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The One Thing We Need to Do With Everyone

I am often asked by students or people attending one of my seminars, “what is the one thing you do that you find works the best.”  What a loaded question!  I wish it were that simple that I could teach everyone just one magic technique.  I have been reflecting on this question for several months, planning on writing a post to provide an answer.  I took me sometime to figure out how I wanted to answer the question, but I think I might have an answer

The One Things I Do That Works the Best

The one thing that I would say that I do that works “the best” is probably something we should all be doing with everyone.  It’s not a stretch, it’s not an exercise, it’s not the latest fad in equipment, and it’s not the lastest manual technique.  It’s actually so simple, that it took me awhile to figure it out.  It is assessing and Reassessing.

A proper assessment and reassessement is by far the best thing we can do for every patient and client we encounter.  This is really the key to understanding each individual, what they need, and what works for them.   Everything should start with a proper assessment and then after treament or training, reassess!  Do it every time you work with that person and even multiple times a session.

[quote]Ask them, “what is your primary complaint?”  Assess it.  Quantify it.  Treat it.  Reassess it.[/quote]

This simple concept can have many meanings.  At the simplest level, imagine if you were working with a weight loss client and didn’t assess their body weight.  How would you know what was or wasn’t working?  How would you know how much improvement that client has made?

For the clinician, we have many evaluation and assessment tools – range of motion, joint mobility, strength, flexibility, and many many more.  But these measurements are irrelevant to the patient.  They don’t really care if they gained 10 degrees of motion.  They simply want to feel better and move better.

OK, your shoulder hurts.  When does it hurt?  What can you do to recreate that pain?  Great – you just established a baseline that you can reassess.  Don’t get me wrong, you still want to take objective measure, but you now have a real life baseline assessment that the patient can feel.

This is why tools like the FMS and SFMA are valuable – systematic methods of assessing movement.  This is especially true in the fitness fields, where assessments are even more limited.  Quantify the quality and feel of movement to assess changes.

FMS

Ultimately, this is going to always lead to better outcomes – instead of just applying treatment or exercise and hoping it works, assess what really works and adjust as needed.

Assess and Reassess

How do you apply this?  The wrong way would be to just start working on someone that complains “my back hurts.”  “Well, hop up and let’s start throwing some massage techniques and exercises at it.”  In this example, there was no assessment, just treatment, so what do you reassess?  Pain?  That is not always the best assessment.

Maybe a better way would be to assess when and how the back hurts.  What movements bother you?  What can’t you do?  Now, provide care to that person and reassess what you just observed.  Simple, yet a powerful message when a person stands up and says, “wow, I can now touch my toes, that really worked!”

Here is an example of a recent patient I evaluated with complaints of left sided diffuse mid thoracic and rib pain.  I provided a comprehensive evaluation, but I will just cut to the chase and outline the important details.  His primary complaint was pain.  I could of just started trying to treat the area to reduce sympotms and essentially “chase the pain.”  However,  my primary focus was on his limited multisegmental rotation to the left.

Multisegmental rotation doesn’t tell us enough, so I dug deeper.  He had a moderate loss of thoracic rotation to the left.  I could of stopped here as the location of his symptoms were in this area, but I again dug deeper.  I was fine with his hip mobility.  However, I found that his pelvis was shifted with a left anterior tilt, causing his entire pelvis and SI joint to rotate to the right.  Subsequently, his lumbar spine was orientated slightly to the right, meaning his “neutral” was actually rotated to the right slightly, causing what looked like limited rotation to the left.

Thoracic Spine Mobility ExercisesWith my assessment in hand, I went to work.  First, I wanted to start at the thoracic spine to see what the precentage of invovlement may have been.  I worked on soft tissue, joint mobility, and few thoracic mobilization corrective exercises.  Reassessment at this point showed a fairly large improvement of thoracic rotation to the left.  I could of again stopped here, but I also wanted to check multisegmental rotation to the left, which only showed approzimately a 50% improvement in rotation to the left.

If I just stopped here, I would have restored half of his dysfunction, and I bet he would have slipped right back to where he started.

I next went to the pelvis and with a few exercises and manual techniques improved his pelvic alignment.  Reassessment of thoracic rotation and multisegmental rotation showed normal symmetrical movement, and naturally a reduction in his complaints of pain.

That is the power of assessing and reassessing.  Not just once, but multiple times in one session so that I can narrow down the effectiveness of each technique as best as possible.

The Power of Reassessment

That was a pretty good example of how I really narrowed down and enhanced by treatments by assessing and reassessing.  To summarize some of the key points:

  • Helps you individualize and find what works.  This is the no-brainer concept, to see if there was an immediate improvement that can be directly correlated to what you just did to the person.
  • Helps you find out what doesn’t work!  Don’t underestimate this one.  By properly assessing and reassessing you also find out what doesn’t work, which is just as valuable so you can shift gears and try another approach.
  • This is also diagnostic.  By assessing what does and doesn’t work you may also narrow down the exact dysfunction.  Perhaps their limited thoracic rotation is related to soft tissue changes rather than joint mobility.
  • Helps buy in.  Lastly, but probably most importantly, assessing and reassessing helps build buy in, confidence, and compliance from the person.  They will see immediate benefit in what you do.

That is probably what I would consider the one thing that we all need to do with every patient or client we see – assess and reassess, what do you think?

