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The Funny Things Our Patients Say

Today’s guest post comes from frequent contributor Trevor Winnegge.  Trevor shares a great, and fun, article on some of the funny things our patients and clients say!  I thought it would be good to mix it up and have a fun article on here!  Even better, I threw in a funny pic of a dog that looks like it is laughing, what a week (photo credit)!  More importantly, Trevor just starts the discussion, please comment and share some of your “Funny Things Our Patients Say” too!

 

The Funny Things Our Patients Say

Funny Things Our Patients SayAs I Listened to my partial medial menisectomy patient describe his injury to another patient, I had to chuckle to myself. “I blew out my knee. The doctor had to do a complete reconstruction of my meniscus and cartilage.”  It was this statement that lead me to think of the funny things we, as physical therapists, hear on a day to day basis. And it inspired me to write this guest post today.

 

Rotor Cup

Anyone who has worked in an outpatient setting treating shoulders has no doubt heard this one. Instead of a patient saying rotator cuff, we hear “rotor cup”, “rotatory cup”, “rotor cuff”.  It always comes up and puts us therapists in an awkward position. Do we correct them and say “it is actually called the rotator cuff”? We run the risk of the patient thinking we are rude for correcting them. However, if we use their words and refer to it as “rotor cup”, now others in the room or in society think we are crazy. I always tactfully correct, but still laugh to myself when I hear it.  This never gets old.

 

Broken

Just last week, I evaluated a patient with a fractured fibula. Upon evaluation, I ask the patient “So how did you break your ankle?” I was quickly corrected not once, but twice by the patient. First, they said “I didn’t break my bone, I fractured it.” Well then, I stand corrected. So much for putting it into laymans terms for the patient. What came next was even more priceless, “And it wasn’t my ankle, it was this bone here (pointing), the fibia”. Ahh yes, the fibia. My mistake.

 

Simply the worst

Another of my favorite patient quotes is “the doctor said it was the worst (insert injury here) they have ever seen.”  Some patients like to glorify their injury, and wear it like a badge of honor. Telling people the doctor has never seen worse is a good way to glorify it for sure.

 

These are just a few of the MANY funny things we hear on a daily basis from our patients. I encourage everyone to comment on this post with their favorite patient-isms. This should be a fun post! I look forward to reading all of them!

About

Trevor WinneggeTrevor Winnegge PT,DPT,MS,OCS,CSCS  has been practicing PT for over 13 years. He graduated from Northeastern University with a Bachelors in PT and a Master of Science Degree. He also graduated from Temple University with a Doctor of physical therapy degree. He is a board certified specialist in orthopedics and also a certified strength and conditioning specialist. He is adjunct faculty at Northeastern University, teaching courses in orthopedics and differential diagnosis. He currently practices at Sturdy Orthopedics and Sports Medicine Associates in Attleboro MA, where he treats many orthopedic and sports medicine patients.

 

Assess Don’t Assume

SFMAI was fortunate last week to swing by and watch my friend Mike Voight teach the SFMA in Boston.  I met Mike’s co-instructors Josh Satterlee and Brandon Gilliam and was impressed with the course.  I have been SFMA certified for some time but I wanted to hear Mike’s take on the system.

I wanted to share with everyone a key theme that was presented that I thought was worth expanding on and sharing.  During one of the introductory presentations, Josh talked about how important the assessment process was and without it, we are just guessing.  This goes along with what I always say, “assess, don’t assume.” [Click to Tweet]

One of the points that was made was that sometimes we get lucky.

Perhaps your client can’t touch their toes and you instruct them to stretch their hamstrings.  Now this person can easily touch their toes.  Take a guess what you are probably going to tell the next 50 people that can’t touch their toes to do?  Probably stretch their hamstrings, because it worked so well on that first person!

We have all been guilty of getting stuck in our box of techniques.  Every time we go to a new seminar or learn something new on the internet, we try it on everyone.  Perhaps we get lucky and hit a bullseye on a few of those people.

