Cumpelik

JiriCumpelik-rehabchiropractorGroupI had the pleasure of hosting Jiri Cumpelik, PT, PhD from Prague.  His physiotherapy and yoga background create a unique blend and a wonderful course.  We had a great group assembled and here are a few of the points and reminders I took away.  [Disclaimer: All brilliance is the result of Jiri’s skills and the history of the Prague school.  Any inaccuracies are my own.]

Breathing:

  • Breathing is often coached into the abdomen.  What is more ideal is to coach lower rib (lateral) expansion.  This leaves the abdomen as a fixed point.
  • Breathing is disrupted if the 3 points of contact for the foot are not kept.  Supportive shoes or orthotics can do this. You will find lateral breathing diminished.
  • When the diaphragm has sternal support breathing is anterior upper abdominal; with costal support it is anterior mid abdominal; with lumbar (TL junction) support it is lower abdominal.  Ideally it should be all 3 simultaneously and lateral expansion of the ribs should occur effortlessly.

Foot contact:

  • The foot is dependent on 3 points of support. This afferent information feeds the system.  Yes, this creates arches.  However, supporting the arch creates the illusion of proper positioning, but it does so without creating any of the necessary afferent info.
  • If you were repairing an archway or a bridge… would you support the arch or would you support the pillars?
  • Arch support or back support without improving afferentation is analogous to putting your team in the right positions, but with little or no communication from the sideline about what play or defense they should be running.  It looks good, but the tendency will be towards chaos and compensation rather than organized, efficient force.
  • Foot contact is often more toward the heels than it should be.  In standing and walking we need to encourage forefoot weight bearing without loading/overloading the toes.  The same is true in squat and dead-lift. The pressure through the heel should feel like it is going into the ground with a 45 degree angle posteriorly.

Posture:

  • Proper sitting doesn’t require a cushioned, supportive,  high back executive chair.  It requires quality input.  Likely a firmer chair.   Think of the piano player, someone who sits for peak performance.  They gracefully sit on an unsupported stool/bench.  With all the practice hours required, why don’t they sit on something more resembling a desk chair?  Do they know something most of us don’t?
  • “It is easier to move a chair than a sack of sand.”  – Reference to firm posture rather than slouched, jello-like, amoebic positioning of some people.  Having structure and support makes movement and control of the body more effortless.  Postural control creates efficiency.
  • Posture can be driven from the foot as described above, it can also be facilitated through the hand.  “Stretch the pinky” (elongate and radially deviate) is a way to get support from the upper extremity.  This can be acheiecd open chain and during gait on the reach forward as well as during true supporting functions.
  • Sitting posture should not be on the “sit bones” as so many conveniently describe.  Looking at the shape of the pelvis is sitting on the ischial tuberosity realistic?  Would you design a system to balance on a roughened, round object?  It was suggested that sitting on the ischiopubic ramus was more ideal.  With a slight anterior lean, this provides a ‘flat spot’ to balance on.  Try it. See what your body tells you.  (remember to use a firm chair)
  • Forward head carriage is understood to be compensatory.  The chin tuck can improve this.  It can also improve posterior breathing.  However, too much chin tuck can impair lateral breathing.  (We do not want to sacrifice lateral breathing for the appearance of good head position.  You can pack the neck too far.  I am playing with finding the right degree of chin tuck based on breathing patterns.  If lateral diminishes, you’ve gone too far.)
  • It must be practiced, “All the time”.  While we discuss sets and reps, one of the main take homes was that the small, but important changes we were making needed to be integrated into all activities.  They should become part of your life.  This was likely the hardest, but most rewarding part.  It requires a lifestyle change, not simply doing some correctives periodically as prescribed.
  • Posture is synergy (or as McGill describes “the orchestra”).  To get synergy back, play a few leading notes (movements or positions that can stimulate quality positions):  abduct the toes, elongate the pinky, open your mouth, “Kaa” (depress the hyoid), tongue position/movement, eye movement, feeling ground contact, …. & many more.  Once the musicians know what tune they’re supposed to be playing others come on line, listen to your body and recognize the changes.

Random:

  • Hand positions (even open chain) can drive breathing.  See mudras and experience it for yourself.  Some beautiful demos during a course break.
  • Children will be able to control their sphincter when they can stand on one leg.  [As this often happens around 3.5 years and we see children potty trained earlier than this, we question what happens?  While uncertain, hyperactive pelvic floor seems very possible to me.]

