What Physical Therapy Is All About

"I know that you are teaching me these exercises, but are you also going to do things to help put me back into alignment?"

"This is great, but can you teach me how I can do this for myself at home?"

These quotes were spoken by my last two patients of today.  They stand in contrast with each other in terms of the differing attitudes that people bring to the clinic each day.

The latter patient is seeking help in figuring out the best strategies for rehabilitating her dislocated shoulder.  When I taught her the Turkish get up, she enthusiastically expressed how she saw its value in helping her regain stability in her shoulder.  She remarked that a self-administered soft tissue release technique nearly replicated the passive technique I had performed with her earlier.  This patient sought the tools to help herself.

 The former views herself as "broken" and is reliant on others to "fix" her.  She speaks with negative terms about her body "falling apart".  In fact, when I met her last week, she told me that she had been going to physical therapy on and off for the past 10 years for "maintenance".  This is not what physical therapy is all about!

Last year, I read somewhere (and I wish I could remember exactly where so that I can give proper credit) a simple definition of what physical therapy should be all about:

"The restoration of thoughtless, painless movement."

I know there are much more elaborate and descriptive definitions of physical therapy, but to me, the above quote captures the essence of what I try to help my patients achieve every day.  I believe the most important aspect of my profession is empowering people to learn how to care for themselves through education.  I didn't always feel that way.  When I first graduated from physical therapy school in 2001, I thought I was on a mission to fix broken bodies.  But now I no longer think like that.  Physical therapists aren't healing anybody.  Time does that.  What we can do is teach you about the body, why it gets injured, how to provide the optimal environment for healing, and how to diminish risk of recurrence.

If you find yourself in need of a physical therapist, try to find one who empowers you to take control of your own rehabilitation as much as possible.  Beware the health care practitioner who makes you feel dependent on them to feel better.  After all, you will only spend a fraction of your week in their presence.  It's all the hours outside of their clinic walls where properly guided intervention will take most effect.

A Quick Guide To Soft Tissue Injuries

Recently, I've treated a couple of friends for calf muscle injuries.  Each of them asked virtually the same questions about what to expect with the healing process, and when they'd be able to return to sport.  While I'm sure all of you have dealt with soft tissue injuries in your lives, I figured it might be a good idea to share what I told them about the healing process.  It may put your mind at ease if and when you get injured, knowing that the healing process won't let you down if you respect the process and allow it to run its course.  I hope this helps you.

Healing tissue goes through three stages:  Inflammation, repair and remodeling.  I'll discuss each phase with the use of an analogy.

Imagine a partial building collapse.  The damaged portion of the building is your tissue damage.  With the building damage, there is generally an immediate rush to the site by first responders.  Those first responders are there to help remove the part of the collapsed building that are now useless.  Similarly, your blood carries all sorts of specialized (inflammatory) cells to your site of injury to carry away the waste and initiate the healing process.  Remember ninth grade biology and phagocytosis?  This is the garbage removal process by cells called macrophages.  There are also a number of chemical releases which help mediate the process, akin to the commanders of an emergency response crew organizing search, rescue and cleanup.  As with the building collapse, this acute response can last several days.

The second part of the healing process is called the repair phase.  Picture erected scaffolding around the damaged portion of that partially collapsed building.  With your soft tissue damage, this scaffolding comes in the form of collagen fibers laid down by your body.  It's the framework upon which new healthy tissue will form.  This collagen "scaffolding" will begin to take some shape, but will hardly be the long term solution, as it's comprised of weak and disorganized pieces.  This repair phase will generally begin a few days after the initial inflammatory response has dissipated, and can last up to 2 months.

The third and final stage of tissue repair is called remodeling.  During this period, which can last up to a year, the disorganized scar tissue and new healthy tissue will become more organized and grow stronger.  Think of the collapsed portion of the building being replaced by new material, surround by that scaffolding.  This is the last step towards the building, and your tissue, becoming whole once again.

So, what can you expect during each of these phases of the healing process, and what can you do to provide the optimal environment that will allow time to do its thing?

In the inflammation stage, you'll likely experience pain, swelling and redness around the area of injury.  Your body is going into protective mode in order to prevent further injury.  Think of swelling as a natural "splint" to limit movement.  It's during this initial phase where the old acronym R.I.C.E. (Rest, Ice, Compression, and Elevation) comes into play.  (There has actually been some recent controversy in the world of rehabilitation regarding the use of ice to treat an injury, but more on that later).  Your goal for the first several days is to protect the area, control excessive swelling (edema) and control pain.

During the repair phase, you can expect your pain level to dissipate.  You'll find your movement slowly begin to return, although you may still experience some swelling and bruising, even away from the actual site of injury.  You may begin to stress the healing tissue by active movement, gentle stretching, and soft tissue work.  This will help align the collagen fibers that comprise your scar tissue, aiding them in becoming stronger.  Other surrounding joints may also be exercised (even beginning in the first phase, barring increased pain to the site of injury).  It is during this phase, a few weeks after the initial injury, that you are most susceptible to re-injury.  This is because you won't necessarily be feeling pain with basic movements, but unexpected demands placed on the body may overwhelm this still weakened and repairing area.