We all know there are dozens of reasons why you may not be able to touch your toes, and realistically, hamstring flexibility is not often the reason!  You can’t recommend hamstring stretching unless you have identified that this is the specific reason why your client can not touch their toes.

Don’t be guilty of being stuck in your box of techniques.  Just because it works on one person, doesn’t mean it will work on the next person.  Everyone is unique and has unique needs.

Don’t get stuck in your ways.  As Josh said, chiropractors are great at mobilizing already mobile people and physical therapists are great at stabilizing already stable patients.  I thought that was hilariously accurate!  It really comes back down to your assessment.  I do use the SFMA but also many other assessments techniques (you can see some of them in my Functional Stability Training system).  They help guide me towards what my client needs, I’m not satisfied with being lucky, neither should you.

 

 

5 Common Stretches We Probably Shouldn’t Be Using

5 Common Stretches We Probably Shouldnt Be DoingThe latest Inner Circle webinar recording on the 5 Common Stretches We Probably Shouldn’t Be Using is now available.

5 Common Stretches We Probably Shouldn’t Be Using

This month’s Inner Circle webinar was on 5 Common Stretches We Probably Shouldn’t Be Using.  Don’t get me wrong, I do perform stretches with people, but I think we often over utilize them as well.  Here are 5 stretches that are pretty common, why I think we overuse them, and what to do about it.

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

Using Social Media to Stay Current

The latest Inner Circle webinar recording on the Using Social Media to Stay Current is now available.

Using Social Media to Stay Current

using social media to stay currentThis month’s Inner Circle webinar was on Using Social Media to Stay Current.  There is a ton of information on the web.  It is difficult to stay on top of all the latest info, unless you have a system in place.

In this webinar, I will show you my exact system for staying on top of all the latest journal articles, news reports, internet articles, and blog posts.  I’ll show you how you can set up the same system customized to your specific interests very easily, but more importantly for free.  My system allows me to find great info, save it to read later when I get a free moment, and even store my favorite articles for future access.  Best part of all this is I can do it on my computer, phone, or tablet at anytime!

This is my updated system with updated apps that I am now using in 2014.

To access the webinar, please be sure you are logged in and are a member 0f the Inner Circle program.

The Minimum Viable Exercise

I was having a conversation recently with one of the big league baseball pitchers that I work with in the offseason that I thought would be worth sharing.  As we were working on his arm care program and laying out the start of his long toss program, we started to discuss how far he should attempt to throw.  In the past, he had only thrown to somewhere in the 120-180 foot range (kids, take note of this, you can make it to the big leagues by only throwing to 180 feet in the offseason…), but he had been hearing about all the trendy long toss programs that have you throw to 300+ feet.

My reply was a less than convincing, “it depends,” as I strongly feel the need to individualize each pitcher’s programs.  However, I casually reminded him that he threw pretty hard and was already in Major League Baseball.  Not just professional baseball, but he is actually a big leaguer.

“Sure, I throw hard, but what if I could throw harder,” was his response!  I agreed, but stated “OK, but at what consequence.”

 

The Minimum Viable Product

This led us to the concept of the “minimum viable product.”

Those in the business world have surely heard of the concept of the “minimum viable product.”  A minimum viable product is a product with the least amount of features that can be released.  Think of it as a bare bones product.  In the lean manufacturing business model, this minimum viable product approach has numerous advantages that center around the concept of assessing the product and making adjustments along the way rather than making a huge gamble and finding out you were off base. If you put all your eggs in one basket and the product fails, you are in trouble as you have put considerable time, energy, and money into this product.

minimum viable exercise

Wow, what a parallel between the business world and the rehab and performance world!  We both thrive on assessing and adjusting!  How many times have I said that before (many)!

In the business world this could be the difference between succeeding and going out of business.

In our world, this could be the difference between enhancing performance and creating an injury.