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The Art of Cueing

There is a simple quote from Don Meyer, winningest basketball coach in NCAA history, that is often an overlooked art of coaching no matter what field we’re considering:

[quote]“The more they think, the slower their feet get.”[/quote]

Even in something like jazz piano, I can attest that the best way to screw up your improvisation is by thinking about where your fingers are and how they’re moving!  By no means am I an expert on cueing (or jazz piano for that matter…mediocre at best), but the more we look toward the emerging research on the “art” of cueing, the better chances our athletes have to succeed.

External and Internal Cueing

Art of CueingMuch has been written about the importance of external vs. internal cueing for sport performance.  The research is pretty conclusive that you don’t want athletes thinking too much about their internal mechanics as they’re performing their sport, or for that matter any other fast-paced movement if the goal is optimal results (e.g. Marchant, Greig, Bullough, & Hitchen, 2009; Freudenheim et al., 2010), including running (Schücker, Hagemann, Strauss, & Völker, 2009).  Coach Don Meyer must have been onto something!  But what about slow movements, weight room work, and what is defined as “too much” when it comes to thinking during movements?  (Photo by USACE Europe District).

“Too much” is relative and depends on your goal at the time.  There may be instances where you can trade thinking (and a slower, possibly less powerful movement) for better mechanics.  In the weight room, if a pattern is faulty, there is an advantage to breaking it down and getting the athlete to realize their movement dysfunction.  Here we are going from unconscious incompetence to conscious incompetence.  The next step as they are correcting the movement (conscious competence) is then followed by unconscious competence- or in other words performing the movement correctly without thinking.

Even for slow, near-maximal strength movements, I like to think that unconscious competence is the ultimate goal.  While it can be beneficial and necessary to remind athletes of a few cues here and there, ideally by the time they’re exhibiting max force on a heavy load, they have these movement patterns down and we are only fine tuning things.  This would mean a better carry-over into functional performance as well, because when athletes are practicing, moving, picking heavy things up off the floor (moving into their dorm rooms, etc.), they won’t be thinking about their form, nor would we want them to be.

The Trouble with Language

Unfortunately, when telling a group of 20 some individuals a particular coaching cue, it seems like half of them will take it to mean something different than what you want.  And that’s OK…it’s just inefficient.  You then have to start your alert, fast-paced walk around the weight room, as everyone breaks off, catching a few athletes just in time who are doing the movement incorrectly while others perform it incorrectly until you get to them!

Coaches who can demonstrate well while explaining are golden for the athletes, since athletes may not be the best listeners, but usually have good bodily-kinesthetic intelligence and awareness (thanks to genius psychologist Howard Gardner’s theory of multiple intelligences).  Additionally, they say a picture is worth a thousand words, so is a video worth tens of thousands?  One idea that I would like to implement in the near future is to take video during our important sets.  I recall seeing video of my baseball swing in college and noticing a few things immediately that I had not previously realized.  I know it has been done before in the weight room, but it’s obviously not commonplace yet.  Just having one of our other assistants walk around and film the athletes would be beneficial for anyone who may be struggling with a movement pattern.

Unconscious Competence

As your athletes move toward unconscious competence (e.g. the movement is becoming second nature), external cueing, or minimal thinking, appears to be best, again given your goals.  This is the time to say “jump up and reach the top of the vertec” (you’re getting them to focus on something outside of their body), as opposed to “hinge at your hips with some knee flexion and quickly extend as fast as possible to exert maximal force!”  Unless, of course, your goal is to just drop knowledge bombs on them…

Focusing the attention to something else will always be an external cue, and again the research is becoming pretty clear that this is better for performance than internal cues.  “Put force into the ground” is another common external cue for using the posterior chain while sprinting, and the good thing about weights and medicine ball plyometrics is that you can direct athletes’ attention to those objects as well.

“Put as much force into the bar as possible” as they’re getting ready to pull, or “move the weight from point A to point B as quick as you can.”

“Throw the medicine through the wall- try to break it!”

Obviously internal cues- focusing the attention in the body- have their place, and do have an important role when an athlete is in a learning phase (which is very often in my training programs for spring sport since I’ll start every athlete from square one in the fall).  However even with internal cueing, because of the different interpretations that each athlete may hear, I try to stick to the one main cue that each individual needs the most at that time.  If they approach the bar and have a bit of lumbar flexion I’ll get them into a neutral spine and work on one thing during that set.  Additionally, while we may think we’re all great coaches, nothing beats an “artificial coach” at explaining things without language.  In this example, raising the plates off the ground (so it’s easy for them to straighten their back), or putting them near a wall where they have to reach their hips back and touch the wall with their butt before starting the pull.  Eventually, if I have to remind them, I want to just say “neutral spine” to this athlete without saying anything else and have them recall what that means.  Then down the road I want to say “put as much force into the bar as possible and move it up as fast as you can!”

Conclusion

When I first started coaching athletes on my own as a graduate assistant, I was spitting out cues left and right- “hips back, chin packed, foot flat on the ground/back on heels, back straight…”  I now think about how confusing that must have been for the athletes!  Just like any other skill in life, they need to figure it out on their own, with our help where we can offer it.  Also, if you work with athletes, don’t forget about the importance of being a great demonstrator.  If you have to, check yourself out in the mirror (not bodybuilder style though!) to make sure you look how you want to come across.  And if you’re not a great demonstrator on an exercise (hey, many great/knowledgeable coaches aren’t), find an athlete on your squad who is, and explain as they demonstrate.

About the Author

travis owenTravis Owen, MS, CSCS, is entering his second year as an assistant softball coach at Northern State University in South Dakota.  Travis was an intern through the University of Louisville’s Sport Performance department, followed by a graduate assistant coaching position in NSU’s strength and conditioning department.

