Friday thoughts – 8/22/14

1. Sorry for the absence, life sometimes has a way of getting in the way of writing blog posts. 

2.This post by @The_OMPT gives a great recap on how to explain manual therapy to patients.

3. When you work in a state with direct access, it is always important to keep up with red flags, both for the health of the patient, but also to protect your livelihood. Here is a nice summary of red flags to look for from a self-referring patient.

4. About two weeks ago I had the pleasure of taking a dry needling course put on by American Academy of Manipulative Therapy. I enjoyed the course and learned a great deal about dry needling and it was also nice to have a thorough recap of human anatomy and pain pathways. One of the greatest strengths of the course is that they acknowledge the shortcomings of trigger point theory, so the aim of treatment is more encompassing and can range anywhere from muscle to connective tissue to neural tissue.

5. Next up on the reading list is A Guide to Better Movement by Todd Hargrove.

6. The nights have been down in the 60s, please don’t tell me that summer is almost over.

Exercise of the Day – Bowler Squat

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In honor of my most recent birthday party at a local bowling alley (I am actually a five year old) I bring to you today the bowler squat. The bowler squat is a single-leg multiplanar mobility/balance/strength exercise for the knee and hip. Even though it is called a squat, it is more of a deadlift with rotation type exercise because though there is some movement at the knee, most of the movement occurs around the hip.

Muscles used

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This exercise is a multijoint exercise, so just like in the past, I feel name a few of the bigger muscles used, but remember that there are several muscles activated to support the ankle/foot/core/trunk/head/scapula. The main target in my book is the gluteus maximus. This exercise effectively challenges the glutes to both lengthen and activate in a weight-bearing position in all three planes

  • Other muscles worked include: gluteus medius, deep lateral rotators, Quad femoris, hamstrings, adductor magnus, gastrocnemius, soleus

Movement of the bowler squat

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Start in a standing position with a shoulder width stance. Lift one foot off the ground and hinge through your hips while making sure to keep slight knee flexion in the plan leg. Bend your trunk over and bring the arm of the raised leg forward and across your body. Your raised leg will simultaneously move backward to create balance. Lower your torso until it is parallel to the floor, making sure not to round the lower back (aka keep in neutral). Return to the start position all the way upright and end with a glute squeeze.

Benefits of the bowler squat

Some of the benefits have already been discussed but they include:

  • Challenges dynamic single leg balance
  • Challenges three dimensional mobility of the hip joint
  • Activates muscles around multiple joint of the lower extremity and core
  • Challenges the glutes in multiple planes, which is required for higher level activities

Additional tips for the bowler squat

  • Tell the client to pretend like he/she is trying to pick up an object with the plant foot to improve balance
  • In order to ensure full motion during the exercise, tell the client to aim for a target on the way down
  • Make sure to watch the knee to make sure it does not move too far forward over the toes

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To student or not to student

As a practicing PT in an outpatient orthopedic setting and having 5 PT schools in the area, I receive many requests to accept students on their clinical affiliations. This is one of the toughest choices that I and my fellow clinicians grapple with on a yearly basis. Unfortunately most of my coworkers are now of the mindset that taking on a student is not worth the effort involved. The #1 reason given is just a general lack of time, partly due to the need to keep up productivity, and partly just needing to be able to go home on time at the end of the night. The #2 reason given is that some students are just not that good, and having them around can drive away clients.

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I am personally of the mindset that having a student can be one of the most rewarding jobs of a practicing physical therapist. I think that a lot of physical therapists forget that we were students at one point, and if everyone thought a student was not worth the effort, none of us would be here. Therefore, I like to practice a little empathy, and put myself back in the shoes of a student.

I also like to think that I have a lot to offer a student that another PT may not be able to. Not to toot my own horn, but I think that I have some very useful skills, and those skills would be valuable in someone else’s hands as well. I am not just thinking about skills like movement assessment, massage and joint mobs (all of which are very important), but also “skills” like customer service, critical thinking, independence, and the importance of your brand.

