Accelerated Rehab Part 1 -Seattle

Accelerated RehabMovement Assessment and Active Care Seminar with Jason Brown, DC

  • Rehab 2 Performance logo Skills Review

  • CERT Prep

  • Master the Fundamentals

  • Excel with Efficiency

Jason W. BrownHone your craft, improve your efficiency and clinical decision making, & prepare for the Clinical Rehabilitation Specialist Certification through the International Society of Clinical Rehab Specialists.

 

Date:
April 5-6, 2014

Time:runner-chiropractic
Saturday 9am-5pm
Sunday 9am-2pm

Location:
NW Sports Rehab
33400 13th Pl S
Federal Way, WA 98003

Questions: Contact me

Registration:
Early-bird discount through Friday 03/14.


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 What others have said about the course:

Thanks for a thought provoking weekend! – Jamie Robertson, PT

 

This course organized my thinking better than any other course I’ve attended.

 

I just wanted to personally thank you for your seminar.  It really gave me clarity on many of the rehabilitation principles, especially motor control using the planes. – Ian Ledger, DC

 

I would consider it one of the best courses I have attended to date. The application of everything that was gone over in the Accelerated Rehab course was straight forward and the workbook that accompanied the course has been a tool that I have not let leave my side as I work with patients and athletes in their training. – Erik Haroldson, DC

Part 1 Course Outline:

  • Functional model overview
  • Functional assessment:  Mag 7 and follow up assessments [train your eye and expand your toolbox]
  • Liebenson’s Clinical Audit Process  [CAP] (in detail with examples).  [How to use your assessment results to drive your exercise selection]
  • Discussion of how several models can fit together.  Combining the work of the Prague school (Janda & Lewit) & DNS, FMS & SFMA, McGill, Butler & Moseley to create synergy.  Find the strengths and limitations; harness the power and avoid the pitfalls. Including addition of current training theory and application for efficient, rapid results.
  • Sparing strategies & finding the functional range [avoid aggravation and encourage activity through the acute stages]
  • Mobilization (emphasis on thoracic, hip, ankle) [enhancing active ROM and proprioception through active mobility exercises]
  • Discussion of mobility and stability.  When to choose which tool.  Review of the CAP.
  • Core stabilization (creating an anchor, while maintaining mobility and the ball and socket joints).  Training the orchestra to play the right tune at the right time.  Then working to increase the volume and duration.  [create harmony of breathing and bracing, then add endurance and power.]
  • Motor control theory, motor learning, and cueing.  How to get your exercise selection to transfer into sport and ADLs. How to achieve retention so your progress lasts.

Part 2 then emphasizes extremity support and function.  Assessment and correction of the upper and lower quarters.

Jiri Cumpelik, PT

Prague RehabBringing the Prague School to you.

Prague School in Newark, NJ!

I had the pleasure of meeting PhDr Jiri Cumpelik during a recent trip to Prague. Jiri Cumpelik & Jason BrownHe was kind enough to allow me to visit him while he was treating performers at the National Theater in Prague.  While we were only able to spend a few hours together it became very clear to me that he has a deep appreciation for movement, body position, breathing, and training mindful movement and that I had a lot to learn.  I’ve remained in contact with Jiri and he’s graciously accepted an invitation to return to the U.S. to instruct.  While he continues to teach in Europe, Jiri has been absent from the US for some time.  Some may remember his last visit to the Rehab Institute of Chicago.  This is a course, I’m honored and excited to host.  Details are below for those who wish to join us.

Jiri Cumpelik with Prof. Frantisek Vele

Cumpelik Course details:

Date: April 12-13, 2014
Times: 9-5:30 Saturday. 9-2:30 Sunday.
Location: Newark, NJ @ the Marriott Newark Liberty International Airport. (Group hotel rate by clicking link.)

This location is at the Newark Airport and there is shuttle service for anyone flying in.