Final Thought:

Contemporary clinicians and trainers (and just about everyone who reads this blog) are aware that we think in terms of the CNS rather than specific muscles or joints.  We reference muscles or joints for the ease of communication, but we appreciate the fact that we are trying to create neurologic change and are evaluating neurologic dysfunctions in movement.  Here’s where I think many of us fall short.

I’ve seen the Gray Cook, PT quote, ““The brain does not think in terms of individual muscles it thinks in terms of movement”  referenced hundreds of times.  The problem I see is while we think we’re training the CNS, many take from this quote “movement not muscles”.  I think too many omit the word “thinks”.  (You’ll notice Gray put it in there.)  Doing correctives to improve movement isn’t enough (but it is a good start).  The brain is familiar with half kneeling, bear position, etc, ….   however it also doesn’t think in these terms.  The brain knows goals.  I want, I need.  As we use positions and movement to improve dysfunction we must engage the brain in thinking.  Run the mental program of reaching for a desired object, operate the software to open the mouth and eat a sandwich, and focus on ground contact & pushing away.  These external cues feed the CNS what it truly wants and knows.  (Ex.  grab the car keys, reach for the doorknob, give me a high-five.)  Give targets and goals during exercise.  They can be physical or based on mental imagery.  You’ll be surprised how much changes even with a different image of what we’re doing.   Follow the same principles of movement, but get the brain running the software it needs to.

Finally, a public thank you to Jiri Cumpelik for sharing his thoughts, ideas, and views.

Link of interest: A blog post from Geoff Girwitz who attended Jiri’s workshop in Newark.

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.

 

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)

 

Nocebo strikes again

Once again the nocebo has struck.  If I was a better web programmer, I would have some ominous and sinister background music playing as you read this.  Since I’m a novice, please play something fitting in your head as you read this.

nefariousninjaThe nocebo sneaks up on us like a nefarious ninja.  Quietly the words we hear sneak into our minds.  Scientific sounding, but often misguided labels infect our thoughts, become our fears, and disable us.  Most don’t see it coming and some don’t even know it happened, but before you know it… the damage has been done.

For those who have read this blog before you’ll recall that I have a fascination with the effects of the nocebo.  In short, the nocebo is a negative reaction to harmless stimulus, the opposite of the placebo.  Quite often in healthcare this is the idea that something is wrong.  The thought that we are broken/damaged/unstable/deranged/etc can be disabling.  Thoughts are a powerful thing and some of us are either naive to this fact or are exploiting it for personal gain.

As one of the main ethical obligations for health care providers is to ‘do no harm’ (Primum non nocere).  I will begin by stating I think planting a nocebo is harmful.   If we can agree that ideas and images can be infectious, (the current buzzword  for this is fittingly ‘viral’), then we should acknowledge that we need to carefully monitor how we communicate with our patients and athletes.

I tell this story today due to a recent case I had.  Generalities will be used to protect the innocent (& guilty) parties, but also to make the point that this could happen to just about anyone and all too often does.

Background:  A teenager reports with a chief complaint of unilateral low back pain (L2/3 level) focused an inch or so from mid-line of several weeks duration. No prior back injuries or episodes.  Back pain was of non-traumatic onset.    Intermittent symptoms are reported, but there is pain every day.  Onset is after prolonged activity, such as sitting and moreso with standing.  No extremity symptoms or nerve tension upon testing.  Full pain free ranges of motion at time of exam.

For those using your clinical acumen, you have a picture in your mind of the possibilities.  At first glance to me this appears to fall into the McKenzie classification of postural syndrome.  To put it in other terms, it’s clearly an accumulation of load or lack of endurance phenomenon.  The question is does this person have an underlying movement flaw, a lack of capacity/endurance, or just a bad habit?  What I suspected was an underlying movement/postural flaw that they couldn’t control that when repeated put straws on the camels back until it broke.  As I explained this to the patient, they looked at me as if I said something they couldn’t believe. At first, I wondered why…..

I was butting up against an existing diagnosis as they had seen another health care provider 2 days ago.

Previous diagnosis: scar tissue/adhesion of the disc based on physical exam and x-ray.  The nocebo had been planted (and was growing). If you can make sense of that diagnosis in this case, please explain it to me.  Perhaps I’ve missed something in the literature or in my clinical training.

