is stability so these muscles are best trained to perform their job by using an isometric contraction with or without motion. 

Here is a link to view the exercise. I have combined it with a dynamic hamstring stretch during the 30 second rest period.  Depending on the patient,  I may skip the Dynamic Hamstring stretch and either rest or incorporate another exercise.  For myself, I do this exercise for a total of 5 minutes. I prescribe varying intervals of time for my patients depending on their fitness level and goals. With patients who I am concerned about losing their balance, I have them do this with a chair or ottoman both in front and behind them. 

http://www.youtube.com/watch?v=-QAgBJerfw0

Did I just kill my Grandma?

Did I just kill my Grandma?

It’s past midnight and I am anxiously awaiting word on my grandma’s condition. A call came to our house shortly after 11pm, when you are well past 40 years of age any call after 9pm is never good. My grandmother was complaining of high blood pressure, 200/90 and profuse sweating.  We all agreed that a trip to the ER was in order.

I am particularly concerned for several reasons: Obviously she is my grandmother; I love her very much, my grandmother is not a complainer, and lastly I treated her foot and calf this morning and my hypochondriac  tendencies are leading me to think that I may have dislodged a blood clot. I made sure that her ER docs were aware of this as a part of her subjective history.

During treatment she showed no sign of a Deep Vein Thrombosis, DVT nor does she have any of the risk factors predisposing her to developing one. Upon my research on the internet, I was informed me that 17% of people over the age of 80 who develop DVT’s do not show signs or symptoms of blood clots.

Symptoms of a DVT are:

• Swelling in one or both legs
• Pain or tenderness in one or both legs, which may occur only while standing or walking
• Warmth in the skin of the affected leg
• Red or discolored skin in the affected leg
• Visible surface veins
• Leg fatigue

Symptoms of embolus are:

• Sudden coughing, which may bring up blood
• Sharp chest pain
• Rapid breathing or shortness of breath
• Severe lightheadedness
• Also important to note that pulmonary embolism are often asymptomatic.

Thankfully all tests including CT scan were negative.  As a therapist who specializing in treating the foot it was important for me to learn of the asymptomatic incidence of DVT in seniors. Going forward I will let my senior patients know of this and be sure to monitor for any symptoms of an embolus.

On the positive side, my grandmother reported that her foot and knee felt great after her treatment and her balance and walking were improved.

Is my patient crazy? Negotiating Complications in patients

It has been a while since my last post. One of the reasons for this was that I was a victim of a Medical Error that became a Medical Complication.

I underwent an elective and routine oral surgery, wisdom teeth removal and 2 dental implants. Both procedures have a low risk of complication and most folks are back to their routine in a few days.  I expected to be one of them, I was not. 

As it turned out, I was one of the rare cases that developed an infection in my gums as a result of the bone graft necessary for the Oral Surgery. 

There were several distressing factors to my case:

• I was in pain and depended upon medication to manage it for 19 days and antibiotics for almost a month.
• I was angry at myself at choosing to have elective surgery knowing that there is always a chance of complications and not being properly prepared for this possibility.
• The amount of time and energy it took to resolve this problem was absurd. It took almost 1 month as I had to diagnose myself with the help of Google and advice from other healthcare professionals.  
• The most disturbing factor in my case was that my Oral Surgeon implied that I was crazy, instructed me to stop calling the office and suggested that I should go see an allergist.

I learned many things from this experience:

• I have a greater appreciation for what patients go through. I can now relate to feeling helpless when your body turns against you and you depend on medications just to get through the day.
• I also learned that pain meds mask the reason why you have pain and can make proper diagnosis difficult. When I went to my appointments I was on meds and didn’t feel that bad so my doctor did not get to witness me holding my jaw and wincing in pain praying that my meds took effect soon. Knowing what your medication does and discontinuing or change them can help to determine the cause of your problem. In my case my pain started 12 hours after I discontinued antibiotics. My pain decreased in half with antibiotics and anti-inflammatory meds. The pain was 85% resolved and I did not require pain meds when I was placed on the correct antibiotic.  The pain and need for antibiotic resolved completely after the abscess was drained and I finished my course of antibiotics. Therefore we deduced that I had an inflammatory problem that was caused by an infection.
• When speaking with an attorney who represents doctors in cases of malpractice, I was told that in his experience surgeons are reluctant to ever admit that something went wrong with their surgery.  Some may say that this is an ego thing and in some cases maybe it is. I think that if surgeons bring to their consciousness the amount of things that can and do wrong in a surgery, they may be unable to operate.
• In my career I have witnessed many patients who have been victims of complications and or medical errors and discarded by healthcare professionals. I believe there is frustration by doctor’s and others who are expected to know how to help these patients, and rather than admitting that they just don’t have an answer, they chose to dismiss the patient.