In Travis’ first year training solely the NSU women’s fast pitch squad, two players had reached a maximum deadlift of 295 lbs. with the team average jumping from 203 lbs. to 239 lbs.  Additionally, the team’s vertical jump had increased from an average of 17.5″ to 19.5″ in just a few months with one athlete hitting 26″.  The increased strength, speed, and power had shown on the field, with Northern State breaking several school records including wins, stolen bases, hits, doubles and RBI, and experiencing zero major injuries in the process.  As a former two-sport collegiate athlete, Travis understands the motivations of athletes and embraces their effort toward healthy and winning habits.  This year, Travis looks to increase his individualized nutrition coaching while continuing to help Northern State Softball improve both on and off the field.

Travis has a website at NSUsoftballtraining.wordpress.com

References

  • Marchant, D.C., Greig, M., Bullough, J., & Hitchen, D. (2009). Instructions to adopt an external focus enhance muscular endurance [Electronic version]. Research Quarterly for Exercise & Sport, 82(3), 466-473.
  • Schücker, L., Hagemann, N., Strauss, B., & Völker, K. (2009). The effect of attentional focus on running economy [Electronic version]. Journal of Sports Sciences, 12, 1241-1248.
  • Freudenheim, A., Wulf, G., Madureira, F., Pasetto, S., & Correa, U. (2010). An external focus of attention results in greater swimming speed [Electronic version]. International Journal of Sports Science and Coaching, 5, 533-542.

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A Day in the Life

One of the most common questions I get, especially from you clinicians looking to get into professional baseball, is what is a typical day like for me.  It certainly isn’t all fun and games, though we try to make it as fun as possible!

Here is a special post on what a typical day is like for me.  I had sent this as a newsletter a couple of years ago, but wanted to share this again with my Inner Circle members.  Inner Circle members please be sure to log in to see the entire post below.

Quality Over Quantity

Quality Over Quantity

Quality over quantity – It is a phrase that we have heard countless times before, though probably could apply it more.  This simple concept has been one of the most recurring themes in my teachings as well as my core philosophies throughout my career.  But, this took me some time to fully understand the true power of “quality over quantity.”   (Photo by David Gallagher)

This is how I learned that lesson.

My Experience

I started my career off in an outpatient setting that thrived off quantity.  Our clinic was huge and always packed.  We could churn out some patient care, that is for sure.  Call it what you want, but it was a high volume machine.  Was it an awesome experience?  Absolutely.  Was it an invaluable learning experience?  Absolutely.  You can learn so much by seeing so many different patients in such a short amount of time.

At the time, that was the culture.  Mass market rehab centers were popular and spreading, and why not, I am sure they made a killing in profit.  Funny thing was, I had no idea why the turn over rate of therapists was so rapid, usually coming and going within a 1-2 year span.

Then one day I figured it out.  I am sad to say that I have treated 40 patients in one eight hour work day with no assistance.  I remember that day clearly.  My assistant had an illness in the family and I had a full schedule.  As I plunged my way through the day, I remember clearly thinking to myself

[box size=”large” icon=”none”]“I am not giving my patients quality care today.”[/box]

I remember that feeling clearly and it was awful, I bet many of you have felt that too.  I marched in my clinic director’s office at the end of the day and said to him (and really myself) that I would never do that again, sacrifice quality because of quantity.

Quality Over Quantity in Our Practices

My experience above is probably not that uncommon and a major reason why so many therapist are willing to take the risk of moving into private practice.  The changes in healthcare and insurance reimbursement is creating a huge challenge for physical therapy clinics that are seeing their per-patient reimbursements shrink.

To me, the solution is obvious – we have to move to include more of a cash-based practice.  But we as a profession just aren’t there yet, people routinely pay for chiropractic, massage, acupuncture, fitness, and other services out of pocket, yet balk at a $20 co-pay for physical therapy.

[box size=”large” icon=”none”]But can you blame the consumer?[/box]

Think about it.  What do they get from the above mentioned providers?  They get quality.  They get individualized care.  They get one-on-one attention.  These are all things that we sometimes miss in physical therapy as we schedule overlapping patients.  What would you think if you went to the dentist and they cleaned two teeth, then went to help someone else, came back to clean a few more teeth, then moved on to someone else, and so on?

Unfortunately cash-based practices aren’t always possible, especially in more rural areas.  (As a side note, Jarod Carter has a whole website dedicated to starting a cash-based practice that is worth checking out if this interests you).  And seeing multiple people at once isn’t always bad.

In the past, I wrote articles about what we can all learn from a barbershop and what we can all learn from Steve Jobs.  If you haven’t read them, this would be a time to go back and take a peek.  The message on both is the same – people come to you for an experience.

[box size=”large” icon=”none”]Don’t be content provided mediocre care.  We are better than that.  [/box]

For the young clinicians, get better at using your hands and less machines.  People come to you for manual therapy.  If you aren’t comfortable yet with your manual therapy skills, keep working on them and attend seminars to continue with your development.  It is well worth your investment.

Quality of Quantity in Our Programs

While the principles above apply more specifically to the broad sense of our business, the “quality over quantity” concept also is important in our programs.  In both the rehabilitation and fitness settings, I have seen many people get locked into a program that they wrote without:

  1. Individualizing the program
  2. Adjusting the program based on the person’s response
  3. Paying attention to the detail

Many times we get caught up in the fight to get from point A to point B that we forget that sometimes the journey is the greatest part.

Rushing through an exercise just to say you finished it without assuring movement quality is just as bad as selecting poor exercises.  You essentially are strengthening the person’s compensatory pattern and fostering poor movement quality.  This is probably what led to their tissue breakdown and into your clinic or facility!

