Do You Want to Learn More About Optimizing Movement and Enhancing Performance? 

I’m really excited to be launching my brand new course for rehabilitation and fitness professionals looking to help people restore, optimize, and enhance performance.   It’s my Introduction to Performance Therapy Training course.

And you know what the best part is???

It’s absolutely FREE!

Check out the information and video below, and click the link below to enroll today!

 

Introduction to Performance Therapy and Training

If you’re anything like me, I’m sure you’d love to work with more highly motivated people, and even athletes, that want to focus on improving their performance.

But I remember not really feeling prepared for this or knowing how to get started, I really felt overwhelmed. We all learned the basics, but no one really teaches you how to optimize movement and enhance performance.

Over these years, I’ve learned a ton. Good and bad! But everything I have learned has shaped what I do, and it took some time and experience to realize this.

There so much info out there, but people tell me all the time they’re still confused and that they feel like they just start treatments and training programs and aren’t even confident that they choosing the right ones!

Check out this video for more of what I mean:

 

Enroll in My Course for FREE

I want to help.  When we started our facility at Champion PT and Performance, one of our biggest goals was to develop a simple system for our physical therapists and strength coaches to help people move and perform better.

My Introduction to Performance Therapy and Training program will teach you our 4-step system at Champion to assure you have everything you need to start helping people move and perform better.

Introduction to Performance Therapy and Training

Best of all, it’s absolutely free to anyone that signs up for my Newsletter. You’ll get all my best articles straight to your email, and immediate free access to the course.

Thank so much, hope you enjoy!

 

 

 

 

 

 

 

How to Perform a Thorough and Systematic Clinical Examination – Part 3

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 3 is now available.

 

How to Perform a Thorough and Systematic Clinical Examination – Part 3

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 3.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect any structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 3 of 4 and will focus on how to sequence your objective portion of your examination, as well as plenty of clinical pearls from experience. Part 3 is the first half of the exam, focusing on observation and mobility.  There’s a ton of info here so I wanted to break it down in detail.

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

To access this webinar:

 

 

Strength Training for Runners

There are still a lot of misconceptions about running and how to best train runners to minimize injuries and enhance performance.

Part of the problem is that there is a low barrier to entry to running.  All you need to do is start running, right? No gym membership, no equipment, heck most people don’t even do anything to prepare themselves for running.  They just decide to start running.

For recreational runners, running also tends to be a fitness choice.  Many people pick a way to get in shape and start exercising, and feel like they need to choose.  Do I want to do strength training or do I want to do cardio work?

Competitive runners also have some misconceptions when it comes to training to enhance their performance.  In the past, many have believed that strength training will bulk you up too much, make you less flexible, and may even slow you down.

There is no doubt that running requires cardiovascular conditioning.  But we can’t ignore how the rest of the body is biomechanically involved.  

Let’s simplify running a little more.

Running is a series of little jumps.  The rear leg has to propel the body forward.  The stride leg has to absorb force.

To minimize your chance of running related injuries and enhance your running performance, you need to understand both of these concepts.  

The key to both of these is strength training.  We can build tissue capacity to handle these forces much more efficiently, especially if we build a specific strength training program for runners with these two concepts in mind.

 

Strength Training for Runners

When it comes to runners, my go-to resource for injury rehab and performance enhancement is Chris Johnson.  Chris has an excellent website and clinic that specializes in runners.  He’s helped me a ton over the years.

Chris has an amazingly comprehensive book right now, Running on Resistance: A Guide to Strength Training for Runners.

We had been talking online recently, and I thought that my readers needed to benefit from Chris’ amazing knowledge on runners.  So we sat down and talked about the book, as well as a bunch of other topics related to strength training in runners:

 

Running on Resistance: A Guide to Strength Training for Runners

If you’re interested in learning more, Chris’s book is an amazing resource for both runners, as well as rehab and fitness professionals that want to work with runners.  It is a detailed guide and program to building capacity, becoming more resilient to injuries, and enhancing running performance.

Chris was nice enough to extend a special 15% off discount just for my readers.  Check out the book below:

 

 

Why You Should Be Using Biofeedback in Rehabilitation

This week’s article is an excellent guest post from my friend Russ Paine, PT, discussing why and how we should be using biofeedback in our rehabilitation patients.  Russ and I are both big fans of biofeedback but unfortunately it’s fallen out of favor because insurance companies don’t reimburse it. But that doesn’t mean it’s not effective.  And now, there’s a new biofeedback device, the mTrigger, that uses an app on your phone that is amazingly easy to use and affordable. I think this is going to be a real game changer.  And mTrigger was nice enough to offer my readers 10% off! More details below, but check out the article and our video first!