For those driving:
Newark Liberty International Airport Marriott
1 Hotel Road
Newark, New Jersey 07114 USA

Please com dressed to participate.

Jiří is the resident physiotherapist for the National Theatre Ballet. He also lectures to students of the Physiotherapy department of the 2nd Faculty of Medicine of the Charles University in Prague and students of the Physical Education and Sport Faculty of the Charles University in Prague, as well as other distinguished institutions throughout Europe.   Jiří’s unique approach combines Yoga with principles of kinesiology (body motion and correct posture).

PhDr. Jiří Čumpelík, PhD is part of the early Prague school learning from the greats of Lewit, Janda, and their contemporaries.  He frequently co-taught with Prof. Vele (seen above) and from his intimate early studies he possesses a deep understanding of the foundation concepts the Prague School of Rehab is known for.  He began studying Yoga in the 1970s in India where he gained an insight into the physiology of breathing and its influence on posture and inner stability. He further researched spinal and breathing exercises as preventive and therapeutic techniques for functional disorders. He is published in several texts including: Yoga-Based Training for Spinal Stability in Dr. Liebenson’s Rehabilitation of the Spine (2nd ed) and Clinical Rehabilitation, edited by Dr. Pavel Kolar.

 

“The goal of our yoga-based exercises is to repair the altered CNS postural and respiratory programs and to restore spinal stability.”

 

jiri-cumpelik-yoga-class-4

“In a functional and mobile spine, the physiological movement of the cervical spine starts from T4 and progresses upward, and the movements of the lumbar spine from T6 and go downward.”

jiri-cumpelik-yoga-class-1

“In chronic cases, local mobilization can relieve local problems temporarily, but resolution of the condition is only possible by repairing the faulty respiratory program controlled by the CNS.”

Course outline:

The relationship of breathing with posture stabilization

The concept is based on personal experiences, own research, child development and yoga

The course emphasis will be on the relationship between breathing, posture and its stabilization

  • Theory, evaluation, therapy, prevention exercises
  • Pelvic floor, diaphragm and upper aperture of the thorax its interaction and correlation with breathing and postural function
  • Stereognosis function and posture
  • Importance of starting position for effective exercise
  • Positioning of the foot and its influence on the breathing and posture (effective treatment of the flat foot)
  • Evaluation of walking movement and treatment

Practical

  • Spinal exercises
  • Breathing
  • Perception of the body and mind
  • Stability of posture

Preparatory sequence of spinal exercise

Concept of breathing

  •  The breathing movement is continual process and therefore if we have right concept about the natural form of breathing movement we can come to conclusion if  posture is stable or needs to be changed. Practical demonstration for diagnosis.

Concept of posture

  • Posture is any position which is holding the body against gravity. Hence posture must be stable otherwise certain parts of the body will be overstraining, which leads to pain and if not treated to structural changes. The longer we ignore the proper concept of the posture, the more difficulty we meet later on in the therapeutics.

Concept of perception

  • Before we are able to move our body we must have the inner picture about the movement. This inner picture is formed in the mind on the base of sensory information. We are getting information about the outside world as well the inner body to be able to control the movement. The mind is able to decide what kind of proprioception setup is good for our stable posture (motoric intelligence).  Perception of the body must be a part of the postural training.

Concept of posture stability

  • There is not general agreement about posture – different authors trying to define their own aspects of vision and there is not any reliable method to prove these individual concepts.
  • Up to now there does not exist a method, which can objectively measure the stability of the posture. Posturography, plantography methods are informing us about how the weight of the body is distributed on to the foot, but not how its influencing other parts of the body. We are trying to develop a photorespirography method, which will tell us much more about it.
  • Body stability is a concept, how all moving segments are aligned with the help of stabilization process initiated by intention to move. All these processes are part of the course training.

Therefore it is proposed to concentrate on the basic principle of child development and on biomechanical, neurophysiology aspects.

Stanford Cook McGill

Rehab 2 Performance logoI recently had the pleasure of writing a blog post for Rehab2Performance.com.