 

The Minimum Viable Exercise

This is where the “minimum viable exercise” comes into play.  A minimum viable exercises is an exercises that is the least intensive that still elicits the desired effect.  Ok, yes, I just made that up, but that is how I would define minimum viable exercise.

To enhance performance and minimize injury, select an exercise that is the least intensive that still elicits the desired training effect. [Click to Tweet]

Using long toss as the “exercise” example and velocity as our desired “effect,” I would want you to throw as far as you need to increase velocity, and no more.  It isn’t always a “more is better” approach.  I can’t help but think of the classic Jerry Seinfeld joke about maximum strength medications where he states “Give me the maximum strength.  Figure out what will kill me and then back it off a little bit.”

This concept also applies to throwing with weighted balls, but I would say applies even more to throwing all year round.  Many baseball coaches feel that taking time off from throwing in the offseason is a missed opportunity to improve, despite statistical research showing that injuries increased 5x by pitching for more than 8 months out of the year!  We are often times too far along towards the “maximum strength exercise” rather than the “minimum viable exercise.”

When it comes to our original discussion about long toss distance, there are two ways of implementing.  One would be to simply jump into a long toss program to 300+ feet with the hope of increasing velocity (and not getting injured).  The minimal viable exercise approach would slowly and gradually extend the distance and then reassess.

Did velocity go up?  Could you perform long tossing at that distance with proper mechanics?  Are there any signs that your body can not handle the stress observed at that distance?  Based on this information you can make an accurate adjustment before it is too late, either continue to progress, back down, or be content with your progress and maintain.

The flip side of this is the young athlete that I commonly see that broke down from jumping too fast and performing for the “maximum strength” exercise.  The fine line between risk and reward is razor thin at this point.

You can apply the minimum viable exercise to any aspect of rehabilitation, fitness, and performance training, not just baseball.  I’m just using this in the context of our conversation.  However, I think this minimum viable exercise concept is already being perform more than we may realize.  Imagine you are trying to increase your deadlift, you wouldn’t make a huge jump in weight and risk performing your lift with bad form or getting injured.  Rather, you would make smaller and more gradual gains, then assess and adjust.

Don’t get me wrong, I am not saying don’t push yourself.  Rather, push yourself but in an intelligent and systematic way.

Don’t get greedy and jump to the maximum strength exercise.  Build intelligent programs that assess and adjust on the way.  This is the minimum viable exercise.

What I learned in 2013

Each year I like to reflect back and summarize some of the ideas or concepts that I have learned over the course of the year.  Realistically, most of these are evolutions of my thoughts rather than brand new concepts, but regardless, represent some of my current thoughts and things I am teaching on how I approach rehabilitation and performance training.

Here are a some of the concepts that I think were important to me in 2013.

 

Alignment First

One of the key concepts that I discussed in Functional Stability Training of the Lower Body was that alignment is important, and in fact, likely one of the most important things to first consider when designing your programs.

In fact, earlier in the year I wrote about the old debate of “which comes first, mobility or stability” where I openly felt the best answer was “neither!”  If I had to order my priorities, I would say it would be “alignment, then mobility, then stability.

Realistically, mobility and stability should likely be developed in tandem, but alignment always comes first.  If not, you risk encouraging compensations and training the wrong areas by working on mobility out of alignment.  In this posture photo below, you can see that there are several deviations from neutral and symmetrical alignment.

posture assessment

Unfortunately, most of the exercises and stretches we use are built using the cardinal planes of motion, however, our bodies are not neutral or symmetrical.  As an example, stretching the hamstrings in the sagital plane is fine if, and this is a big “if,” your pelvis is neutral and symmetrical.  It likely isn’t.

While we have done a great job as a profession moving away from machine based exercises that lock the body in a specific plane of movement, you have to also wonder if double limb exercises like barbell bench press and back squats are too restrictive and force the body to move both limbs with the assumption neutrality and symmetry.