I now understood why this was scheduled as an urgent visit and the patient thought we were going to be seeing each other frequently and for a long time.  With diligent self-management, I doubt either of these will turn out to be true.

Listen to Yoda.

As doctors, coaches, healthcare providers, or trainers we are seen as leaders to our patients, clients, and athletes.  We must respect this relationship.

Leaders can lead through love or fear.  Fear is a shortcut to loyalty and compliance, but it will always create a half-hearted bond and an oppressive relationship.  Leading from a place of trust, openness and passion requires more of us as healthcare providers, but it can also create loyalty and compliance.  Also when achieved it will foster positivity, drive, and a nurturing relationship where great things, perhaps beyond expectation can happen.  In both chronic pain patients and elite performers, I see this lead to great things.

“Men are driven by two two principal impulses, either by love or by fear.”
― Niccolò Machiavelli, The Discourses

 

“Since love and fear can hardly exist together, if we must choose between them, it is far safer to be feared than loved”
― Niccolò Machiavelli

Is Machiavelli correct?  Here he notes it’s safer to be feared.  He does not state that it is more productive, better in the long term, or the most ethical way, just that it is safer.

“It is best to be both feared and loved; however, if one cannot be both it is better to be feared than loved.”
― Niccolò Machiavelli, The Prince

Let’s just say, I disagree.  In the terms of healthcare providers, coaches, and fitness trainers the current state of affairs warrants us dropping the fear based, nocebo inducing model.  For an interesting discussion of this and to learn about motivation 2.0, see Drive by Daniel Pink.  The carrot and the stick have changed.

More about the nocebo…

Motivating through fear may work in the short term to get people to do something, but over the long run I believe personal pride is a much greater motivator.  It produces far better results that last for a much longer time.  -John Wooden

Stretching the marionette

Many of us, myself included, were raised in a sporting environment that emphasized stretching.  As a distance runner, I was routinely advised to stretch for 1/2 hour or more prior to running every day.  Unfortunately, many continue to repeat what they were taught and never question the status quo. There is a wealth of evidence that suggests static stretching can rob us of performance, although I do acknowledge some degree of tissue extensibility/mobility is necessary.

Liars! Changing the length of my strings makes things harder.

Those who treat runners know motor control (stability) is often an issue, particularly in the frontal and transverse planes.  Recently I saw the most under-controlled runner I’ve seen in a long time.  After an evaluation, corrective strategy, and conversation we reassessed and saw a nice improvement in symptoms and movement quality.  We discussed the future course of care and home exercise prescription and were about to part ways when…. the patient asked me what stretches he should add to the 2 exercises I just taught him.  Maybe I did the world’s worst job communicating what I thought the problem and potential solution were, but I suspect I was just up against an insurmountable preconceived notion.  Stretching is not a panacea solution.  It is also not a necessity for all activities, in particular running.  See NY Times Article: Reasons Not to Stretch.

There is also abundant evidence questioning the value and timing of static stretching.  A random selection, in no particular order:

I understand that handing out copies of the NY Times article or giving patients research citations, abstracts, or even full text articles isn’t a solution to the problem.  Further, in the current healthcare setting time and efficiency is often a key factor in clinical treatment.  So how do we effectively communicate this idea that stretching may impede performance as clearly and succinctly as possible?

Here’s one way I’ve had success.  I recommend you judge your successful communication by the change in facial expression (shocked), demeanor (surprised and curious), and the light bulb appearing above your patient/clients head.   

The way you move is coordinated in the subconscious portion of your brain.  This is done based on feedback regarding length and tension.  Changing your length and tension by stretching just before you run is like changing the length of the strings on a marionette just before the puppeteer takes the stage.  The performance will suffer.

I’m not sure why this analogy works better than all others I’ve tried, but it seems to.  Perhaps it’s the image of the clumsy puppeteer?  Maybe it’s the non-threatening nature of the analogy as it doesn’t directly compete with what so many ‘experts’ have told the athlete before?  Either way, it seems to be a way for people to grasp a complex concept that is often in opposition of their existing beliefs.

 

This conversation often continues into why they feel ‘tight’.  Here’s a nice recap of Professor Janda’s thoughts by Craig Liebenson, DC.