As a patient I would recommend the following:

• Do your research. Search the internet for “complications of ________” and/or search your symptoms. See what comes up, disregard that which does not make sense or does not apply.  Consider and share with your healthcare provider the possible reasons for your problem. If they rule out a possibility that seems plausible to you, ask them to explain why they are ruling it out and how they can be so certain. I would have had a quicker resolution to my problem had I done this. Unfortunately, I choose to accept my surgeon’s word that “there was no possible way that I had an infection “without question.
• Be honest with yourself.  Is there any way possible that your symptoms may be psychological in origin? I had to go through this process myself and list the reasons why my symptoms were not psychosomatic to justly discredit this possibility.
• WRITE YOUR CONCERNS/QUESTIONS DOWN ON PAPER AND MAKE SURE THEY GET ADDRESSED DURING YOUR VISIT.  I made this mistake as well. I had my list in my head and got distracted as I became upset by my doctor’s behavior.
• Find an ally. Get another opinion. I was referred by my surgeon to a dentist. Thankfully, this Dentist believed my story, and acted as a liaison between myself and the surgeon. Make sure that when you seek another professional ‘s opinion you are prepared for this visit by bringing all of your medical records and diagnostic tests. (PT’s and OT’s are often great allies).
• Communicate effectively to your health care provider by being concise and fact oriented. Give examples; in my case, I informed my surgeon that this was the sickest I have ever been in my life and the longest time I had been on antibiotics and pain meds. I added that when I gave birth to my daughter I did so without drugs and took a total of 3 Tylenol postpartum.  I don’t enjoy nor have the time in my life to be sick and that while he is the expert in dentistry, I am the expert of me and I believe that something is wrong.
• If you are having an elective or surgery do your research prior to your consultation, ask questions and make sure that you are prepared if circumstances do not turn out favorable.
• Understand that not having the answers and support from your healthcare professional in addition to feeling sick is DRAINING. Do only what you can and manage your energy.
• Get the word out to your doctors, friends and social media. It is an opportunity to get ideas from others as well as a venue to express yourself and share your story.

As a Professional I would recommend:

• Provide your patient with the before mentioned list of patient recommendations.
• Listen to the patient’s subjective history.  The answer or clues to why problem is occurring is usually there.
• If you are unable to help your patient for whatever reason, it is your obligation to tell them and refer them to someone who may help. This is scary territory.  As a highly trained professional you are sometimes expected to know everything. I have a former patient who praises me to this day for admitting that I was unable to help her and referring her to someone who knew how to perform a technique that at the time I was not trained to perform.
• Delicately discuss with your patient the possibility that their pain may be psychosomatic in nature and ask them to explain why they are sure it is not. If you are acting as a liaison with their doctor, you can share this information.  This is a very sensitive conversation, a suggested way to present it to your patient is the following; “you are experiencing some unusual symptoms and while they are real and legitimate, some people may feel that their origin is not physical, lets rule out not only the possible physical causes lets also rule out any possibility of an psychological cause”.  Ask them to list reasons way they are sure that their symptoms are physical in origin and ask them if they believe that there anything positive in going through what they are experiencing
• Ask advice from your colleagues. Use LinkedIn or other social media.  For those of you who have taken courses with the Institute of Physical Art, there is an IPA Google group where therapists share information and ask for ideas about challenging patients. You can request to join at ipa-functional-manual-therapy@googlegroups.com

The Mysterious Gait Deviation

Gait Deviations is one of the most perplexing ADL's to figure out. 

There are so many components that contribute to an efficient gait pattern, determining a patient's dysfunction can be extremely challenging when it come to treating walking problems.