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The other benefit from having a student is that he/she is able to teach me a thing or two. As much of a genius as I already am, the field is always changing and research is always evolving, and I do not always have the time to keep up with it all. A student can bring a perspective/information to the table that I may not have encountered. A student does not just teach me knowledge either, but also re-teaches me patience, which can sometimes be lost as I get comfortable in my day-to-day work.

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There were approximately 8,000 PT degrees awarded in 2012. If I can influence just one or two of the next 8,000, then I feel like I have accomplished something for the year. I hope that other PTs also have the same point of view. The future of our profession depends on it.

Friday Thoughts – 8/1/14

1. Congrats to all the DPT students who passed the NPTE. Now go make some $$$.

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2. Breathing is something that all of us do, we do it all day, and it uses a bunch of different muscles. Yet it is frequently ignored in rehab. The Manual Therapist (@The_OMPT) wrote a great post on 5 cues to assist with breathing education.

3. As physical therapists try to move towards more autonomy, it is more important than ever that we keep up to date with red flags for various condition. This will help both protect ourselves, and help protect the patients. Here is a comprehensive review of red flags for LBP, a must read for any PT.

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4. I have not yet taken a course by NAIOMT (though I am taking one in October), but I did come across this post on “The Rules of Manual Therapy” by Brett Windsor, PT, and I subscribe to a lot of what he has to say.

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5. Is this really the first day of August? Where has the summer gone?

Exercise of the Day – The Push-up

The push-up is another one of my favorite exercises. It only requires a floor/wall/table, and some bodyweight (which I have plenty of). The push-up is a great exercise because it challenges muscles of the chest, back, core, and hips. You can also more specifically challenge certain muscle groups just by changing the positions of your hands, or the angle of your body.

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Muscles Used

The push-up, like the pull-up, uses a lot of different muscles throughout the exercise, so I will not list out every single muscle, but just the biggest contributors. 

  • Pectoralis major, pectoralis minor, anterior deltoid, serratus anterior, triceps brachii, coracobrachialis, gluteus maximus, transverse abdominus, rectus abdominus, obliques

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Phases of the push-up

The first phase, which starts while lying on your belly with feet together and hands starting just outside of the chest, is the pushing phase. This is the concentric phase of the push-up. The major joint motions involved are elbow extension, shoulder horizontal adduction and flexion, and scapular abduction and protraction. The core and hip muscles must work to make the rest of the body a stable lever.

The lowering phase is when the body is slowly lowered back down towards the floor. The opposite joint motions occur, with elbow flexion, shoulder horizontal abduction and extension, and scapular adduction and retraction.

Benefits of the push-up

As discussed earlier, the push-up works several large muscle groups of the body. This is another exercise that will allow for proximal stability of the shoulder girdle while allowing multidirectional motions and multiple muscular contractions, which is important for athletic activities. Performers can increase strength, endurance, and power, depending on type of push-up performed.

Push-up variations

There are several different ways to alter a push-up. It can be quite a challenging exercise for beginners, so if this is the case, instead of starting out with hands the floor, the hands can start elevated on a wall of counter. This will take a little bit of gravity out of the equation. Also, instead of starting with the body weight on the toes, trying bending the legs putting the weight on the knees

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Conversely, if the push-up on the floor is too easy, methods of increase the challenge could include wearing a weighted vest, putting a weight on the upper back with the assist of a workout buddy, or by elevating the feet.

Another way of changing the push-up to target different muscle groups, is to change the hand position. There are several different styles to choose from overall. One method to more specifically target the triceps is to start with the hands placed closer together. A method to more specifically target the chest, start with a wider stance. For the real fitness buffs, go for the one handed push-up.

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Why did I become a PT?

