Tag Archive for: rehab

Treating Patients with Low Back Pain

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My thoughts on treating low back pain

As many of you may know, I have been practicing physical therapy since 2003. Throughout that time, the clear majority of my patients have had injuries to their extremities. Yet, I somehow was able to ‘avoid’ treating patients with low back pain (LBP). As has been with most of my career, I wanted to share my thoughts on treating low back pain and how I went from completely confused, to utterly intimidated and finally to embracing a common injury.

My early years of LBP rehab and confusion

When I first graduated from PT school, I worked in an outpatient sports medicine practice in North Carolina. I saw a little of everything. There, I was mentored by a very senior PT who specialized in low back pain.

She tried to introduce me to the rotated innominate (didn’t even know what that meant at the time) and how she could fix people with those issues. I looked at the charts of her patients and they had been coming for years.

To me, that seemed like they trusted her and she was helping them. Then I realized quickly that maybe there was more to the story. Maybe she was or wasn’t helping them, but I could never say anything. Something was working so this new grad just went with it.

She would spend hours of her time explaining the pelvis and how we could influence its position. My mind just couldn’t grasp the biomechanics. To this day, I think I’ve blocked out many of the concepts because they just didn’t make sense to me.

They even sent me to an Institute of Physical Art class out in western NC. Again, I couldn’t grasp it which is ironic because I’m very much a biomechanics type guy when it comes to the extremities.

The back was just a mystery to me!

Nothing against the IPA course, but it didn’t jive with me. I just couldn’t apply it to my patients when I didn’t understand it in the 1st place.

Going back to my rotated innominate… I just faked it that I could feel the sacral torsion or the elevated ASIS.

As a new grad, I didn’t want to seem like my palpation skills sucked so I went along with the process. I just never applied it to my patients. I just did exercise with them, because that’s all I knew.

The Evolution of my LBP Fear

When I moved to HealthSouth in Birmingham, AL we had a separate spine department that was run by 2 PT’s. You know what that meant, I didn’t treat any spine patients!! Not sure why they did that, but I wasn’t going to complain.

This trend continued on when HealthSouth had a little accounting issue and Champion Sports Medicine was founded in late 2004.

Again, no spine patients on my schedule for ~ 10 years. Rarely, a patient would be on my schedule for more than a visit or 2 before I’d move them to the “Spine PT.”

Spine Scaries

I just didn’t have an interest in the spine and from what I had seen and heard, I didn’t agree with many of the ‘theories’ out there. I watched other PT’s look for limitations in individual spinal segments from the cervical spine to the sacrum…and even the coccyx (mind blown!).

Any time someone tried to teach me their assessments, I could never feel what they were feeling. No one felt limited or rotated unless I pushed a little harder with one thumb, then all of them were ‘rotated.’ I’m right handed so everyone seemed left rotated because I could push harder into the patient’s anatomy with my right hand.

So again, my faith in spine rehab dwindled and I built my practice around sports medicine and post-op injuries. That’s my niche but I knew that when I moved to Boston to help open Champion PT and Performance that I would have to make my skills better.

My current Approach to low back rehab

My career has been about simplifying my approach to physical therapy. In my earlier days, people were trying to help me (definitely grateful) but conceptually I just couldn’t grasp it.

I knew that there were very small the joints in the spine, but I just couldn’t ‘feel’ the millimeter or 2 of motion that was present. My palpation skills were dismal, but it turns out we may not be able to palpate what we think we’re palpating. (research) (More research) (even more research)

With that, I needed a game plan for my big return to my hometown, Boston.

My Macro Views

In my head, I could conceptualize watching someone move and trying to figure out if a movement dysfunction was the culprit. More of a macro view of the person instead of a micro view, like looking at individual joint segments.

My macro approach often came back to a strength issue or a simple overuse issue that led to back pain. We often blow this off and don’t account for it in our education and treatment.

Don’t Overcomplicate it!

In PT, we try too hard to complicate things.

Let’s think about it, if someone has pushed their tissues beyond their physiological limits (whatever that means), then something has to give.

In my opinion, most people that I see have overuse injuries as a result of overactivity or inactivity. It’s that simple. They’ve either pushed their muscles/joints beyond their capacity and the body is giving a warning.

Or they just don’t do enough to maintain, and the body is pissed off.

Answer in the details

For example, I see many people with non-specific low back pain that are active. Either playing baseball or working out. But, when you dive a bit deeper into their lives, they may have just started a new program that had more volume (weight training volume, more swings of the bat, more deadlifts).