Your patient will just not walk right. Or even better, they will walk perfectly out of your clinic after a session, and walk back in using their same old dysfunctional pattern.

I was dealing with this when I worked with my family member years ago. We were rehabbing at my home in spring time. After treatment, his home program would be to walk along the perimeter of the deck holding on the the railing with one hand and use the cane with the other.

He gait pattern was beautiful.

When he walked with the rolling walker on the sidewalk or 2 canes in the house, he reverted back to what I call his ugly gait:

• A small step length
• Narrow base of support
• Bent knee walking style.
• Slow deliberate cadence

What was going on?

He presented with what I call a Non Structural Dysfunction that was causing his Gait Deviation. What that means is that there wasn't a lack of range of motion due to an anatomical structure or tissue restriction that was physically blocking his range of motion that was causing the Ugly Gait.

It was something else.

Non-Structural Dysfunctions could be due to one of the following reasons:

• Inflammation
• Alignment
• Upper Motor Neuron or Lower Motor Neuron Disease or Injury
• Psychological Dysfunction including Fear
• Severe Atrophy

I noticed the same phenomenon in a toddlers gymnastics class the other day. A little one was walking the low  bean presenting with what I would consider to be a normal gait pattern. Yet when she went on the high beam, she presented with the Ugly Gait.

I realize now that my family members primary dysfunction was not a lack of range of motion, strength or even balance, it was a lack of confidence.

I was treating the wrong thing.

In addition to treating his physical symptoms, I should have also been doing things to boost his confidence and ease his fears. 

When the patient is a "train wreck" where do I start?

I was recently asked my advice on a complicated patient.

Although the patient was young in age and active, their past medical history read like Evil Knieval's (again I am dating myself). The therapist provided a through past medical history in about 3 pages of text.

Obviously both he and I understood that there were numerous areas with the potential for treatment, the question was where to start.

In spite of the therapist's complete description of the patient history, he forgot to include what I feel to be the most important component of the Subjective history. Questions that will be used to not only guide the evaluation, treatment, documentation and progress, but it will let the clinician know where to start, especially with complex patients.

It is: 

"What activities cause your pain and what activities do you have difficulty performing or can you not perform?" If my patient is being evaluated for balance and falling I then ask: "What were the circumstances of your falls or what activities cause you to feel off balance?"

This is usually is the first question that I ask when I meet my patient for multiple reasons:

1. I will now be able to provide functional goals for my documentation which are vital for insurance    reimbursement.

2. I can direct my evaluation to determine why a person is having pain or an inability to perform a task by; taking that activity,  breaking it down into its component parts, and evaluating each one. This will almost always show me the patient's dysfunction that is causing their functional problem or pain. As a result I now know where to start and what to treat. As a result, I can make significant gains in one visit.

3. While past medical history is important to avoid performing therapies that are contraindicated and understanding mechanism of injury, patients can spend their entire evaluation time telling you their life story. In today's healthcare setting we simply don't have the time and this information can be listed by the patient on their intake form.  I prefer to ask direct questions regarding these factors so I am in control of the conversation and can specifically ask the factors that are appropriate for their care right now.

4. While pain often inhibits ones ability to function, once the painful activity has been established, both the patient and I can determine their progress by the patient's ability to perform a certain activity rather than ask "how are you feeling?"

5. Their past medical history may not be a factor in their current functional deficit.

My greatest success using this process of evaluation was on a patient who had sustained multiple falls  resulting in fractured bones on 2 separate occasions. When I asked the circumstances of her falling, I had her safely repeat that motion. When she performed it, I observed that 1 of her feet was coming off of the ground prematurely.

Therefore, the reason that she was falling was that she was losing her base of support with only a slight weight shift.

I then determined why it was happening and treated her in one visit.

In the 3 years since that 1 evaluation and treatment she has not fallen.

It is interesting to note that this patient's fractures were on the opposite side of her dysfunctional foot and if I based my treatment on her past medical history, I would not have been treating the correct side of her body.

If you are not already asking these questions during your Initial Evaluation, give it a try, it is guaranteed to save you time and money while avoiding frustration and confusion.