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Other than “Did you have to go to school for this?” the most common question I am asked is “why did I want to become a physical therapist?” I really wish I had a perfect response for this because I don’t have some of the usual reasons that PTs have, such as:

“Oh PT helped me when I was injured in the past”

“Someone in my family was injured and PT was very helpful”

“I just love helping people” (people who say this in high school are liars)

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When I was a senior in high school (which is when I deciced to pursue physical therapy), I had not been seriously injured or had a family member who was injured. Of course I liked to help people, but this was hardly at the forefront of my mind as a teenager. Instead, this was the thought process that  went through my head:

What am I good at? Science and math

Maybe I could be a doctor, but do I want to go to medical school? No

What else requires science and math skills? Psych, physics, physical therapy, athletic training

Which one can you actually get a job doing? Physical therapy and athletic training

Maybe I’ll be able to just work with athletes (Ah, I was so young and so naive)

Whoa, look you can get a doctorate doing physical therapy. Everyone will respect me with that!! (see first quote above to see if this has been realized)

 

So I applied to college, and after being accepted into a few PT programs, and settling on one that allowed for 6 years instead of 7 years, I began the trek to discover what this physical therapy thing was all about. This included three years of prerequisite courses, before even starting a PT course

Finally after spending time in classes and in actual clinics, I liked what I saw and realized I made the right choice. I discovered that I really do like helping people. However, there are still several selfish reasons I am glad I chose physical therapy.

  • It allows me to stay on my feet and out of a chair, and with all this new research showing that sitting is like smoking 30 packs of cigarettes a day, I feel like I struck gold.
  • I also love the challenge of it, it is certainly not a mindless job, every day is unique in some what. Plus it utilizes those skills that I am strongest at (science/math)
  • Every once in awhile, I get to work with an athlete. Or at the very least try to help someone become more athletic.

So anyway, I am still trying to figure out why I decided to become a physical therapist. Maybe I never really will understand the reason, but I am very glad that I did.

Saturday thoughts – 7/26/14

1. This really should be Friday thoughts but what can I say, I was really lazy yesterday.

2. This is a very serious, and very interesting piece via@CynicalPT for intermediate level therapists, and how to be the best that they can be

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3. As some how struggles with hip mobility, I can appreciate some these higher levels anterior hip stretches via @mobilityWOD

4. Can your scapular anatomy impact that likelihood of developing a degenerative  rotator cuff tear?  Maybe. Hopefully this does not mean that they start doing elective acromioplasties on healthy shoulders.

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5. Apparently graft types for an ACL recontruction have no impact on developing knee OA. I would like to see more research on whether its the ACL that’s the important piece, or bone bruising and meniscus tearing that is really the culprit.

6. Just because we think we know about pain and the brain, does not mean we really know about pain and the brain. Interesting “case study” via @The_OMPT

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7. Please feel free to comment, ask questions, or leave feedback. My skin is only moderately thin.

“Rotator cuff” of the hip?

As most people know, there is a group of four muscles in the shoulder known as the rotator cuff. One of the main tasks of the rotator cuff is to help stabilize the glenohumeral joint throughout arm elevation. The rotator cuff basically counterbalance the effects of the big strong guys (lats, deltoids, pecs) to allow for proper shoulder mechanics and to prevent the ball from coming out of the socket. What people are less aware of is there are smaller muscles in the hip joint (deep lateral rotators) which also help to provide stability and counterbalance to the big strong guys (glutes). The hip, like the shoulder, is a ball and socket joint which allows for a large amount of multidirectional motion.  In order to keep the ball in the socket, this type of joint requires use of muscle tissue and with a labrum.

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The muscles that we will be looking at today include the piriformis, gemellus superior, obturator internus, gemellus, inferior, obturator externus, and quadrates femoris, and the are collectively known as the deep lateral rotators of the hip. Now these muscles in the hip are certainly not an exact replica of the rotator cuff in the shoulder, because they are anatomically different and the hip is more inherently stable due to being a weight bearing joint, but they do have some underlying functional similarities. The main actions of the muscles are lateral/external rotation of the hip, but their line of pull also pulls the ball of the femur into the acetabulum. These muscles do not tend to act individually, but will act as a functional unit to stabilize the hip by creating a compressive force in the joint throughout motion. This is important because an increase in joint translation or gliding can lead to other pathology, such as a hip labral tear. Rotational muscles of the hip are also being looked at more and more as large dynamic stabilizing influence on the kinetic chain, primarily in the frontal and transverse planes, which may play a large factor in patellofemoral pain. There may also be some relation between hip rotation strength and lower back pain