Two giants in the field, Gray Cook, PT and Stuart McGill, PhD, assembled to present their viewpoints on movement assessment, arranged and moderated by Craig Liebenson, DC.  Assessing Movement: A contrast in approaches & future directions was held at Stanford University and co-hosted by Stanford Sports Medicine and Rehab2Performance.  Such a prestigious location was fitting, and even led to Gray uncharacteristically appearing in a jacket (which didn’t last the whole day, and he quietly told me “jackets are for funerals and Stanford”).  For the nearly 350 professionals in attendance, it was nothing short of spectacular.  With representatives from Asia, Europe, and throughout North America ranging from students, to fitness professionals, performance coaches, and clinicians, there was a bit of perspective for everyone.

See the rest of the review on the Rehab2Performance Blog

Liebenson with Cook and McGill

Organized by Craig Liebenson, DC (left) a great conversation between Stuart McGill, PhD (center) and Gray Cook, PT (right) was held at Stanford University.

 

Therapeutic analogies

Analogies are a great tool to explain a difficult, complex, or unfamiliar topics.  Much of what we try to communicate to our patients took years of foundational education, scientific inquiry, and clinical training.  Somehow we’re supposed to relay all this information to a patient within a short visit, and we’re attempting to do so with varying levels of background knowledge.  In short, clinical communication is a challenge, and something I’m always trying to improve.  Quality communication improves efficiency and outcomes.  Poor communication creates confusion, nocebo effect, and fosters disability and dependency (see last paragraph, but read the whole post).

I will try to remember to share more of the analogies I use, in hopes others will post theirs as well.  All analogies inherently have flaws, but if we can communicate concepts quickly and efficiently our patients and athlete’s will benefit.

Today’s therapeutic analogy:

“Your leg is the scoreboard and your back is the crowd noise.  We need to stay focused on the score, as this is a game we can win.”

After this analogy, the patient’s facial expression revealed immediate comprehension and understanding.  The path to victory was clear.  Other times I’ve spent longer than I care to admit struggling to communicate this idea.

Trying to explain centralization phenomenon to a patient can be a challenge.  Particularly when local pain gets worse and tinging/numbness in the extremity improves (ex.  back pain intensifies, but leg numbness resolves).  Numerous times patients tell me they can live with the numbness they just need the pain to go away.  Our pain centric ideas often get this one backward.  The extremity symptoms need to be resolved — a concept well taught in MDT (McKenzie) training.

Focus on what is important.

Ignore the distractions.

Etch-a-Sketch Exam

When a patient arrives with a chief complaint, be it back pain, limited hip ROM, headache, sore neck, or tingling/numbness down one leg.  What do you choose to do for an evaluation? 

While there are certain standards of care clinicians must follow, various schools of thought place emphasis on different parts of the examination process.  (side note: non-clinicians should recognize these symptoms and make appropriate referral)

I was once taught that the patient history will reveal 85% of the diagnosis.

I have also heard that history is unnecessary, movement/functional assessment alone will show us where the truly problem lies.

Let’s compare:

Take a complete, thorough, and detailed history.

History taking = ???% of your diagnosis

  • When did it start?
  • How did it start (mechanism of injury)?
  • What makes it worse?  Better?
  • Have you had it before?
  • What does it feel like?
  • How is it impacting your work, sport/recreation, and daily life?
  • Constant or intermittent?
  • Other treatment?  Pictures/imaging?
  • Past medical history? Medications? Surgeries?  Family history?
  • What are your concerns about your condition?
  • & more based on the answers provided.

View a complete movement assessment.

Observing movement, posture, and exercise gives us all the information that the patient is unable to provide.

