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.