It’s often stories of their (in)activities that are directly contributing to their current state. Never mind if you dive even deeper, then they reveal a stressor in their lives that MAY also be adding to their pain.

I am certainly not a pain science expert, but I can add up 1+1 and realize that life stress + physical stress can play a HUGE role in someone’s experiences of pain.

How I treat Low back pain

So what I do is pretty simple.

I assure my patients with lots of education and encourage early motions. Like any other joint, our body needs to move. Our joints need to move.

The last thing I want to do is discourage someone from moving.

I need to create an environment that is relatively pain-free and creates confidence in their ability to move. Trust me, I’ve been there!

What helped me, you ask?

I had an acute low back spasm a few years ago that was awful!

Advil, foam rolling my low back (what seemed to be my quadratus lumborum), soft tissue work to my low back (again, maybe my QL) and general low back/hip muscles and exercises. No one told me that I had a rotated innominate or that I had too much motion at L5/S1.

I don’t even know what that means.

All I did was try to move each day with a little less pain. I did things like Cat-Cow and dead bugs. I also did clams and bridging. I stretched my hip flexors and tried to squat a bit. I just did anything to promote a safe and pain-free movement.

It built confidence and it built function.

Most people need that after they hurt their back. I know we’re always looking for the reason why the pain occurs. We try to blame the anatomy or the biomechanics because we’re ‘movement experts’.

Keep it Simple

But I say we need to take a step back and realize that it can be even simpler than that. If we sit 8 hours a day, then we’re stagnant and our tissue capacity dwindles. Imagine sitting all day then randomly try to go play 18 holes of golf!

The muscles, tendons, ligaments and anything else in that area are not conditioned for the 90+ strokes it will take to finish the frustrating round.

You wouldn’t try to run a 10K without training for it 1st. Your legs and the cardiovascular system just wouldn’t allow it.

It’s the same thing with the concept of sitting all day then trying to be active. It often won’t work. You need to train the tissue!

Final Thoughts on Low Back Pain

If anything comes out of this blog, I hope it takes some of the scary thoughts that are out there and simplifies them a bit. The human anatomy is so much more complicated than we think. We can’t just blame a rotated innominate or left rotated lumbar spine segment for the dysfunction.

All of the systems seem to play a role but as PT’s we think we can control a couple of them.

I say build tissue capacity by a general strength training program that builds confidence in the client. Let them leave feeling super positive about themselves and I guarantee that your outcomes will be so much better.

No worrying about fake palpation, popping backs and charts that are years deep of short term relief. Hope I didn’t offend anyone but sometimes the truth hurts and I want my readers to hear my simple perspectives.

Now get out there and embrace your next low back pain patient (but don’t worry about the cavitation!)

Why you need “Feel” as a Physical Therapist

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I haven’t written a post in a while but wanted get back into the swing of things. In this post, I wanted to talk about having ‘Feel’ as a PT.

When I say feel, I’m talking about being able to read people and adjust the situation based on their response to things. So, what does that mean? Not really sure… but wanted to give a few examples that I have heard recently that I think happen pretty commonly in our profession.

Exercise Progression (or lack of)

This one happens a bunch in our profession and I was guilty of this early on in my career. It’s much easier to have someone come in 2-3 times per week and give them the same exercises, right? But to do this for multiple weeks, if not months, is a travesty!

Listen, I don’t think we need to progress someone’s program every session. Adding a new exercise each visit can be a bit much. know we want to make people feel as if they are moving forward in their rehab but there are other ways we can progress people besides giving them 17 different exercises that keeps them in PT for 2+ hours.

Again, I was guilty!

There are so many variables that we can manipulate for each session, it’s silly! Think about each move that someone does and break it down.

Exercise Variables to Manipulate

We can play with:

  • Tempo
  • Single leg versus double leg
  • Reps/sets scheme
  • Upper body or lower body
  • Time under tension
  • External resistance (bands, chains)
  • Rest periods between exercises
  • Perceived RPE (stole that one from Kiefer!)
  • Volume

So as you can see, even if you don’t have heavy weights as we do here at Champion PT and Performance, then you can still get creative with progressions.

The training facility at Champion PT and Performance in Waltham, MA
The training facility at Champion PT and Performance in Waltham, MA

Personally, my clients have the same program for 4 weeks and then we write them a new program. That means that they can focus on the aforementioned variables as needed even though they are doing the same exercises for 4 weeks.

The client likes it because they get really good at that movement plus they can see their progression in their weights, which is a huge mental gain!