I have talked about this quite a bit as it comes to core training.  This is an underlying theme in my Functional Stability Training of the Core program, quality over quantity.  This serves as a good model for discussion but it really goes well beyond the “core.”  As an example, the internet is filled with aggressive and advanced core exercises that realistically are not appropriate for many people.  Forcing these on your patients and clients just to seem cutting edge will only hurt them in the long run.  The body will find a way to accomplish a task, sort of like the path of least resistance.

While there are a million bad examples on the internet, I’ll use an example of myself showing poor technique during a plank:

Poor Plank Technique

This is a great way for me to perform a plank poorly, using too much of my right side wall and right hip flexor.  This avoids my deficiency with my left side wall and kicks in the psoas for lumbar stability.  In long run, doing this will feed into my poor motor patterns and cause more harm.

Remember motor control is one of the bigger issues we should all be addressing, not just stretching what is tight and strengthening what is weak.  Remember that next time some is performing an exercise with poor technique right in front of you…  correct them!   This is again another example of “quality over quantity.”  Help people move better and help them feel better.

Think about this next time you are working with someone.  Be a stickler for technique.  We have to do this to truly enhance performance, wether it is athletic performance or just simply human performance.

Sorry, I rarely take advantage of my audience and use this forum to “rant.”  I much prefer teaching!  However, I can’t tell you how many people ask me where to get started when trying to improve their own skill set.  Quality is a good place to start!  What are some of your experiences as you have learned the concept of quality of quantity?

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Best iPad Apps for Physical Therapy

The iPad is truly an amazing and powerful device that can really be helpful when using specifically designed apps for physical therapy.  Below are 7 iPad apps that I use everyday and find really useful in the clinical setting.  These aren’t designed just for physical therapy, and can be helpful for many rehabilitation, fitness, and manual therapy specialties.

Clicking any of the titles below will take you to the iTunes app store for more information.

VisibleBody – 3D Muscular Premium Anatomy

VisibleBody’s muscle anatomy app is really impressive.  The detailes of each muscle look great on the iPad, however the ability to rotate, title, shift and move in any direction to look at the anatomy from any angle is priceless.  This is probably my favorite anatomy app at the moment.  You can also selectively remove muscles and fade muscles to get a sense of depth and how different muscles are positioned.  Here is a video demo of the app:

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PocketBody

I used PocketBody for a long time before I found VisibleBody.  PocketBody is another great anatomy app.  Unlike VisibleBody, you can not freely zoom, rotate, and pan around the body to see the anatomy from any angle.  However, PocketBody excels at showing you the depth of anatomy, taking back layer by layer to see how each interacts.  This app really reminds me of the old Primal Pictures anatomy DVDs that were so popular in the past.

If you have to pick one, I would go with the VisibleBody Muscular Anatomy app above, however, I use both routinely together as the features of each really compliment one another.

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Muscle Trigger Points

Muscle Trigger Points is an anatomy app that discusses trigger points in detail.  You can select any muscle you would like and see a detailed explanation and photo of common trigger points and referral patterns.  I’ve found the app to be pretty accurate and a valuable resource to help find and treat trigger points, if that is your thing.

I had a hard time finding a video clip demo of this app for some reason.  Here is a screenshot from my iPad.  I’ll try to embed a demo video below too but at the time of publishing this was giving me a glitch:

Trigger Points App

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iOrtho+

iOrtho+ is a comprehensive resource of over 200 orthopedic special tests and 88 joint mobilization techniques.  There are a good amount of references available with links to journal abstracts to define the efficacy of each procedure, which is a nice touch.  The main limitation of this app is the lack of video, however the techniques are clearly shown in well designed photos with force vector arrows added for clarity.

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CORE – Clinical Orthopedic Exam

CORE, which stands for Clinical Orthopedic Exam, is another app with demonstrations of clinical tests.  Like iOrtho+ above, there are over 200 tests available with numerous references and links to view the abstract or entire article.  I feel like CORE has more references that iOrtho+ in my testing, but the biggest advantage CORE has is that there are actual video demonstrations of the techniques, not just still photos.  However, iOrtho+ has both special tests and treatment techniques in one app.    CORE is designed specifically for special tests with addition apps for manual techniques (see below).

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Mobile OMT

Mobile OMT, or Mobile Orthopedic Manipulative Therapy, is an app by the makers of CORE above.  The Mobile OMT app has a ton of high quality videos of mobilization and manipulative techniques.  I thought the videos were easy to follow with nice descriptions of each test.  There are three seperate apps for the spine, lower extremity, and upper extremity.

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Kinesiocapture

Kinesiocapture is an extremely powerful video capture and analysis app.  For those that have used Dartfish on their computers, this is a similar piece of software that offers way more convenience by being able to record video, analyze, and review right on your iPad.  The app has lots of useful tools to measure angles, apply posture grids, overlay video, and watch two videos side by side.

There are a ton of great uses for Kinesiocapture.  In the fitness, performance, and biomechanical fields, the ability to assess sport performance is top notch.  For the rehabilitation specialist, you can measure angles, show changes over time or post-treatment, analyze posture, and assess movement quality.

Here is a screenshot from a couple of clips I shot measure hip ROM bilaterally, followed by a demo video of some sport performance applications:

Top iPad apps for physical therapy

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Bonus!  Dropbox!

I should note that my FAVORITE iPad app is actually Dropbox as I can basically work with all my files from all my computers right on my laptop.  That isn’t really a physical therapy iPad app but worth mentioning!  Get 2.25 GB free space on dropbox by clicking here.  I will have to do a webinar for my Inner Circle members on how I use Dropbox one day!