Respecting regional interdependence, understanding that patients lie or at least fail to tell us the whole truth (intentionally or unintentionally), and that movement is a window into the nervous system often revealing the true cause of the condition we could look at:

  • Breathing
  • Upright posture
  • Active ROM (passive ROM if appropriate)
  • Basic functional movements: Squat, lunge, gait or single leg stance
  • View sports positions or activities of daily living
  • Or follow a commercial assessment model (insert a high quality acronym here… SFMA, DNS…..)
  • Perform condition specific tests or follow up tests based on the results of the initial assessment….

I have seen both of these work.  At times  a high quality history reveals a very clear picture of what is wrong and what the likely treatment solution should be.  Other times, it doesn’t.  Often, a movement based assessment the dysfunction reveals itself clearly and the path to progress is ready to be followed, but not always.  However, both have challenges:

Histories are subjective.  They are subject to bias based on the patients ideas, beliefs, fears, internet-reading habits, recollection, and motivations.  Movement assessment is more revealing but also only gives a present snapshot, it does not tell you what else lurks in the past that need to be aware of.  Red flags, yellow flags, recent surgeries, and the possibility of gross instability are all very difficult to detect based on movement assessment, until it’s too late.


I’ve heard many answers and there are several competing thoughts.  Here’s my take.

Take a history.  Draw the clearest clinical picture you can.  Also take a moment and think about what you expect to see in the future (exam, treatment, exercise, prognosis).  The ability to identify red flags and determine if this is in your box, or should be referred out of your office is invaluable.  These issues are rare, but do happen.  Early identification of yellow flags, complicating factors and psychosocial overlays is also necessary to effective treatment strategy and determination of prognosis.  Further, in a wonderful TED talk Abraham Verghese describes that the art and ritual of the physical exam earns the doctor the right to advise the patient.  I believe that history taking does as well.  Once the patient feels they have been heard and are understood, the likelihood of engagement and compliance increases.

Then, wipe the slate clean.

Begin assessing the patient’s movements and function with a fresh eye.  Forget what you know you’ll find.  Forget what you expect to see.  See the patient as if it’s the first time you’ve met.  Paraphrased from a conversation with the manual medicine pioneer Dr. Karel Lewit, “You need to see what your eye sees and then work on explaining it.”  A radiology instructor of mine (the great chiropractic radiologist Dr. John Taylor), warned of ‘satisfaction of search’, once you find what you’re looking for, most people stop looking.  That’s when you miss something important.  An open mind and blank slate prevent  cognitive bias.

This fresh view approach takes time to master.  It is learning the short memory of great athletes. The tennis player who can forget losing the last point and refocus.  The golfer who shanked the last drive and needs to hit a narrow fairway.  A quarterback who has thrown a few picks and now needs to aim for a tight window.  Your clinical mind needs to master this same skill.

In clinical practice you will need both high quality history taking, and skilled interpretation of movement and functional assessment.  By doing both well and resetting your mind in between, you can compare the results.  I’ve found this to be very prognostic.  When my understanding of the history matches my fresh look at the movement assessment, it tends to be a straight forward case with a good prognosis.  When they fail to match cleanly, it tells me there are more layers to this case and the patient and I should be prepared for that.

  • See what your eye sees, then explain it.
  • Understand your patient (from their viewpoint and then from yours).
  • Compare the results; what does that tell you.
  • Then, decide on a plan of action.

With the holidays coming, it’s a great time to ask for an Etch-a-Sketch (or to watch Elf)

 

Premature Celebration

To err is human…

When I look back at my own education and experience I often learned the most from my failures, mistakes, and complete embarrassments.  These struggles drive future success.  In the interest of admitting my mistake and hopefully someone else learning from it… here is my latest folly.

Premature Celebration

Bolt celebrates before the line in the 100m finals in Bejing.

Sometimes you get away with celebrating before the finish line (as Usain Bolt did in the Olympic 100m finals), but on occasion it shows you to be a classic fool.

As an avid sports fan I’ve witnessed others suffer from premature celebration with both excitement and ridicule.  Yesterday it was my turn.