Besides the obvious weight progressions, there’s a ton that can be manipulated but I don’t see or hear it enough from the patients that come through here. I rarely hear a client tell me that their previous PT experiences involved any type of variable manipulation but maybe that’s why they find us in the 1st place. Who knows…

My advice, let the patient feel as if they are moving forward in their exercise prescription because they are a smarter consumer than you would think. As PT’s we must do better with this stuff and the above bullet points are a good starting point for you.

Running on Empty

On another note, I recently started treating someone for a knee injury she sustained while skiing. Fortunately, she didn’t require surgery but the fracture needed time to heal. I don’t want to reveal too many details of the case for privacy reasons but just know she could’ve easily done more damage to her knee from the mechanism of injury.

She was given a brace and a prescription for PT to begin immediately for ROM and strengthening. She was limited in weight bearing for a period of time (I don’t remember the exact amount) so she had those effects that she had to deal with too.

At the beginning of the 6th week after the injury, her doc said she was fine to begin running even though no new x-rays were done on her knee. Guess they were just going off of time and that she was a healthy female without any co-morbidities.

Back at PT, she was told to start a running program that she thought was a bit early but she was excited to progress to more aggressive exercises.

According to her, she had been doing straight leg raises, clams, bridging and other low-level exercises for the whole duration of the rehab…see above rant!

Upon beginning her running program, she felt immediate pain and had to stop. She said she felt bad because the PT was surprised that the pain was still present but she wanted to work through it a bit. Despite trying to push through it, she still felt pain and had to stop again. She felt a big sense of failure because the pain persisted and she just couldn’t get over this hump.

Think Mode

Let’s think about this scenario for a second. Six weeks after a joint fracture, little strength training after a decent period of immobilization and the patient was expected to run?

As it turns out, the patient was frustrated enough with the scenario that she sought a second opinion and found us. I’ll never put down another PT’s plan of care but it was obvious that the plan was rushed and the patient’s opinions and communications were not fully observed.

She was frustrated and felt defeated but why? Why would someone be expected to run 6 weeks after a fracture without loading the joint and going through a progressive program?

I’m not sure but I wanted to use this case as a teaching moment for other clinicians, especially the younger crowd that may struggle with rehab progressions.

Listen Up!

Listen to the client and have a good understanding of basic soft tissue healing. I told the client that she needed a good 6-8 weeks of strength training before even talking about running. She was relieved that I wanted to take it slow and we now have a very happy client who has completely bought into my system.

Again, listen to your clients. They’ll tell you what’s wrong with themselves if you listen closely!

My Dad’s Knee Replacement

Switching gears, my Dad has his knee replaced a few weeks ago. Despite having treated a gazillion knee patients in my career, my Dad has yet to step foot in our facility. I’ve given him advice from a distance and have tried to keep an eye on things as they came up.

I’m not a home health PT and respect their jobs. I was surprised that no one ever tried to bend his knee during the home visits he had for nearly 6 weeks. Fortunately, he had about 80-90 degrees of flexion but the home health PT kept telling him he didn’t need more than 90 degrees of motion.

You try to get up from a chair with only 90 degrees of knee flexion! I’ll bet it’s much more difficult than 110+ degrees of motion. For the record, I shoot for 120 degrees of knee flexion ROM for all.

After home health, my Dad started outpatient PT and he sounded confident and happy. Yet again, no one felt the need to bend his knee (he did get some patella mob’s) and just showed him basic exercises like straight leg raises and squats.

Obviously an important component to PT but I still think getting more ROM is critical. I’ve talked about how I like to bend the knee after surgery at my YouTube channel that you can access here. As you can see, I prefer the seated position at the edge of the table for its comfort and isolation of the knee joint without hip compensation.

However, no one is bending his knee and he was feeling stiff. He did get a new PT for one of his sessions and they did bend his knee but only 2 times…and each time they cranked on it to the point he had to tell them to stop because of the pain.

Not how I would’ve initiated ROM!

Bad Ass Arya wouldn’t have been so aggressive either!

He’s now 3 days after the PT session and frustrated. He told me he can’t do anything around the house anymore and has considered taking pain medication to help get over the hump. This is the ‘feel’ that I’m talking about.

Why on Earth would any PT think this technique would be beneficial? I’ve heard this way too often in the past and am frustrated by it.

If that were you 🤔

My advice…as always, put yourself in their position and consider the risk/reward. Is this the best we can do and will the patient absolutely benefit from this?

In my Dad’s situation(s) I say he has received mediocre care so far. Fortunately, I have guided his home program and have tried to keep him positive and realistic.

He’s frustrated and vows to never consider his other knee even if he can’t walk. I hope he changes his mind once he gets stronger and more functional.