Addition by subtraction

I had a new patient enter the office recently who had been under the care of another chiropractor.  This was an interesting visit as often times when a patient comes from another health care provider there is a reason.  Perhaps they are in some way dissatisfied, not improving as fast as they would like, have a new condition, recently moved, etc.  This one was different.  The patient was thrilled with their current health care provider.  You may be thinking the same thing as I was, “why make a change when you’re extremely satisfied?”.  Here’s the answer I was given (paraphrased):  “I love my current doctor, but cannot drive all the way to see him more than 1x/week due to gas prices and time.  I’ve had these symptoms for 3 months, I lived with it for 8 weeks and then have been receiving treatment 1x/week for the past 4 weeks.  I am gradually getting better, but if I could be seen more often, I would get better faster.”   Sounds logical, if some is good, more must be better.

Patient history includes back pain and left sided leg symptoms (S1 sensory changes).   No signs of ominous pathology.
Prior treatment: weekly instrument assisted manipulative therapy with mild improvement each week.  Patient was also stretching at home.

So at this point the question is what to do.  First, I’ll say that  when I take over care for a patient who believes their current treatment regimen is working, I rarely change it initially unless I have significant concerns.  I instead work with it and make gradual changes in most cases.  I believe that what the patient thinks will make them better often does.  Their confidence in their treatment is an important part of the puzzle. (Is this approach right or wrong?  Feel free to weigh in.) 
Next issue is what to change in the treatment to make it more effective… the frequent debate is with whether to mobilize or stabilize first.  From Boyle’s Joint by Joint approach we have some general guidance as to what tends to need to be mobilized and what areas tend to need stability.  From FMS/SFMA (& others) we have the general concept that mobility is necessary before stability.  While I agree that mobility is often needed first, this is not a rule as much as it is a guideline.  Frequently, I’ve seen that providing stability where needed allows the nervous system to reduce the ‘tightness’ of other areas.  As stability is restored, the nervous system stops drawing upon ‘prime movers’ to act as stabilizers and mobility is restored.  To determine what type of treatment is most likely to benefit an individual patient, I follow this model, as outlined by Dr. Craig Liebenson.  Its brilliant simplicity is applying a McKenzie (MDT) concept to active care, including mobility & stability exercise.  While the mobility vs. stability debate will continue on, there is a more important first step that is at times overlooked. So let’s go back to this patient I saw and the case at hand.  I did provide instrument assisted manipulative therapy, similar to what the patient had previously received.  The patient was satisfied with this portion of care.  I also reviewed the patient’s current stretches.

After realizing that the patient was performing positions that involve common back injury mechanism (repeated or prolonged end-range loading, in this case lumbar flexion), I simply asked that she stop doing 2 of the 4 stretches the patient was doing on her own each day to try and remedy her condition.  (Picture on right was #1, a seated version with legs spread was #2.)

The outcome:  Patient returned 2 days later and was 50+% improved.  After 3 months of symptoms, I consider that a positive outcome.  Please realize, this is not a post about me, how good a job I did, or the quality of care I strive to provide.  It is also not a post to say, look at what someone  else was doing wrong.  (I hate these types of blog posts and FB posts.  We’re all on the same team.)  In fact, if you reread this you’ll see that I actually did very little.  I simply duplicated someone’s treatment.  The only thing that was changed is I followed the advice of one of the Prague school pioneers.Karel Lewit

“The first treatment is to teach the patient to avoid what harms him.”  Karel Lewit, MD

Patients who are not well informed as to what harms them are unlikely to respond favorably. Removing offending movements, positions, and activities is essential.  Sparing advice trumps mobility, stability, balance, etc.  (In reality it often includes bits and pieces of all of them.)  At times patients have a hard time understanding how important and powerful this part of treatment is.  I’ve heard and use the following story, “If you came here with thumb pain, I could treat your thumb any way imaginable, but if it hurt because you were hitting it over and over again with a hammer, wouldn’t you agree that teaching you to swing the hammer differently is most important?”  Change hammer & thumb to anything that resonates with the person in front of you and I think you’ll have a productive first interaction.

Don’t skip step 1:  “Teach the patient to avoid what harms.”  (Added note: Don’t let step 1, become ‘avoid activity’, be specific.)

Sparing strategies:

A) For repeated movements: ergonomic advice, teach/train better quality movement, and improve joint centration. 

B) For prolonged loads: microbreaks.  If you stand, sit. If you sit, stand.  Examples:  Brugger’s postural relief position.  McGill’s overhead reach.  McGill's overhead reach