Why You Should Be Using Biofeedback in Rehabilitation

I have been involved in the evaluation and treatment of sports medicine injuries for 33 years.  I have been very fortunate to have a “true” sports medicine practice that predominantly includes professional, college, high school, amateur, and aging athletes.  Having this type of clientele has forced me to explore and pursue restoring full function in the timeliest manner, being very careful to not cause harm using an aggressive approach.  

I believe that one of the secrets to having successful return to sports with minimal adverse effects is fully restoring muscle function.  

Although many aspects of our field have seen excellent advancements and growth, we continue to combat one of the most difficult challenges following injury and surgery, muscle atrophy and weakness.  

Restoration of muscle function should not only be measured by muscle force output and scores obtained on functional tests, but neurological function. In my practice, establishing normal neurological function following knee surgery is goal number one for our patients’ initial step on the path toward successful return to function.  

 

The Use of Biofeedback in Rehabilitation

So how do I do this?  The use of biofeedback is my preferential method of attacking the neurological deficit following surgery or injury.  

New advances in biofeedback devices have recently allowed the ability to provide a general assessment of the patients’ EMG neurological status. The subjects’ ability to fire the inhibited muscle may now be conveniently measured by recording EMG activity of the involved extremity and comparing this to the opposite normally functioning muscle group.

The primary rationale for use of biofeedback is the belief that the patient should begin use their own “electrical system” as soon as possible through volitional contraction.  

The concept known as order of recruitment lends support to the use of biofeedback to enhance volitional contraction.  This order is based on the size principle. Heinemann’s size principle states that under load, motor units are recruited from smallest to largest. In practice, this means that slow-twitch, low-force, fatigue-resistant muscle fibers are activated before fast-twitch, high-force, less fatigue-resistant muscle fibers.  

When using a biofeedback device, the clinician sets the goal for the inhibited muscle so that a strong voluntary effort is required by the patent for each contraction.  This is visible to the patient and forces a strong contraction to reach the pre-set goal. I believe that voluntary contraction using biofeedback produces the greatest results in restoring muscle function early.

 

Biofeedback or Neuromuscular Stimulation?

Neuromuscular electrical muscle stimulation (NMES) is often used to stimulate muscle contraction.  There is a vast amount of literature supporting NMES for use during rehabilitation. Until recently, NMES has been a reimbursable modality, thus there was much financial support to research its’ effectiveness.  

Biofeedback has not been reimbursable and that may have had an effect on the comparative lack of literature.  One article from Draper and Ballard supports the use of biofeedback over NMES.  This article compared the two modalities during ACL rehabilitation.  After 6 weeks, the biofeedback group was shown to provide greater quadriceps isometric muscle strength than NMES treated group.

I believe in the use of NMES if a patient is unable to make any voluntary contraction, which sometimes happens following ACL reconstruction surgery.  But, once a patient is able to produce a voluntary contraction, detected by the biofeedback, we immediately switch the patient to biofeedback.

When using NMES, all nerve fibers are stimulated simultaneously.  This, in my opinion, is not as effective as biofeedback because the order of recruitment from small to large diameter nerve fibers is not sequential as is the case with voluntary contraction.  NMES actually recruits the large diameter nerve fibers first because they are more excitable, as large diameter axons have less resistance to firing. Atrophy of muscles has predominate effects on the slow twitch smaller diameter Type I  fibers, so recruiting these muscle fibers is critical to reverse the effects of muscle inhibition and atrophy.

 

How to Use Biofeedback in Rehabilitation

I use biofeedback on virtually every knee patient that has decreased neurological EMG output.  As previously mentioned, we are able to use a new device to provide a side to side assessment of EMG activity.  

This information as also very educational and motivational to the patient as they can see the actual deficit via visual EMG numbers between normal and involved.  

Cycles of 10 seconds on and 10 seconds off are utilized during the 10 minute biofeedback session.  My instructions to the patient for quadriceps re-education are to “tighten your muscle and force your knee straight”.  Progress is continued to be monitored on a weekly basis to measure the change in EMG activity, as shown using the biofeedback application.  