My lesson in this post- listen to the client and do what’s in their best interest. Have some FEEL and progress people more appropriately.

We can do better!

The Week in Research Review, etc 11-26-18

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This week, I discussed the progression of someone after a knee surgery. I tried to highlight the key stages and some techniques that I like to use to advance the patient’s mobility and comfort. Take a look at The Week in Research Review, etc 11-26-18 and share with your friends. Hope it helps you improve your patient care tomorrow and beyond!

 

ACL Reconstruction in a Pediatric and Adolescent Population

1st Day of #PT after an ACL Surgery

Patella Mobilization after Knee Surgery

Knee Flexion PROM after Surgery- Seated or Supine?

Stretching the Quads after Knee Surgery

Assessing for a Cyclops Lesion after an ACL

Assessing for Fat Pad Irritation of the Knee

 

 

ACL Reconstruction in a Pediatric and Adolescent Population

17 Year Follow-up After Meniscal Repair With Concomitant ACL Reconstruction in a Pediatric and Adolescent Population. Tagliero et al AJSM 2018

Results: 28% failed meniscal repair and required repeat surgery at the time of final follow-up. They also showed that outcomes and failures rates were comparable across tear complexity.

Guess that means that no matter the tear type, there was no difference in outcomes or retear rates. Although the repair techniques are now outdated and no longer used.

Their study also showed a 30% failure rate for meniscal tear repaired in the medial compartment at index surgery and 7% in the lateral compartment.

Interesting long-term outcomes that may help to guide your rehab and client advancement (and prognosis). Keep these in mind when you treat a future adolescent or pediatric ACL patient.

 

 

💥1st Day of #PT after an ACL Surgery 💥

If you have never treated a post-op ACL, then this video should interest you!

This is what the knee looks like that 1st day after surgery and can often set the stage for what’s to come over the next 6-12 months.

Often, the patient is both very curious and ultra-grossed out by the 1st unveiling. It can be stressful for them to see their knee in this condition so you really have to confidently reassure them that it is very normal.

The blood-soaked gauze is mainly saline that was used to irrigate the knee during the reconstruction. Some still leaks out of the incisions the 1st few days and can often be confused with true blood.

Understand that this is quite normal and happens to most every ACL patient’s knee that I’ve seen…nothing to worry about!

From here, I’d work on patella mobility (see the post later today) and then work on flexion ROM at the end of the table.

Again, it’s very important to get the knee moving after surgery. This will help with pain, swelling and gain confidence that the rehab process is moving forward.

 

Patella Mobilization after Knee Surgery

Get the patella moving early with #patella mobilizations immediately after surgery. One major reason (amongst many others) why we need to get our clients into #PT early.

I am certainly a very loud advocate for early PT and getting the patella moving can help to prevent excessive scarring, which can affect ROM and quadriceps force output.

Glove up and get that patella moving in all directions… medial, lateral, superior, inferior!

 

 

🤔Knee Flexion PROM after Surgery- Seated or Supine? 🤔

I’ve treated many patients after an ACL I can honestly say that this may be a huge influence on the early ROM outcomes that you may see.

I’ve tried to bend the knee in both supine or seated, as the video shows, and there’s no doubt that most people tolerate the seated version so much better after a knee surgery. In particular, a big surgery like an ACL, TKA or MPFL reconstruction.

It just seems to be more comfortable and with less stress on the anterior knee because of the position of the tibia (at least I think so!).

My theory, it seems as if the supine position may cause a slight posterior sag which may cause more pain and guarding than when they’re seated at the edge of the table.

I use a similar concept later on in the rehab process when I’m initiating my prone quad stretching. You can see a definitive improvement when I wedge my hand in the popliteal fossa and create a slight anterior translation on the tibia.

Most people say that the anterior knee pain that they were feeling (and not a quad stretch) was replaced by a stretch feeling only and no more anterior knee pain.

Try it out with your ACL patients and see what position they like best…I’ll bet I can covert you over if you still bend your knee patients in supine!

 

💥Stretching the Quads after Knee Surgery 💥

Continuing my sequence of videos after a knee surgery, I discussed my technique for progressing knee flexion PROM once they hit 120 degrees or so of flexion.

At this point, they’ve probably maxed out how much ROM they can achieve at the edge of the table. They’re ready to get that end range of motion and even some quadriceps flexibility.

In prone, most people will often feel a pain or pressure in the front of their knee when you try to bend it.

To overcome this, I like to wedge my hand into the back of the knee and give an anteriorly directed force through the gastrocnemius (calf) soft tissue and into the tibia.