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Exercising these muscles can be accomplished in a variety of ways, but the important thing to remember is the more the hip is flexed, the more likely you are to “isolate” the deep lateral rotators, as opposed to the bigger movers, such as the gluteus medius and gluteus maximus. Just remember you cannot selectively isolate these muscles, you can just hope to maximize recruitment. One group of exercises that may be beneficial include clam shells with the hips flexed in different positions. Another good exercise to get baseline strength is seated hip external rotation with the hip flexed to 90 degrees, both with and without outside resitance.

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Another method to target the deep rotators is to challenge them with other functional movements. My favorite method to accomplish this is to use a band round the knees/thighs while squatting or using a leg press.

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Hopefully this has been a somewhat helpful refresher of hip anatomy, and will help you think outside the box when addressing hip pathology.

Low back pain education

As everyone knows, LBP is one of the most common reasons a patient will visit a physician or a physical therapist. Educating the patient about LBP is particularly important because it is something that will usually resolve by itself, and most of the time no imaging or medication is needed. I came across this video on NPR, and found that it provides one of the easier to follow explanations of LBP. I believe that this should be a must watch by any physical therapist.

Exercise of the Day: The Pull-up

The pull-up is one my favorite exercises. Mastering it can be one of the more rewarding experiences someone will experience while working out. It is a closed-chain, multijoint exercise that can strength a number of muscles around the shoulder girdle, upper arm, forearm, and hand, as well as work on shoulder stability and power production.

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Muscles used:

Here are just a sampling on the muscles used during a pull-up, I am not going to list every core and lower extremity that fire to help stabilize throughout the exercise.

  •  Latissimus dorsi, biceps brachii, middle trapezius, lower trapezius, rhomboids, pectoralis minor, pectoralis major, posterior deltoid, infraspinatus,, teres major, subscapularis, brachialis, brachioradialis, flexor carpi radialis, flexor carpi ulnaris, palmaris longus, flexor digitorum profundus, flexor digitorum superficialis, and flexor pollicis longus

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Phases of the pull-up

There are three main phases involved. They include the starting position (or dead hang), the ascending phase, and the descending phase. During the starting position the hands hold the bar overhead while facing away from the body and there are several static contractions around the shoulder girdle to create stability and allow for the ascending phase to begin. During the ascending phase the scapulae are forcibly depressed, retracted, and rotated in a downward position, the glenohumeral joint is adducted, and the elbow, wrist/hand joints are flexed. The combined joint motions and concentric musculature contractions allow the body to be pulled upright in a linear path until the underside of the chin is level with or above the top surface of the bar. Finally, during the descending phase the muscle contract eccentrically and lower the body with the opposite joint motions listed above.

There are variations of the exercise, including starting with a supinated grip (hands facing the body), or with a neutral grip (hands facing towards each other). These variations will create differences in joint motion and muscle activation.

Benefits of the pull-up

The pull-up is an exercise that allows for proximal stability of the shoulder girdle, multiplanar motion, and multiple muscle cocontractions necessary to perform various athletic activities. Performers can increase their muscular strength, muscular endurance, and ability to perform more pull-up repetitions by combining sets of full body weight pull-ups with sets of assisted pull-ups (such as with bands, or with a partner). In addition, full body weight pull-ups can be made more challenging by adding weight (weight belts/vests). Plus the ultimate benefit, a good looking back.

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References

  1. Ronai P, Scibek E. The Pull-Up. Strength and Conditioning Journal 36:3; 88-90, 2014
  2. Antinori F, Felici F, Figura F, Marchetti M, Ricci B. Joint moments and work during pull-ups. J Sports Med Phys Fitness 28: 132–137, 1988.