There is always going to be a great time and place for exercises like these, I’m not saying not to squat!  But this concept strengthens the idea of assuring that single limb exercises are a major component of your programs as well.

 

If You Focus on Movement Quality First, Everything Gets Easier

This concept is something that I have been following for over a decade now, but is something that I wanted to focus on sharing more through my education this year as I am seeing young professionals continue to miss this point.

Don’t get caught up on designing programs based on focusing on muscles.  Rather focus on our body’s basic movement patterns – squat, lift, push, pull, carry.  Many of our professions greats, like Dan John, Alwyn Cosgrove, Mike Robertson, and many more have driven this point home well in their educational programs.

But one thing I would add is that you also work on movement quality in all of these movement patterns rather than just strength in these planes.  As Gray Cook always says, don’t put strength on top of dysfunction.  Don’t just pick exercises to get these movement patterns strong, add self-myofascial release, dynamic warm up, manual therapy, and corrective exercises to improve each of these movement patterns as well.

For those working with people in pain, worry first about enhancing movement rather than reducing pain.  If you have a huge loss of shoulder mobility, as an example, you can treat the shoulder pain all day but will find little improvement without also focusing on the things like soft tissue quality, glenohumeral arthrokinematics, and thoracic mobility.

 

Design Your Manual Therapy to Enhance Movement and Your Corrective Exercises

I have been pretty open about the fact that I think I really missed the boat very early on in my career regarding soft tissue and manual therapy.  My mentors and background were based on exercise science and biomechanics.  While this background is fantastic and effective, enhancing my manual therapy skills every year has really improved my outcomes.

I use soft tissue techniques and manual therapy to enhance movement quality.  That is a really important concept.

I am not just “massaging” someone as a fluff treatment, my intent is to help them move better with less pain and restriction.  This is why I may be working areas throughout the kinetic chain that are far from the location of symptoms.

This goes for both manual therapy and other tissue quality techniques like self-myofascial release.  Trust me, I know there is no way that rolling on a foam roll releases your fascia, realize it is just a popular “name.”  However getting someone actively engaged, reducing tone, and decreasing any perceived threats with movement are all great reasons to use things like foam rollers.

Think of manual therapy and self-myofascial release techniques as ways to enhance movement and your corrective exercises.

 

You Still Really Need to Know How to Treat a Joint

Here is the flip side to the above point regarding focusing on movement quality.  At the risk of contradicting myself, I also am seeing another new wave of young professionals.

These are those that have gone to every trendy continuing education course to learn a new system like FMS, SFMA, DNS, and PRI.  Don’t get me wrong, I have gone through these courses myself and have really benefited from these concepts and recommend them all.  However, I really feel like some of the younger professionals are getting a little too caught up at times and may miss the boat.

I think it is great you are trying to stimulate the diaphragm or working on enhancing breathing patterns for someone with shoulder pain, I do too.  However there is one very important concept I would add to that:

You have to know how to treat a joint!

Don’t forget this simple fact and get caught up in the latest trend.  Integrate all these great new concepts into your thought process but don’t forget the fundamentals.

 

I hope these few things that I have reflected on will help you also reflect on what you learned this year.  In fact, I want to hear what key concept your learned this year that has really influenced you, perhaps you’ll teach me something that I can include in next year’s article!

 

 

The Dale Carnegie Approach to Assessments

We are often guilty of making a big mistake when we are performing assessments.  This applies to both rehabilitation and fitness specialists.

Imagine this scenario, your throat hurts so you go see your doctor.  Your doctor takes pride in being thorough and “getting to the root of your dysfunction.”  Over the course of the next 30-minutes you find out you have high blood pressure, are technically obese, maybe pre-diabetic, have psoriasis on your scalp, and maybe even a little athlete’s foot.

Your next question has to be, “but what about my throat?”  Your doctor responds, “Oh it’s nothing, probably a little post-nasal drip from seasonal allergies.”  Do you leave the doctor’s office happy that you don’t have strep throat or are you depressed that your throat is fine but that your health is a ticking time bomb?