This seems to create just enough movement of the tibia on the femur to take the pressure off the front of the knee. This may redirect the forces more onto the quadriceps muscle.

You’ll need to play with the amount and direction of force but most often they’ll begin to feel a better quad stretch.

Try this technique out on your next knee surgery client and see if it helps them. I usually initiate this ~4 weeks after an ACL but timeframes will vary person to person.⠀

 

💥Assessing for a Cyclops Lesion after an ACL 💥

In this video snippet from my YouTube Channel, I discuss how to assess for a Cyclops lesion in a knee. In particular, after knee surgery.

A patient with a potential cyclops lesion, they often present with loss of normal knee extension compared to the other side. They’ll often have anterior knee pain and poor patella mobility. Sometimes a tight feeling in their hamstrings and calves, too.

No matter how they try to regain their extension ROM, the knee just never feels right. Often times, surgical intervention is needed to remove that scar tissue.

Immediate rehab should continue to work on knee extension ROM using low load long duration stretching and aggressive patella mob’s.

No one’s to blame if this occurs. We don’t know exactly why it occurs in some people but we believe a remnant of the ACL stump may be a source of the frustrating issue.

 

💥Assessing for Fat Pad Irritation of the Knee 💥

Anterior knee pain is very common in the outpatient #PhysicalTherapy setting.

One of my go-to tests to assess for fat pad irritation is simply trying to capture the fatty tissue in the anterior aspect of the knee joint during active and/or passive ROM.

In this snippet from my YouTube channel, you can see that I pinch the fat pads on either side of the patella tendon as @corrine_evelyn is actively extending her knee. I’ll also do it in a relaxed state to assess passive irritability.

I 1st learned this test from @wilk_kevin and it continues to be a mainstay in my knee examination algorithm.

As for a treatment, it usually comes down to a volume issue and/or strength issue or both.

I’ll usually have to address the volume of the activity by relatively easing off of the activity while simultaneously adding in exercises to address an underlying weakness.

Remember the Dye et al study in AJSM 1998 when he talked about the fat pads being super painful during his arthroscopic surgery without anesthesia. Makes sense why they can be so painful if the knee stresses fall upon this tissue.

We talk about this study, fat pad irritability and much much more in our online knee seminar course.

If you want to learn more about how I treat ACL’s or the knee in general, then you can check out our all online knee seminar at www.onlinekneeseminar.com and let me know what you think.

We cover the anatomy, rehab prescription, ACL, meniscal injuries knee replacements and patellofemoral issues. Furthermore, the course covers both the non-operative and post-operative treatment.t

This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.

The Week in Research Review, etc 11-19-18

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Great ‘Week in Research Review, etc 11-19-18’ that I hope you find helpful to your practice.

I’ve always touted the importance of the subjective portion of the exam so I wanted to share a slide from a recent talk I gave to a group in Canandaigua, NY. Obviously, the squat is a fundamental movement and I wanted to give some basic positions that I use to help assess. So excited that I’ve launched a brand new Medbridge course that helps the rehab specialist better eval and treat the baseball pitcher. On my YouTube channel, I discussed my thoughts on setting the scapula with various upper and lower body exercises. And finally, my co-worker Kiefer Lammi discusses the landmine with exercise.

 

Importance of the Subjective Exam

Assessing the Squat

My New Baseball Medbridge Course

Set the Scapula with Shoulder Exercises?

6 Ways to use the Landmine by @kieferlammi

 

💥Subjective the most important aspect of the Evaluation💥

This slide, taken from this past weekend’s course in Canandaigua, NY is always a favorite of mine.

I try to keep a slide like this in all of my lectures because I have found that this portion of the examination can give the rehab specialist a huge look into what is going on with the person in front of them.

Don’t get me wrong, I still consider the biomechanical aspect of what may be causing their symptoms.

It often comes down to a tissue capacity issue but it’s up to me to determine the appropriate course of treatment.

These questions will help build confidence in your client and guide the early stages of rehab.

Do you have any specific questions that you like to ask your clients during their 1st few sessions? Remember, these questions are just not for the evaluation. You should be asking these questions periodically to gauge progress and help guide the next phases of rehab, too!

 

🔅Assessing the Squat 🔅

Squatting is a fundamental movement that all of us have to do on a daily basis.

Utilizing several different positions can help the rehab specialist better assess the squat and develop a treatment plan that enables their client the ability to improve their squat pattern.

In the above videos, I have utilized 3 different squat patterns and will outline them by the degree of difficulty.