The remodeling phase takes the longest, lasting many months.  It's during this final phase where rehabilitative efforts ought to focus on continued strengthening of the healed tissue, with a goal of returning to full activity or sport.  Concentric (contracting and shortening of a muscle) followed by eccentric (contracting and lengthening of a muscle) loading activities will prepare the injured tissues for 100% function.

A key point in the healing process is that while it always involves these three phases, the time frames for each may vary.  Factors such as age, previous tissue quality and extent of injury will all play a role.  These guidelines are meant to give you an understanding of what to expect and what to do about it when it comes to soft tissue injuries.

A quick sidebar on R.I.C.E., the term coined in 1978 by Dr. Gabe Mirkin.  It has essentially been the gold standard when it comes to treating acute injuries.  However, just this year, Dr. Mirkin wrote an article claiming that he may have been wrong about the ice part (http://drmirkin.com/fitness/why-ice-delays-recovery.html).  Those who are opposed to icing EVER argue that it blocks the body's natural response to injury (inflammation), thereby slowing the healing process.  "How can we presume to know better than the body?", has been the typical refrain voiced by those looking to turn conventional wisdom upside down.

I know that it certainly got me thinking about the topic, as I believe it's ALWAYS important to remain open to new pieces of evidence.  It's not always easy, especially with something as ingrained as icing acute injuries.  I have read articles, listened to podcasts, and read countless comments from all sorts of healthcare and training professionals.  For me, the best commentary on the subject was found in an article entitled "Misinflammation", by Dr. Jonathan Sullivan (http://startingstrength.com/index.php/site/inflammation_sullivan).  After reviewing many studies on ice, he concluded that the evidence just isn't solid enough either way to allow folks to make such declarative statements as "You should NEVER use ice."  Even Dr. Mirkin, as part of his reversal on ice, still advocates for its use for the first six hours after the injury occurs.  The human body is just too variable to completely rule out ice for everyone.  In my opinion, ice is a good thing during the acute phase of healing, for its analgesic effects alone.  It just needs to be used judiciously, for roughly ten minutes at a time, and in conjunction with the R.C.E. part of R.I.C.E.

So, to summarize, here are some key points to remember about soft tissue injuries:

-three phases always occur: inflammation, repair, and remodeling
-those three phases follow general time frames, but may vary.  Always ask your healthcare professional if you have any concerns about your progress, or lack thereof.
-ice (in my opinion) is still okay to use during the acute phase of injury, as long as it's used judiciously and never placed in direct contact with the skin.
-Just because pain has evaporated, you are still susceptible to re-injury as the body goes through its healing phases.  By having a general understanding of what occurs during each phase, and knowing how to provide the best environment to allow each to play out, you'll minimize your re-injury risk and maximize your outcomes.

Of course, being armed with this knowledge should not preclude you from contacting your doctor in the event of an injury.  It can't hurt to be cautious.  In addition to consulting a doctor, physical therapists are trained to help educate and assist in the process.  They are also experts at identifying and correctly the compensatory movement patterns that typically develop with painful injuries.

Hips on a Swivel

This past weekend I briefly assessed a friend's hip as he had tweaked a flexor playing platform tennis last week.  Aside from the acute pain he was experiencing on his right side, the most obvious finding was his lack of hip rotation on both sides.

Why does this matter?

Your body was designed to be both mobile and stable.  But some areas are better suited for mobility, and others for stability.  When a big ball-and-socket joint like the hip isn't as mobile as it ought to be, then your body will seek it elsewhere.  Usually, that's somewhere above or below in your kinetic chain.  With the hip, that means the knee and/or the lumbar spine, neither of which are designed for a heck of a lot of rotational movement.  When you force a relatively stable segment of your body to move beyond its capacity, you risk painful dysfunction.

As I've written about in the past, many of us are living life in only one "lane" of movement, the sagittal plane.  That's the front to back plane.  Since we generally don't run around playgrounds in our adulthood as kids so aptly do, we lose mobility in one or more of these three planes.  Then, we head out for our weekend warrior activities and injuries ensue.

Be mobile where you were meant to be mobile, and allow your stable parts to do their thing.  Normal ranges of motion for hip internal and external rotation are 45 degrees.  That is to say, if you were to lie prone on your abdomen with your knee bent to 90 degrees, you ought to be able to make a windshield wiper movement with you lower leg totaling roughly 90 degrees, without your pelvis coming off the surface of the floor/table.  It looks like the middle image below:

Grab 30 seconds and do a self assessment.  If you find yourself limited in either direction, or have a large right to left asymmetry, then get to work doing something about it.  Your back and knees will thank you for it.

Go Up the Chain for Plantarfasciitis

You know the old song, "The foot bones connected to the shin bone, the shin bones connected to the...."?  Well, it turns out that this reality of anatomy known as the kinetic chain is a good thing to keep in mind when it comes to dealing with pain.  Just because you're feeling pain in a particular spot doesn't mean the driver of that pain isn't located somewhere further away.