Now I am obviously a fan of thoroughness and preventative medicine, however sometimes we are guilty of overloading our clients with everything that is “wrong” with them.  How many times do you think we do this in our professions?

How many times has a shoulder patient come to you and you find 40 things wrong with their arm, spine, and legs?  How many times has a fat loss client come to you and you are focused on their poor rotary stability and shoulder mobility?

The problem with these three scenarios is not your thoroughness or your findings from the assessments, it is with your delivery.  We recently were all guilty of this when we all discussed my article on assessing overhead arm elevation.  We found a lot of flaws but not a lot of positive findings!

The Dale Carnegie Approach to Assessments

dale carnegie approach to assessmentsI started to teach the concept of what I call the Dale Carnegie approach to assessments (If you don’t get the reference, you have some reading to do).  I mentioned this briefly during the lumbopelvic assessment I perform in my Functional Stability Training of the Lower Body program but wanted to expand on this topic.  (photo from Wikipedia)

Here are a couple of key principles of how I implement the Dale Carnegie approach to assessments.

Sandwich The Negatives with Positives

Next time you are assessing someone, try this simple task – start and end with something positive.  Try to avoid just bombarding your client with all their flaws, which is really easy to do.  Let’s be honest, we are trained to see the negatives, and you are probably really good at it, right?  Your assessment should not be about finding everything that is wrong with your client to show off your intelligence.  There need to be some positives as well.

What about someone who really has a lot of flaws?  In this case, perform your thorough assessment, take detailed notes, but try to limit what you share with your client to what is only needed to 1) help them reach their goal, and 2) allow you to perform your job as best as you can.

If you can’t find any positives (you really should…), compliment them on their haircut, new sneakers, or anything else, but find something!

I also try to explain that no one is perfect and talk about some of my own flaws.  This seems to relieve a little tension, but your client is still going to focus on themselves.  So try to give them some positive to shift their focus.

Arouse in the Other Person an Eager Want

A little earlier in this article we mentioned the fat loss client.  My friend Pat Rigsby and I were talking recently and he asked an interesting question, “Do you think someone who comes to you for fat loss really cares about their shoulder mobility?”  This was a pretty great thought.  I think we sometimes get a little caught up in what “we” want to do with our clients instead of what our clients want.

Again, this doesn’t mean to avoid assessing their shoulder mobility, but rather, talk in terms of your clients’ interests.  You need to connect the dots, as Ryan Ketchum likes to say, and help your client see how addressing your assessment findings are going to help them achieve their goals.

Taking this another step, don’t forget more classic Carnegie wisdom by using encouragement and praising any improvement.  This is important for each session and during re-evaluation periods.  If your clients are seeing gains in “their” goals and “your” assessment, they are going to make the correlation.

Next time you have a new client, try using my Dale Carnegie approach to assessments and see what happens – Let me know in the comments below!

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The Corrective Exercise Bell Curve

I’m going to admit something that may come as a surprise to you.  Corrective exercises don’t always work for me.  There, I said it, I feel liberated now!

Corrective exercises are one of those things that have seen a recent rage in popularity, in both the rehab world but probably even more so in the personal trainer world.  Everyone is now assessing biomechanics and movement patterns and trying to prescribe corrective exercises to address what they see.  This is fantastic.

I recently co-authored an article with Jon Goodman from the Personal Trainer Development Center on how physical therapy and personal training can collaborate more effectively.  We discussed this concept a little bit.  Jon took more of a hard stance against personal trainers performing assessments, for several reasons that he discussed.  I don’t feel as strongly Jon on the subject and welcome the development of systems like the Functional Movement Screen that all of us can use to look at movement patterns and communicate better between professions.  Anything we can do to individualize someone’s programming is awesome in my mind.  But there is a caveat…

[quote]There is a dirty little secret that I don’t hear a lot of people talking about – corrective exercises don’t always work.[/quote]

This has almost become like the story of the Emperor’s New Clothes, where people are a little afraid to admit that corrective exercises don’t always work.  Perhaps they think they aren’t skilled or intelligent enough to make the corrective exercises work!  Well, I am here to make you feel better.  Corrective exercises don’t always work for me, either, and understanding why they “don’t work” is just as important to understanding why the “do work.”