I vividly remember Steve Tasker, (perhaps the greatest special teams player of his era, and perhaps the most impactful non-kicker or returner special teams player ever) chase down Leon Lett at the goal line in Super Bowl XXVII.  As a Buffalo Bills fan, I recall the devastation of the fumble, followed by the elation and finger-pointing  as Leon Lett carelessly celebrated from the 10 yard line to the 1 yard line where he was caught from behind and stripped by Tasker.  Premature Celebration = Failure(There was also the Thanksgiving Day slide for Mr. Lett, but that’s another story)

Again 2008 premature celebration struck. The promising young Philadelphia Eagles star DeSean Jackson catches a deep ball, runs ahead of the defense towards the goal line, and releases the ball in celebration at the 1 yard line, failing to score.  A spectacular 61 yard touch down reception and 6 points, erased by hubris.  I remember shaking my head, chalking this up to a rookie mistake, and hoping for a better future for #10.

In both cases, the excitement of the moment, the palpable sense of accomplishment, and certainty of success clouded judgement and action… resulting in heartbreaking and public failure.  Premature celebration is hazardous to your outcomes.


Yesterday I found out that I was Leon & DeSean, only the camera wasn’t on.  Admitting our own failures is humbling, but it is also where the best learning comes from.

I had a patient/recreational athlete who initial reported with a right shoulder injury, post swimming that had persisted for 10 weeks.  This was a chronic, recurrent problem in a very active adult.  We set out to resolve this and modified but didn’t limit activity level and were successful.  As the shoulder resolved, the patient explained she’d had 8-10 years worth of daily back pain and wondered if that too could improve.  While taking a deeper look we uncovered layer upon layer of dysfunction, compensation, and guarding that had protected her and allowed her to continue life and training for years.  With some guidance, her diligence and determination chipped away at these layers (and her shoulder remained functional and pain free).  We rebuilt her ability to breathe from the ground up, we rebalanced her orchestra of core muscles, we improved freedom at the ball & socket joints, and we challenged these things in progressively higher positions, with endurance, load, and speed.  In the end we had a human who was pain and injury free,  who could feel movements, muscles, and body positions that were previously unknown to her.  She was to attempt self-care and had a discharge exam scheduled  month later where we would see how she was doing.  At that follow up it was clear we had someone who had been training for 4 weeks with no issues doing things that were previously painful and some that were unimaginable.  In short, we started with little, had come a long way, and felt like we were in the end zone; but we weren’t.  At her discharge exam we assessed her progress and then spoke about what came next.  Her movements looked coordinated and strong, functional assessment was relatively clean, and her endurance was beyond good.  There was excitement in the room, there was optimism in our tone and words, and there was a sense that the world could now be conquered.  We spoke about the future, new goals, and further achievements.  We were both proud of her journey.

It took me a day or two to reflect and realize that perhaps the emotion of accomplishment was driving us a bit too far.  I remember a feeling of concern as I reflected, “too much too soon” was my fear.  In my detailed assessment of physical measures (movement, muscle activation/tone, joint ROM, functional abilities, etc) I had failed to realize that this biomechanical model was insufficient.  I was dealing with a human; emotion, psychology, and other psychosocial factors play a role — and in this case an important role.  There are two types of patients; those who need prodding and motivation, and those who need restraint and guidelines.  My patient fell into the later category.  I knew this about her, but failed to address it at her discharge.  My excitement for her and pride in how far we’d come caused me to overlook discussion of graded exposure, pacing, and appropriate advances in training loads.  I sat thinking about this possibility but I didn’t act.

Then it hit me like a ton of bricks.  A week after discharge I was getting an urgent visit call from this patient.  We took the ball to the one yard line, but failed at the last moment.  Our beautiful play had turned into a tragic recurrence.  We will pick up the pieces and try to win the game (as they Eagles did after DeSean’s performance), but this bitter pill will serve as a reminder.  Knowing your patients, understanding their mindset, and preparing them for the future is just as important as assessing their function.