The mTrigger Biofeedback device that we use utilize has an amplifier that sends the measured EMG activity via a Bluetooth signal to an android or IOS device with the appropriately downloaded software application.  

This mTrigger is available for home use as well as clinical use.  Patient reported motivation using this type of biofeedback product is very high as they can actually visualize their intensity of muscle contraction when performing home exercise programs.  There seems to be an interesting psychological connection between the use of one’s personal smartphone or computer pad and their muscle activity.

Lack of extension of the knee has been shown to have an adverse effect of knee function.  Loss of extension alters the gait pattern and can produce abnormal stresses to the patellofemoral joint.  Due to a lack of quadriceps control many quad inhibited patients will ambulate with a flexed knee gait pattern.  

The use of biofeedback can be used to combat this common malady often associated with post-op care of the knee.  Lacking quad control, patients’ are unable to eccentrically control the knee flexion moment that occurs during single limb balance.  A quad inhibited patient will assume this flexed knee position because they “know” the position of the knee during single limb balance.

This sets up the knee for a co-contracted state and presents as muscle splinting until normal muscle tone and function are restored.  This muscle splinting will continue to exacerbate the lack of extension in the knee. Biofeedback can be very effective at addressing this issue.  

With muscle splinting, we want to teach the patient to relax the hamstring muscle during knee extension stretching, thus negating the effect of a contracting hamstring muscle.  The patient is placed in a prone position, with both patella over the edge of the table. Electrodes are placed over the hamstring muscle. Unlike the inhibited quadriceps muscle where we are trying to elicit a more perfect contraction, the biofeedback unit is now used for relaxation purposes.  As the patient uses the relaxation mode of the unit, and learns to control the overly active hamstring contraction immediate increase in passive knee extension is observed.

This position is maintained for a 10 minute period.  Once the patient has “learned” to control the hamstring over activity, a light weight may be applied for the 10-minute period to produce a low-load long-duration stretch.  Change in knee extension can be measured using heel height difference measurement technique. Dale Daniel described this measurement and showed that 1cm of HHD = 1 degree of flexion contracture.

Note from Mike: That’s a great example of how you would use biofeedback to work reducing muscle activity.  It’s not always used to increase activity. Another way we use it is to use both channels together on 2 different muscle groups.  Imagine doing a bird dog or glute bridge with the pads on the glutes and low back. You would focus on performing the drill with high glute activity and low back activity.  It’s pretty neat.

 

Return to Play

Return to play is a hot topic in rehab right now.  It’s difficult to determine if the athlete is ready to return to sport.  There are many obstacles when assisting your athlete to the ultimate goal of returning to sport with pre-injury level of performance.  

Too often, a shift is made during the rehabilitation process to more functional activities and reduced emphasis on strengthening.  If your patient continues to possess a decreased EMG signal compared to normal side, it will be highly unlikely that they will be able to resume the pre-injury level of function.  

With biofeedback, we have a tool that makes certain that we have completed one of the early critical steps in the process of rehabilitation – restoring and measuring normal neurological function of the inhibited muscle group.  Don’t allow decreased EMG function be one of the obstacles to continue to linger.

 

The mTrigger Biofeedback Device

I thought that was a great article from Russ.  Many don’t even realize how impactful biofeedback can be as it has fallen out of favor.  Here’s a great video from Russ and I demonstrating the mTrigger device and talking about how and why we use biofeedback:

 

As you can see, the new mTrigger device is so simple to use and completely affordable.  That has always been a limitation in biofeedback devices, they were just to clunky and expensive.

If you want to get started using biofeedback, mTrigger was nice enough to offer my readers 10% off their purchase, making this even more affordable.  Click the link below and be sure to use coupon code REINOLD to get your 10% off

 

About the Author

Russ Paine, PT, is known for his experience in sports medicine with special interests in injuries to the knee and shoulder, as well as golfing injuries and conditioning. His client list includes many professional athletes who have sought his expertise to help them recover to their prior level of function. Russ has a long career in sports medicine, having served as rehabilitation consultant to the Houston Astros, Houston Rockets, and NASA. Currently the Director of Sports Medicine Rehabilitation at UT Physicians in Houston, TX, Russ continues to devote his time to research and education while maintaining a busy sports medicine clinical practice.  Russ was inducted into the Sports Physical Therapy Hall of Fame in 2018. As a well-established author and lecturer on topics related to sports medicine, he has lectured at over 500 meetings in the US and abroad. He has published 25 chapters in textbooks and over thirty research articles in peer review journals.