I’m sure there are plenty more iPad apps for physical therapy that I never seen, there are so many!  What other iPad apps have you tried and recommend?

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What 15 Top Experts Are Doing Differently

About once or twice a year, I like to ask a a bunch of experts in a broad range of fitness, sports medicine, rehabilitation, and performance specialties to answer one question for my readers.  In the past I accumulated the best career advice for sports medicine and performance as well as formulated a comprehensive essential reading list for sports medicine and performance (which I need to update this summer…).

These are by far some of my favorite types of posts as I receive so much feedback from my readers on how much these posts have helped them.  It is hard to get advice from experts in our field, so being able to provide this to my readers is awesome!

This year’s question was simple:

What have you done differently this year?

I received a ton of nice responses, and I will share my answer to this question at the end as well.   There are some amazing and inspiring answers below.  There are also some trends that seem to appear:

  • We need to start thinking out side the box and probably more importantly outside the text book
  • We need to appreciate a wider approach to rehabilitation and performance and think about the integration of total body, movement awareness, and multiple systems (musculoskeletal, fascia, neuroscience, etc)
  • We need to use advanced techniques but master the basics first
  • We need to never to stop learning, adapting, learning, adapting…

Charlie Weingroff

Charlie Weingroff

I have come to appreciate that kinesiology, biomechanics, and EMG don’t lie, but they rarely tell the whole story.  Just because things are in the “literature,” doesn’t completely validate their message.  Often things are in the literature because they are easy to measure and can be studied in univariant environments.  It is important to look past the literature into the neuromuscular model which is inherently much more difficult to develop research around.

Charlie Weingroff

http://charlieweingroff.com/

Erwin Valencia

Erwin ValenciaThis year, I was not afraid to use every skill I’ve learned and apply it to every athlete I see, regardless of what others may think. My goal is to keep players on the field, by whatever means necessary within my scope of knowledge and skill set.

E Benedict Valencia 

Pittsburgh Pirates

Ken Crenshaw

Ken CrenshawMy motto in 2012 has been “Less is More”. I have found that with all of the techniques, methods and styles that our Sports Medicine Team has we tend to strive to learn more versus refining what we already know. With more focus on using the things that get results and cutting out the things that don’t we can improve our results with the knowledge that we already have. Secondly communication and evaluation of strengths and weaknesses from our piers has really improved each member individually which in turn improves us collectively.

Hope this helps as it really seems simple but many times simplifying is improving.

Ken Crenshaw

Arizona Diamondbacks

Bret Contreras

Bret ContrerasI’m always trying different things and experimenting. I’ll read some new research, or watch a new technique on someone’s blog, and then try it out in my routines and those of my clients. Many things fade away, but certain things stick. My beliefs today are completely subject to change based on what I learn tomorrow. Here are some of my current beliefs today:

When training everyday folks, know that full range resistance exercises with good form will do more for their “functionalism” than just about anything. It will increase their mobility, stability, motor control, breathing function, posture, hypertrophy, strength, power, and endurance.

I used to feel overwhelmed thinking that I had to include every method in existence to the point where my programs were too crammed. Now I just view all folks as being on a certain continuum with each movement pattern and my job is to get them better at squatting, lunging, hip hinging, hip thrusting, vertical and horizontal pressing, and vertical and horizontal pulling.

I used to think the secret to curing knee pain was all about the hips, now I know that it’s often more complicated and that strong quads are important too.

I used to be afraid of strengthening certain muscles – for example the psoas and the upper traps. Now I believe that every muscle and every muscle part should be strong through a full ROM to maximize body function.

For core stability training, I used to only consider the lumbar spine; now I also consider the pelvis and believe that proper pelvic strength and stability is one of the most underrated aspects of ridding and preventing low back pain.

When training sprinters, I believe coaches should focus the vast majority of their strength training efforts on strengthening hip extension and knee flexion and get the glutes and hammies strong and powerful. I feel that many coaches overvalue the importance of certain movements patterns or muscles when training for speed and shouldn’t worry so much about the upper body, the core, or the quads for this group of athletes.

When training women who simply want to look better, I used to prescribe too much work for the upper body and quads. These days their training sessions focus mostly on the gluteus maximus. It’s not always an easy muscle to re-shape, but if you succeed they’ll never want to give up training! Not to mention the fact that hip extension exercises effectively raise the metabolism especially as strength improves so you’re essentially performing HIIT training to help lean them out.

These are just some of the things I’ve changed up in the past year.

Bret Contreras

http://bretcontreras.com/

Anna Hartman

Anna HartmanWhen I look over the past year and think about my clinical approach to movement, dysfunction, and injury have a renewed passion for learning and practicing what I do. It has been a fun year, as I have stepped away a bit from the clinical picture and really focused on movement. How it looks, how it feels, how it is affected by breathing, emotion, and exercise or sport.

The movement practices of Pilates, gyrotonic, feldenkrais, and Tai Chi have really been able to teach me what it means to really move from the center and how important spinal movement or mobility is to truly find stability and the movement from your center. These movement practices have allowed me to take a closer look at the myofascial system as a whole, pulling from the likes of Tom Myers and his “Anatomy Trains” and tensegrity to James Oschmann and “Energy Medicine”. As well as a closer look at the bony and visceral anatomy and how everything slides, glides, and spins together to create efficient movement pulling from Eric Franklin and his “Dynamic Alignment Through Imagery” and use of small props to create a movement experience for the athletes to feel efficiency, stability, and moving from their center without spending a lot of time in the unconsciously incompetent stage of motor acquisition.