 

The Corrective Exercise Bell Curve

To better illustrate the spectrum of corrective exercise efficacy, I have developed the corrective exercise bell curve.  The corrective exercise bell curve explains why some people don’t respond to corrective exercises.  I am not 100% certain of the exact percentages, this is just a model, but a starting point for discussion at least.

corrective exercise bell curve

In this diagram, you can see that there is a certain percentage of people who are going to respond very favorably (and often rapidly) to corrective exercise.  These are the all-stars that we all love to work with, call them the rapid responders!

Conversely, there is a certain percentage of people who just aren’t going to respond to corrective exercises at all.  For these people, something is not allowing the correctives to work.  Perhaps its pain, pathology, malalignment, biomechanical, structural abnormalities, or even neurophysiological.  These people essentially need more than corrective exercises.

Then there is everyone else in the middle.  These are the people who may respond to corrective exercises, but it probably isn’t going to be a quick fix.  These people are going to take some time.

 

Applying the Corrective Exercise Bell Curve

This is all important to understand so you can begin to classify the people you screen.  If you are a personal trainer that just performed a movement screen, programmed some corrective exercise, and was able to clean up some poor movement patterns, congratulations!  That is awesome, you did a great job for your client and maybe even saved our healthcare system some money in the future!

For people who do not respond to corrective exercises, this is where I really see the benefit of personal trainers and physical therapists collaborating.  We can do much greater things together than alone!

For the smaller percentage that is never going to respond to corrective exercises alone, they need a full physical therapy evaluation and will need a combination of treatments including things like manual therapy techniques, neuromuscular motor planning techniques, and eventually corrective exercises.

But here is the really cool group to work with – everyone else!  This is the gray area that we could really collaborate well on to help people achieve their goals.  Notice in the middle group, I stated that corrective exercises MAY work or may take LONGER to work.  In this situation, if physical therapists and personal trainers collaborated more, we could really make a difference in a lot of people.

Physical therapy can work in tandem with personal training to help people achieve their goals faster by combining things like manual therapy with their workouts.

I’m lucky, throughout my career I have worked side by side with some of the best strength coaches and personal trainers, people who have made me better at why I do.  This is by far my ideal work environment and why I always try to team up with a multidiscipline group of people.

 

Examples

To better illustrate, let me come up with a a couple of examples.  Perhaps you notice someone has pretty poor squat mechanics.  Corrective exercises aren’t working.  This is a perfect person to collaborate with a physical therapists.  Perhaps their hip capsule is tight or their hips are not aligned well (just a couple of examples, it could be several things).  All they may need is just a kick start in the right direction with specific manual therapy and they may be good to go.

Or how about you screen someone with really poor shoulder mobility on one side.  They don’t really have many symptoms other than a general ache in their shoulder from time to time, but the corrective exercises don’t seem to be working.  I was actually referred a patient just like this last week from one of the personal trainers I work with frequently.  That specific patient had very specific glenohumeral capsular tightness that wasn’t going to get better with corrective exercises alone.

I do this all the time and can often times clean up someone’s patterns in a few sessions, sometimes even less, by using the right manual therapy techniques to address their concerns while they continue to train.  To me, that is fun.  Helping people achieve their goals faster through collaboration.

So next time you feel like your corrective exercises are not working, don’t feel bad about it.  You are not alone.  If you are a physical therapist or personal trainer, find a respective partner to collaborate with and remember the corrective exercise bell curve.

 

 

 

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