 

 

 

Measuring the Position and Mobility of the Patella

Measuring the position and mobility of the patella is still a very important component of my clinical examination of the knee.  It gives me a great sense of soft tissue restrictions that may be present when patellar hypomobility is noted.  This is especially common after knee surgery.  But measuring patella mobility is also important to assess generalized laxity when patellar hypermobility is observed.

The first time you feel either of these during your clinical exam, you’ll know what I mean.

But if you read through the literature, you may find conflicting results regarding the validity and reliability of assessing patella position and mobility.

The Reliability of Measuring Patella Mobility

One study that I reference often is a systematic review by Smith, who looked at the reliability of assessing patella position, specifically in the medial-lateral position.  Like any examination technique that is commonly performed, it is necessary to establish that the test has adequate intra-rater and inter-rater reliability. The test needs to be easily replicated and produce accurate results both between two different clinicians but also when repeated during re-evaluation with the same clinician.

Otherwise, the test may have limited use and not be able to provide helpful information.

The authors conclude the intra-tester reliability is good to assess medial-lateral patellar position, but inter-tester reliability was variable.  The variability is interesting to me and makes me wonder if we just aren’t standardizing how we look at patella mobility.

Another study by Herrington demonstrated that a group of 20 experienced therapists could reliably measure patellar position.  This tells me that a group of similar trained or skilled clinicians will show greater inter-tester reliability than a randomized selection of clinicians.  When I see that a test has good intra-tester and worse inter-tester reliability, I think one of two things:
The test is difficult to perform and/or is more accurate with more experience.

Reliability can be enhanced if we all use the same examination techniques. There may be subtle differences in techniques that may produce poor inter-tester reliability. This is what came to my mind when the Herrington study showed good inter-tester reliability with a group of experienced clinicians.

The Validity of Measuring Patella Mobility

In regard to validity of the measurements, the authors conclude that the criterion validity of this test is at worse moderate, based on limited evidence.  However, a couple of interesting studies were referenced.  A study by McEwan demonstrated that a lateral tilt of the patella greater than 5 degrees can be detected.  This was confirmed with MRI measurements.  The previously reported study by Herrington also reported that medial-lateral patellar position could accurately be measured as confirmed by MRI measurements.

A Simple Way to Measure Patella Mobility

It appears that clinical measurements of patellar positions can be both reliable and valid.  While intra-tester reliability, or your own ability to accurately repeat a test, appears to be more accurate, inter-tester reliability may be enhanced with a standardized examination technique.

Taking all this into consideration, I honestly do not try to “measure” patellar position.

I will assess the position but I do not try to place a label, such as millimeters or degrees, on the exact position.  If I want or need this information, I would much rather obtain this from a MRI.  I focus more on assessing the amount of hypomobility or hypermobility.

And there is a really simple way that we can do this that I think will great enhance our reliability.

To simplify this measurement, I try to just use a percentage of the patella that I feel can displace.  Here is how I do it:

  1. I break the patella down into 4 equal segments representing 25% of the width of the patella each.
  2. I visually try to establish where I believe the midline of the trochlea is located when I am measuring position.  If I am measuring displacement, I will visualize the edge of the lateral trochlea.
  3. I then measure the percentage of the patella that is positioned beyond the midline of the trochlea and then displace the patella and attempt to determine if 25%, 50%, 75%, or 100% of the patella can displace beyond the lateral edge of the trochlea, as in the image below:

Measuring the Position and Mobility of the Patella

I’ve learned over the years that knee experts, such as Dr. Frank Noyes, consider 50% displacement to be “normal.”  I use that as a frame of reference, but comparing side-to-side is probably even more important.

I feel that this provides me with plenty of information to compare to the other extremity and simplifies the process, which I hope would enhance intra- and inter-tester reliability.  If we all do it this way, I think we’ll be far more accurate.

What do you think? Is this too simple? How do you measure patellar mobility?

 

How to Perform a Thorough and Systematic Clinical Examination – Part 2

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 2 is now available.


How to Perform a Thorough and Systematic Clinical Examination – Part 2

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 2.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect an structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 2 of 2 and will focus on the objective, assessment, and planning portions of the exam.