All in all I have been inspired by the passion for learning, doing, and sharing by the many movement practitioners I have encountered along the way, regardless of the letters behind their name or yours there is something to be learned; something to be shared, to improve, grow and truly be able to support someone with their health and happiness.

Anna Hartman

Athlete’s Performance

Dean Somerset

Dean SomersetMy biggest difference was a change in thought process away from conventional “rehab in the gym” training to looking to get someone stronger while taking into consideration their specific concerns. For instance, someone with rotator cuff tendinitis or partial impingement may not benefit very much from doing external and internal rotations on a systemic level, but would see a lot of benefit from doing something like a loaded carry or lunges while holding a weight in a goblet position, and even from trying to do chinups with additional weights. These are all positions that could be said to help save any potential damage to the area while also getting the person a really awesome workout. The transfer between these is that they tend to recover faster than simply performing isolated segmental exercises, which means it’s more than a simple conditioning or total body strength program.

Dean Somerset

http://deansomerset.com/

Tom Myers

Tom MyersThis past year something filled in me.  From a tiny local business, I have built to giving classes on every continent save Antarctica.  My desire had been to see all these different places and work with a variety of professional groups.  When this desire was filled – and teaching in Japan just weeks after the tsunami really started the end of this process – I began to be indifferent or even dislike what I had actively sought out before – not the teaching nor the people, but the travel and the lonely life.  Recognizing these changes in the inner weather and altering to meet them is really important to me as a ‘change agent’ – so I am initiating a new internet stage to teach from, and now I am happy and excited again.

Tom Myers

http://www.anatomytrains.com/

Michael Boyle

Michael BoyleI think the one big change I made is to tailor FMS correctives to the lower body strength exercise being done. I think in the past we were a little random in what we did between sets. We are now trying to program lunge correctives ( hip flexor stretches) with split position single leg exercises and Active Straight Leg Raise correctives with single leg hip dominant exercises. Gray Cook talks about “correct the pattern/ strengthen the pattern” and we have probably not done that as well as we could have in the past.

We have also begun to implement more half kneeling exercises in an in-line split position. I think this creates a different type of core challenge to diagonal pattern work like chops and lifts.

Michael Boyle

http://strengthcoachblog.com/

Eric Cressey

Eric CresseyWe’ve regressed our most “advanced” athletes more than ever before, particularly with respect to core training (this was a prominent theme in our Functional Stability Training of the Core resource).

At the end of a long baseball season, everyone assumes that you’re just going to be managing tired arms, but the truth is that you likely see as many cranky hips and lower back after a year of aggressive extension and rotation.  Many people will try to progress professional athletes too quickly because they assume a base level of fitness, but the truth is that you need some time to not only build back up “weight room work capacity,” but reapply the basics.

So, last fall, we did more prone and side bridges, birddogs, reverse crunches, and get-ups than before – and we did them for a longer period of time.  Over the course of the off-season, they went from building initial stability to being low-level motor control exercises we could use as “reminders” of where neutral spine was.

We combined these exercises with a ton of soft tissue work (both foam rolling and manual therapy, particularly on adductors), and it led to what I’d call the healthiest hips and lower backs I could have foreseen in our 70+ professional baseball players.

Eric Cressey

http://www.ericcressey.com/

Mike Robertson

Mike RobertsonNot sure if it’s “new” but I always feel like I’m getting better about cuing neutral spine. Most importantly, I’m getting better at cuing people to keep the chest up/t-spine extended while also keeping the ribs down.  I actually wrote an entire blog post discussing this concept.

Mike Robertson

http://robertsontrainingsystems.com/

Patrick Ward

Patrick WardI think the main thing that I have done differently this year (and not only this year but sort of progressively over the past two years) is to move towards working lighter when doing soft tissue work. Everyone seems to want to work really deep, push really hard, and try and “work things out”. I think my main shift has been towards working only has deep as I need to work (i.e., only as deep as the client’s body allows me to work) and then progressing from there based on their brain’s ability to adapt to my stimulus.

Patrick Ward

http://optimumsportsperformance.com/blog/

Jeff Cubos

Jeff CubosAs a clinician in a predominantly “hands-on” profession, my early years found me utilizing a passive approach in 99% of my clinical cases. While this approach is often warranted, I have found myself using a “hands-off” approach more and more, especially with the improvement in my functional diagnostic skills as well as my increasing knowledge in motor control principles. Some of the techniques I have found beneficial to this approach lie in the principles of Dynamic Neuromuscular Stabilization and Reactive Neuromuscular Training for example, but again only with better precision in functional diagnostics. And because of this, I have found that my outcomes are achieved much more rapidly than previous approaches used by passive care alone.

Jeff Cubos

http://www.jeffcubos.com/

Sue Falsone

Sue FalsoneWhat have I done differently this year?  EVERYTHING!  My entire job is new :-)  I equate it to an orthopedic doctor, after 15 years of practice and 10 years of specializing on the shoulder elbow, all of the sudden decides to become a hand specialist.  It’s still the upper extremity, right?  It still orthopedics, right?  But the hand is so specialized and different!!  That is what I am doing with my new role with the Dodgers.  It is still rehab, prehab and sport performance but it is so specialized compared to what I have been doing.  I am uncomfortable…in a good way! To do something new like this, at this stage of my career and time in my life is scary!  But being comfortable with the uncomfortable is awesome at any stage in life!  There are new challenges, new things to learn every day, and it’s hard.  But it’s great.  My advice…Be uncomfortable.  It will make you stronger and better on many levels when it is all over.