✅The Overhead Squat- by far the most challenging version which challenges the shoulders, thoracic spine, lumbar spine, pelvis, knee and ankles.

A movement limitation at any of these joints will most likely cause the squat pattern to break down. Using overhead resistance would further challenge the system and potentially cause the squat to further breakdown.

✅Arms Crossed Chest Squat- alters the challenge by taking most of the shoulder and thoracic spine out of the equation and isolates the motions to the lumbar spine, hips, knees and ankles.

I often use this position as my fundamental motion because most people don’t have to squat with any weights over their head. This position, in my opinion, should be the most informational and utilized.

✅Counter-weight Squat

This position changes the center of mass by moving some of the weight distribution more anteriorly (front) and making the squat motion slightly easier. I use this position as a regression, for some, which allows them to squat with less stress and potential difficulty.

There are many other variations to the squat that you can make but I wanted to highlight a few of the major changes that you cause successfully. Assessing the squat is essential and can give the rehab specialist a nice picture of the function of multiple joints during a common movement.

 

My BRAND NEW course on Medbridge’s platform

…that helps the sports and ortho rehab specialist (PT, OT, ATC) better understand the anatomy and biomechanics involved in the baseball pitching motion.

Advanced Rehab for the Baseball Pitcher to Improve ROM & Strength@medbridge_education

The goal of this course was to allow the clinician to be able to evaluate and treat the baseball pitcher using evidence-based guidelines that I use on a daily basis.

Numerous research studies discuss the adaptive changes that occur with the pitching motion followed by numerous videos to help guide the treatment process.

If you’re already a Medbridge subscriber, then you have immediate access today.

If you’re not a Medbridge member, then you can use my promo code “Lenny2018” to save up to 40% off a yearly membership.

This gets you unlimited CEU’s for 1 year and potential access to their online HEP and a lot more!

Students can also get 1 year of unlimited courses (no CEU’s) by using promo code LennySTUDENT2018 and pay only $100.

Check out my other shoulder courses as well by using the Medbridge platform…along with many other great speakers!

Hope you enjoy and good luck!

 

💥Should you Set the Scapula with your Shoulder Exercise?💥

In this video excerpt from my YouTube channel, I wanted to discuss my opinion on setting the scapula during common exercises.

I think there’s an obvious role for setting the scapula during a heavier lower body lift like a deadlift.

But for a classic upper body exercise like the Full Can (Scaption Raises) or prone T (horizontal abduction), prone Y (Prone full can), etc then I definitely want the scapula to freely move along the rib cage.

I did a quick literature search and didn’t see anything obvious that helped to guide my thoughts so most of this is anecdotal. Check out the video and comment below.

Do you coach your clients to set their scapulae before a rotator cuff workout? If so, why? If not, do you think we should reconsider?

 

6 WAYS TO USE THE LANDMINE!⁣

Great post from our own @kieferlammi at @championptp on various ways to use the landmine in your client’s workout routine.

If you don’t have one, then I’d highly recommend you try to obtain one because they are highly versatile and can be used in many stages of rehab. See Kiefer’s original post below 👏🏼

_____________

6 WAYS TO USE THE LANDMINE!⁣

The landmine attachment is a super versatile tool for loading that is traditionally known for being used for angled pressing variations. While that’s probably my most programmed use for it, it also provides benefit to a ton of other movements by placing the load and direction of force at a bit of an angle, which can help to promote a particular path of movement, like sitting back more in a squat or lunge. Here are 6 of my favorite ways to use the landmine:⁣

1️⃣1-Leg RDL⁣

2️⃣Split Stance Row⁣

3️⃣Reverse Lunge⁣

4️⃣Deadlift⁣

5️⃣Squat⁣

6️⃣Russian Twist⁣⠀

Save 25% off our OnLine Knee Seminar Course…all this week!

Expires Sunday, November 25th at midnight ET

If you want to learn more about how I treat ACL’s or the knee in general, then you can check out our all online knee seminar at www.onlinekneeseminar.com and let me know what you think.

We cover the anatomy, rehab prescription, ACL, meniscal injuries knee replacements and patellofemoral issues. Furthermore, the course covers both the non-operative and post-operative treatment.t

This is an awesome course if you’re interested in learning more about rehabilitating the knee joint. And if you’re a PT, there’s a good chance you can get CEU’s as well.

The Week in Research Review, etc 7-29-18

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Last week was the 1st of my research review that summarized my social media posts from the previous week. It seemed to be well received so I figured I’d continue it. My goal is to help summarize some of the research that I found interesting and package it nicely for my readers.