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

To access this webinar:

 

 

How to Perform a Thorough and Systematic Clinical Examination – Part 1

The latest Inner Circle webinar recording on How to Perform a Thorough and Systematic Clinical Examination – Part 1 is now available.


How to Perform a Thorough and Systematic Clinical Examination – Part 1

This month’s Inner Circle webinar is on How to Perform a Thorough and Systematic Clinical Examination – Part 1.  In this presentation, I discuss some of the concepts behind how to structure an excellent clinical examination process.  This will assure that you are always following a systematic process to detect any structural and functional issues, and that you can easily create a plan of treatment to help the person reach their goals.  This is part 1 of 2 and will focus on the general concepts and subjective component of the exam.

This webinar series will cover:

  • The 4 main buckets of any clinical examination process
  • How to assure you follow a systematic approach each and every time
  • How to look for structural pathology, as well as find any suboptimal areas of function that may be related
  • How to take your exam and make an effective assessment and treatment plan

To access this webinar:

 

5 Common Core Exercise Mistakes and Fixes

We’ve come along way over the last decade when it comes to training the core.  Not too long ago, training the core consisted of mainly exercises like sit ups, with no specific attention to how the core functions.

One of the key areas of core training that I focus on to enhance movement quality and performance is stabilizing the core while the arms and legs move.  Essentially proximal stability, with underlying distal mobility of the extremities.

However, don’t forget that the body is amazing at compensating to get the job done.

Any lack of mobility or motor control will often result in compensatory movements.  Many people want to fly through their core program, but often times don’t focus on the quality of the movement.

Here are 5 common core exercise mistakes that I see, along with some suggestions on how to fix them.  I posted these as a series on Instagram, if you want to see more posts like this, be sure to follow me there.

 

Front Plank

A common error I see when people perform a front plank is over relying on the hip flexors to hold the position. You sometimes see them tighten their core but also come up into a bit of hip flexion.

If you hold planks for too long, you may also notice that you slowly creep up into this position as your core fatigues and your hip flexors take over.

There are two easy ways to improve this:

1. Focus on tightening your core AND your glutes.  This should help hold the neutral pelvic position.
2. Perform sets of planks with each rep being ~8-10 seconds, with no break, just a quick reset, instead of sustained holds.⠀This will keep the focus on the core before the hip flexors take over.

 

 

Side Plank

Similar to the front plank, the side plank is easy to use larger muscle groups to compensate.  One easy way to ruin a good side plank is simply to lift the body too high off the table. You’ll see too much side bend and will make this a lateral bend motion instead of a core stability exercise.

To fix this, try performing with a mirror so you can see your form. Your body should be in a straight line with a nice neutral spine.

 

 

Dead Bug

One of the common faults we see with the dead bug core exercises is a loss of neutral spine when the arms or the legs are full extended. ⠀The person tends to focus on getting there hands and feet extended, rather than keeping their core stable.

Remember the goal of the exercise is to brace and stabilize the core while moving the extremities.

Be sure to keep that brace, but also realize that it’s often better to reduce your arm and leg motion a bit if you are struggling and arching your back.⠀I’d rather you make the exercise less challenging, but performed well, then slowly progress over time.

 

 

Bird Dog

I’m a big fan of the bird dog exercise for two main reasons:

1) It’s great exercise to work on driving hip extension with proper core stability. A lot of people hyperextend their back instead of extending their hip.
2) Because you use alternate arm and leg for advanced variations, it also provides some rotational stability through the core.

But people LOVE to perform this exercise poorly by compensating and arching their back.  Many people struggle to extend their hip while keeping their spine stable.  Be sure to keep your core stable and just work on reaching with arms and legs.⠀Similar to the dead bug, I’d rather you reduce the quantity of your motion, and focus on the quality of the motion.

 

 

Glute Bridge

A common flaw with the glute bridge exercise (and hip thrusts) is thinking that you need to go as far as possible, as far as your body will go.

But keep in mind, the goal here is the glutes, not the low back. So the exercise should really be performed to extend you hips and NOT your back.

To help with this, really tighten your anterior core during the exercise and focus on squeezing your glutes. Then, simply stop the motion when the glutes are done squeezing. Many people want to keep going.  They tighten their glutes, but then keep pushing the body higher over the ground.  Resist the urge to continue by hyperextending at your back.

 

 

Want to Learn More About How I Train the Core?

Check out Eric Cressey and I’s Functional Stability Training of the Core program.  We discuss the core in detail and how we rehabilitate and train the core.