Sue Falsone

Los Angeles Dodgers

Mike Reinold

Mike ReinoldTo answer my own question, I have really probably changed three different thought processes over the last year or so.

  1. With the large trend towards “function” and “movement,” as well as the explosion of information sharing on the internet, I feel that we sometimes get excited with our progressions and get to fancy too quickly.  I know I have been guilty of this in the past.  My new (or should I say “renewed”) focus has been on quality over quantity.  While this is important in rehabilitation, this is even more important in performance training.  Compensatory movement patterns will always catch up with you over time.  This was a huge reason why Cressey and I wanted to create our Functional Stability Training of the Core program.
  2. The huge trend towards “movement” seems to mean mobility to a lot of people.  I often find that movement quality issues tend to be even more related to poor “stability.”  Don’t get me wrong, you need both, but being stable in your limited mobility is much better than being mobile without stability over the long run.  In fact, too much mobility my be even worse.
  3. Manual therapy and corrective exercise needs to be three dimensional in many ways – planes, motions, depths, etc.  The glute max is just as important of a hip external rotator and abductor as it is an extensor.  In addition to planes of motion, soft tissue needs to be pliable at every depth.  One soft tissue approach is, well, one dimensional.  I now try to focus my manual work on several layers of depth of the tissue, and this requires different techniques to achieve optimal results.

Hope this summary provides some great advice and more importunely motivation to continue improving yourself.  Think about it, if all these great experts keep doing things differently, shouldn’t we all?

Help me really spread the word about this post and email, tweet, share, like, poke, pin, +1, and anything else that exists right now that I don’t even know about! 

Did you notice that there were only 14 people on the list above?  The 15th “expert” is you.  Let’s not stop here, comment on this post below and share what you have done differently this year too!  THANKS!

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4 Things I learned in 2011

What I Learned in 2011As 2011 comes to a close, I always like to reflect back on some of the things that I learned in the past year.  I have done this in the past two years in my articles in 2010 and 2009.  Here are 4 things that I learned this year, but honestly, I really want to hear what YOU learned this year.  I  created a post on my forum asking this question.  Please check it out and add to the discussion!

1. Sometimes we do More Harm than Good When Training the Core

I’ve actually know this for some time, it really isn’t something that I learned in 2011.  However, what I did learn this year was that the internet can be very, very powerful.  It is a great resource to share information.  Unfortunately it is also an easy way to share misinformation.  I spend a lot of time on the internet trying to learn and expand my practice.  I emphasize professional development probably more than any other characteristic.  I may not be the smartest guy around, but it isn’t from lack of effort.

When I was putting together my presentations for my talks at the Functional Stability Training of the Core seminar that I conducted with Eric Cressey, I dedicated a portion of my presentation on some of the mistakes we make in core training.  One of the first things I do when treating someone with low back pain is STOP emphasizing lumbar mobility.  I’m amazed at how often this really helps facilitate improvement.  Don’t get me wrong, there are times I still need to mobilize and manipulate, however more often than not, I feel like low back pain is from poor movement and stability of the lumbar spine and lack of mobility elsewhere, such as the thoracic spine and hips.  Yet what does everyone want to do?  Stretch and force themselves into lumbar rotation.

This really is what made me want to create the Functional Stability Training of the Core program.  Eric and I are almost done finalizing the videos from the seminar and hope to have it available online sometime in early 2012.  Check out FunctionalStability.com for more information.

2. The True Function of the Brain is to Produce Movement

This is something I actually came across this month.  If you keep tabs on my forum (and why wouldn’t you???), you saw my post on the function of the brain and it’s influence of movement.  If you are reading this article than I assume you are of the same thought process I am in that movement quality is probably the most important area we should be focusing on in rehabilitation, injury prevention, and performance enhancement.

So, when I saw a recent TED talk on the function of the brain by author Daniel Wolpert, I really took a step back.  His presentation completely revolved around the concept that the true function, and really the only function, of the brain was to produce movement.  Our brain basically perceives stimulus from the outside world and takes it in to produce movement.  Not rocket science, we define neuromuscular control as the efferent response to afferent input already, right?  Well he brought up a ton of great thoughts to strengthen this concept.  Two that I really liked:

  1. The sea squirt, of of the most simplistic animals, swims around early in life to only one day plant itself on a rock.  This is just what they do.  Once they do this, and stop moving, the first thing they do is digest their own brain and nervous system for food.  Once they stop moving, they can still live without it!
  2. We can easily write a computer program that will beat any human in chess.  We can simulate the thought process.  Yet, we still can not build a robot to replicate physically moving the chess pieces!  We can not program fluid mobility because our movement patterns are based on feedback patterns from our senses.  He shows some great videos to demonstrate this.  If we are moving a bottle of water, we make small adjustments to assure we don’t spill it.  A program can’t do this.

I also talked about his concept of “noise” and how this can influence the rehabilitation and performance training realms.  You really need to check out this video and discuss this amazing concept that movement is the real reason we have brain.

3. We Are Really Abusing the Sleeper Stretch

The sleeper stretch sure is popular right now.  Everywhere you turn you see people either performing it or recommending it.  I wrote a three article series this summer on why I don’t use the sleeper stretchhow to perform the sleeper stretch if you really want to, and alternatives to the sleeper stretch.  Check out these articles if you haven’t yet as they may change your mind about the sleeper stretch.  There is a time and place for everything, including the sleeper stretch, I just think we are going through a phase right now where it is VERY popular and that often leads to overdoing it and abusing it.