Each photo contains a link back to a social media feed where you can see the conversation that ensued and maybe chime in…or just be a passive reader and see where the conversation went. You never know where the conversation may go on social media…so be ready! haha!

Socioeconomic Factors for Sports Specialization and Injury in Youth Athletes Jayanthi et al Sports Health Journal 2018.

This study looked at the effect of socioeconomic status (SES) on rates of sports specialization and injury among youth athletes.

They looked at injured athletes between the ages of 7 to 18 years that were recruited from 2 hospital-based sports medicine clinics. They compared these with uninjured athletes presenting for sports physicals at primary care clinics between 2010 and 2013.

They concluded that:
✅High-SES athletes reported more serious overuse injuries than low-SES athletes
✅More hours/wk playing organized sports
✅Higher ratio of weekly hours in organized sports to free play
✅Greater participation in individual sports

I applaud the authors for attempting to bring this very difficult collection of data into a formal research paper. I will say some of the statistics and standard deviations may not make the conclusions as powerful.

I do think this is a good paper to help educate our athletes on injury rates, especially in those that specialize in 1 sport.

What do you think? Tag a friend that may benefit from this article!

From #Twitter’s @retlouping that perfectly sums up what I’ve observed recently on social media with many PT’s.

For some reason, pain science has overtaken most diagnosis and treatment conversations.

It’s as if you get bullied into talking pain science and ignoring our clinical judgment and diagnosis skills. I understand there’s a constant tug-of-war between the biomechanical PT’s and the pain science PTs.

But as usual, the answer usually lies somewhere in between and both groups are correct. The biomechanics of an injury are often important as well as the language we use to explain these tissue biomechanics.

To my fellow clinicians, especially the newer grads and #dptstudent, remember this little cartoon for every future encounter.

Yeah, speak to people in non-threatening tones (in my world it’s just being respectful) but trust me, they WANT to hear what could be going wrong or what may be causing their pain.

Don’t blow off their symptoms and don’t go into depth about pain science because they won’t understand.

Trust me, the clinicians that try to do that often end up losing their patients in the long run.

I hear these stories day after day of people coming to me because the last PT either only talks to them or made them ONLY do strength exercises and it didn’t help their pain.

The PT didn’t listen to them and was so blinded by their pain science background that they ignored the person sitting right in front of them. Remember, the person sitting there will tell you what is going on and what treatment will most help them feel/move better.

Influence of Body Position on Shoulder and Trunk Muscle Activation During Resisted Isometric Shoulder External Rotation Krause et al Sports Health 2018.

The purpose of this study was to examine ER torque and electromyographic (EMG) activation of shoulder and trunk muscles while performing resisted isometric shoulder ER in 3 positions:
✔️Standing
✔️Side-lying
✔️Side plank

Using surface EMG and a hand-held dynamometer, the researchers tried to determine EMG activity of the:
✔️infraspinatus
✔️Posterior Deltoids
✔️Mid traps
✔️Multifidi
✔️External/internal obliques (dominant side)
✔️External/internal obliques (non-dominant side)

EMG values for the infraspinatus were greatest in the side plank position. In general, EMG values for the trunk muscles were also greatest in the side plank position.

✅Their Conclusions: If the purpose of a rehabilitation program is to strengthen the rotator cuff, in particular, the infraspinatus, the side plank is preferred over standing or side lying. If the goal is to simultaneously strengthen both the rotator cuff and trunk muscles, the side plank position again is preferred.

Makes sense but good to see the research and have concrete evidence to back up what we think actually goes on.

Tag a friend who may be interested in this research paper!

Reliability of heel-height measurement for documenting knee extension deficits. Schlegel et al AJSM 2002

Prone heel-height difference of 1cm equates to 1.2 degree difference in knee extension ROM.

Do you use this method to assess knee ROM? I still measure knee extension ROM is supine but find this method helpful as well.

I know my friend and colleague @wilk_kevin has measured this way for many years. i originally saw his use this technique at @ChampionSportsM

I don’t want people to confuse this with prone hangs for knee extension ROM. I am not a fan of that method as I’ve stated in the past.

This is a method to assess knee extension differences, particularly after an ACL reconstruction. I have gone back to using this method for some people that have subtle ROM differences side-to-side.

The patella position (on the plinth or off) did not matter in the study and thigh girth did not appear to make a difference.

I would recommend stabilizing the pelvis to prevent excess ROM from occurring at that region and to better isolate the knee joint.

Have you tried this method? Tag a friend who may benefit from using this ROM method…thanks!