4. We Can Get Inspiration from Unlikely Sources

This year I published two unusual articles for this website about what we can learn from a barbershop and what we can learn from Steve Jobs.  These are both unusual sources of inspiration for us in the rehab and fitness industries, but illustrates that inspiration can come from many sources.  In both articles, I discussed what ultimately came down to providing a superior product to your customer, wether that be a patient, client, or athlete.  Not sure why these thoughts came to me.  For the barbershop I was just getting a haircut and my mind wandered.  For the Steve Jobs articles, I literally wrote that at 2:00 in the morning the night he resigned from Apple, marking what we all knew was coming.

Where do you get your inspiration from?

How Self-Pay Patients Have Made Me a More Effective Clinician

self-pay patientsToday’s post is a guest article by Jarod Carter, owner of a cash-based physical therapy practice, describing how self-pay patients have made him a more effective clinician.  I think this is a great thought and something we should all work towards.  His thoughts can apply to many different fields as well, especially the fitness and performance specialists with self-pay clients.  Here is the real challenge, though, if you aren’t in a self-pay situation, or you are an employee, how can you use these tips to make yourself more effective?

How Self-Pay Patients Have Made Me a More Effective Clinician

If I have to see a patient with an ankle sprain for more than 4-5 visits, I start to get nervous. Why? Because my patients pay $120 out-of-pocket for each one-hour session, and they expect to get better very quickly with that kind of expense; and the same expectations exist for just about any fairly recent non-surgical injury.

Aside from avoiding the hassles of Medicare and Insurance reimbursement, cash-pay patients can have another positive impact on your practice.  In many ways their presence both requires and leads you to become a better clinician. The ways in which this occurs are numerous, but I will expand on a few of them below.

Self-Pay Patients Are More Motivated

Whether you have an entirely fee-for-service clinic like mine, or just see a few private-pay patients here and there, you will likely notice a distinct difference between them and insurance-utilizing patients. On average, they tend to be more motivated to get better quickly and are more compliant with their home program. When they are paying 3-5 times more than a co-pay for each session, there is an inherent financial motivation to minimize the amount of needed treatments. I could be wrong, but if you were to grow the private-pay portion of your patient population, I imagine you would start to see faster and better outcomes solely for the above reason. Another positive side effect of this is that when the majority of your patients are highly motivated and compliant, it makes your job more enjoyable and rewarding.

[Editor note – I agree with this 100%.  This is also probably a big factor in the recent study that was published reporting that direct-access physical therapy produced better results with fewer visits.  Patients that choose to go to PT are going to be the most motivated.

More Hands On Time Means Better Patient Satisfaction

There are a variety of approaches to treatment and scheduling in the cash-based practices that I know of, but in general they all seem to provide more than average one-on-one time with each patient. There is also less (or no) utilization of techs or PTAs, and often modalities are not used either. In these situations, the added one-on-one time with the PT is another reason why clinical outcomes tend to be better with self-pay patients.

This is what compels the majority of my patients to forgo using insurance and pay up front for my treatments. My focus in the clinic is primarily on Manual Therapy and anything else that the patient can’t reproduce on their own time (I should also note that I don’t see a lot of post-surgical rehab patients, but see plenty that are trying to avoid surgery).

Trust me, you can get a lot done in 60 minutes of individualized treatment, and it’s quite luxurious for you as the Physical Therapist as well. In a normal clinic you may only have time for a few Manual techniques and some Therex before it’s time to move to the next patient. With a full hour available, if the first couple things I try don’t make an immediate and significant difference, I can keep trying new approaches and techniques.

For this reason, it’s rare that a patient leaves my office without having some type of significant improvement in their symptoms/movement. Simply put, if all else is equal in terms of clinical skills, the PT who spends an hour with each patient is going to produce more results per session than the PT who races from one to the next every 15-30 minutes.

Motivation to Improve My Skills

Returning to the first paragraph, one of the biggest motivating factors for me to always improve my skills is the pressure of higher expectations from my patients. Most self-pay patients will be paying out-of-pocket in hopes that fewer total visits will be needed. I’m not saying patients in a traditional PT clinic don’t expect you to do a great job; but I’ve worked in both insurance-based and cash-based settings and I assure you that the expectations are not quite the same.

To live up to this (especially as a fairly young PT), you tend to go beyond just the requisite CEU hours and continually seek out new information to improve your skills. If you’re a subscriber to Mike Reinold’s website and newsletter, you’re already displaying this type of drive to be better.

After all, if self-pay patients can get similar results by going to the insurance-based PT down the road, why in the world would they pay top dollar to see you?

My Patients are My Biggest Referral Source

This pressure to perform does not just stem from patient expectations, but also the nature of how referral sources shift in a cash-based practice. At least in my experience (and the experience of other private-pay PTs I know), a cash practice relies on word-of-mouth to produce new patients much more than it relies on Physicians. The reason why is beyond the scope of this article but is explained in more detail here if you’re interested.

In no way am I saying that every patient doesn’t count in a traditional PT clinic; but when your primary referral source becomes the patients themselves rather than physicians, you tend to go that extra mile for each individual on a more regular basis. If you disagree, please think of the times when you’ve had a referring physician come to you for treatment. Now imagine that every one of your patients was a referring physician. Interesting concept isn’t it?

About the Author

Jarod CarterJarod Carter, PT, DPT, MTC is a private practice owner in Austin, TX.  Jarod has formed a successful cash-based physical therapy practice and now has a website to help others do the same.  Check out his site for more information on cash-based physical therapy.