Evidence-Based Best-Practice Guidelines for Preventing #ACL Injuries in Young Female Athletes: A Systematic Review and Meta-analysis Petushek et al AJSM 2018.

Injury prevention neuromuscular training (NMT) programs reduce the risk for anterior cruciate ligament (ACL) injury.

Eighteen studies were included in the meta-analyses, with a total of 27,231 participants, 347 sustaining an ACL injury.

The overall mean training amount was 57 sessions totaling 18.17 hours (roughly 24 minutes per session, 2.5 times per week).

They concluded:

✔️Interventions targeting middle school or high school–aged athletes reduced injury risk to a greater degree than did interventions for college or professional-aged athletes.

✔️Continued exposure to neuromuscular training throughout the sport season seems to enhance prophylactic effects of NMT.

✔️NMT interventions were effective for female basketball, and handball athletes and interventions including various athletes were potentially effective (eg, soccer, basketball, and volleyball).

✔️ Interventions included some form of implementer training (eg, instructional workshop, video, or brochure) on proper program implementation.

✔️Programs including more landing stabilization and lower body strength exercises during each session were most effective.

🤔Programs including balance, core-strengthening, stretching, or agility exercises were no more effective than programs that did not incorporate these components.

✔️ Specifically, programs that included more landing stabilization exercises (eg, drop landings, jump/hop and holds), hamstring strength (eg, Nordic hamstring), lunges, and heel-calf raises reduced the risk for ACL injury to a greater degree than did programs without these exercises.

✅ Wow, lots of great information here. Please share this with a friend or colleague who may benefit from knowing this information.

Hope that helped to catch you up on my posts from this week.

Do you like these weekly updates? Let me know if I should continue…love your feedback!

Thanks for reading!

The one change I made that significantly improved my patient’s outcomes

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As a physical therapist, athletic trainer or any other rehabilitation specialist, we are always looking to improve our client’s outcomes. Without question, that is the single most important thing we can do to help others.

How do we do improve outcomes?

I can honestly say that you don’t always need to take every continuing education course under the sun and build all of your manual therapy skills in order to achieve better outcomes.

That’s not to say that it can’t help…but I’d say the one thing that helped improve my outcomes with my clients was a philosophical change I made with them and myself.

Too much of a softy

You see, I was too easy on them. I spent hours upon hours working with them in the clinic. I used all of my knowledge acquired from going to CEU courses, teaching me how to improve my manual therapy skills or how to assess their movement even better than I thought I was already doing.

All of this is great, I suppose, but only a very small fraction of what is truly needed to succeed as a PT (or any other clinician).

Empower the Client

To me, the greatest change that I made was to empower my clients (translation: hold them accountable!)

When I first started practicing PT in 2003, I would assign homework, so to speak, in the form of a home exercise program, like most of us do. The problem was, I didn’t always follow through in making sure the client was accountable.

I remember people telling me that they just didn’t have the time to do the work or forgot to do it. I tried to blame them and  wasn’t pro-active enough. In retrospect, I was always reacting to each situation instead of setting the tone for the treatment plan.

Philosophical Change

I had to change my philosophy, my delivery, my rapport and my interactions. It was me, not them. It’s this mindset that many need to utilize when they’re dealing with others, in general. If something doesn’t go as expected, one needs to look at their own actions and emotions and figure out how to make the situation better in the future.

It’s easy to blame others when things don’t go right.

In the PT-client relationship, you are dictating the situation therefore the outcomes will rely on your ability to take the lead. The client has no idea what to expect or what to do. Often times, they’ve never been to PT before or have never had to deal with an injury or surgery.

Understand the WHY

The PT needs to step up and ensure that the client fully understands the home program and WHY the program will help them in their recovery.  It’s easy to slip a pre-made sheet of exercises at someone and tell them to do it daily (which I very rarely tell people to do anyway) or to do them every other day (yeah, that’s more my style!)

The key is for the client to feel excited by their new home program because it will be the key to their success, the key to their recovery and the key to returning to whatever they’re looking to do. I somehow missed that point when I was first practicing as a PT.

My key, now, is to connect with the client as quickly as possible so they have the utmost trust in all I say and do. They trust that I’m not going to waste their time and efforts. They fully understand the exercise, why it will help them and a potential mechanism of why it is the best for them right now.

I’m not afraid to tell them “I don’t know” but I will tell them that a particular movement or exercise has helped others in the past and believe the same is true for them too. Take each experience and interaction and file it away…you’ll need it for the future.

Take it to the house

So, if you’re looking to improve your outcomes, make sure the client is held accountable and they fully buy in to your plan. That edge will be the game changer in your practice, trust me!