When it comes to a painful foot condition called plantar fasciitis, it's important to look beyond the foot and ankle for a long term solution.  The pain you'll feel with this issue is primarily located at the bottom of the foot, back by the heel bone (calcaneus).  People describe an "ice pick" feeling that is especially intense with the first steps out of bed every morning.  Most conservative interventions include but are not limited to "rolling out" the bottom of the foot with a water bottle or ball, along with a ton of stretching of the calf muscles.  Those steps are certainly helpful, but unless you look further up the kinetic chain, you may be missing something.

The plantar fascia is connective tissue that helps provide support to the undersurface of your foot.  It plays a role in the complex mechanics that occur throughout the gait cycle.  Your foot goes through a series of pronations (flattened arch) to supinations (raised arch) as it alternates between being a mobile adaptor to feel the ground to a rigid level to propel you forward.  But in order to keep the fascia in good working order, the foot must be allowed to do what it's meant to do.

Decreased hip extension may be something that prevents someone from making true strides (bad pun) when it comes to their plantar fasciitis rehabilitation.  With all the sitting that's done in today's society, it's easy to see why hip extension may become compromised.  When you sit with your hips flexed for hours on end, the hip flexors will get tight, thereby limiting your legs' ability to "get behind you" during the gait cycle.

Why does this matter?  Well, for starters, tight hip flexors will tend to pull one into what's known as an anterior pelvic tilt.  Think of the bony part of the front of your pelvis aiming towards the floor in front of you.  That's an anterior pelvic tilt.  When that happens, your center of gravity shifts.  In order to maintain an upright position, your calf muscles will have to work harder.  Try it.  Stand up and tilt your pelvis forward.  Feel the weight transfer towards the front of your feet.  Unless you want to fall flat on your face, your calf muscles and other foot plantar flexors (toes pointing away from you) will activate.  And remember what I mentioned as a common intervention for plantar fasciitis?  Calf stretching!  You can stretch all day long, but if your lack of hip extension continues to make your calves tighten up, you'll be fighting a losing battle.

Another reason why decreased hip extension may effect your plantar fascia is that when you can't fully get your leg back during the gait cycle, you won't give your foot enough time to progress through that natural toggle between pronation and supination.  You'll end up putting more pressure on the plantar fascia in a pronated position, which will only aggravate the situation.  Pronation is not a dirty word, as many shoe salespeople at your local Foot Locker may lead you to believe.  But excessive pronation may not be so great.

So, if you're dealing with that annoying ice pick pain at the bottom of your foot and it's preventing you from functioning at your best, don't forget to look elsewhere for possible causes.  Your best bet is to get assessed by a professional, so that you're not idling away your time fruitlessly rolling out the undersurface of your foot.  The potential causative factors for pain can be vast, and it's vital to remember that old song about the connectedness of the human body.

Beware the MRI

Last week a 34 year old patient came into the clinic with a 15 year history of low back pain.  The first thing he did was to lay a large folder containing his MRI images down on the table.  I did not look at them.

It's not to say that I was indifferent to his magnetic resonance imaging results.  Rather, I wanted to hear from him first.  I wanted to know about his history.  When did his pain start?  What does he do for a living?  When does his back bother him most?  Are there changes in his pain based on positional changes?  These a just a few of the many questions I'll ask a patient before I even bother to look at an imaging report.  And here's why:

Imaging can reveal tissue "damage" without associated painful dysfunction.  In other words, there is not necessarily a direct causative relationship between a positive MRI and pain.

This is a pretty powerful concept for patients to be educated about.  If a person believes that they have a "bad" back based on imaging that reveals a disc herniation or some other "defect" in their spine, then their mind can play crazy tricks on them.  It's called the nocebo (Latin for "I will harm") effect and is opposite the more commonly known placebo effect.  Just thinking that something is wrong may lead to disproportionate pain and dysfunction.

Here's what I always say to my patients who present to the clinic similar to the above referenced person:

"If you went out on the street an grabbed 100 pain-free people above the age of 30 and imaged their spines, there's a good chance that a large portion of them will show something "funky" with their results.  The same can be said for other areas of the body.  Unless you have an MRI result from a month or two before your symptom onset (which is never the case, because nobody ever gets MRIs done just for the heck of it!), then it's really impossible to draw a direct line from your results to your pain."

I want patients like the example above to stop carrying around their positive MRI results like a 100 pound gorilla on their backs.  If they view themselves as damaged goods, then it will surely slow their road to recovery.  We are made to move.  We stress our bodies all the time in myriad ways.  Like all things mechanical, we are subject to wear and tear.  But that's okay.  Unlike a car or some other machine, we humans are incredibly adept at self-repair and adaptation.

MRI's have value, don't misunderstand me.  They can help confirm a diagnosis based on a thorough subjective and objective examination.  But they should not be the "be all, end all" when it comes to figuring out why you're in pain.  And rarely should they be a first step along the path towards recovery.

If you ever find yourself with a positive MRI result, don't be too quick to hit the panic button.  The odds that you'll be destined for an operating room are not as high as that report might lead you to believe.

21 Random Thoughts.......

I'd like to share some of the things that I've learned after practicing physical therapy for the past 13 years.  They are in no particular order, nor is this an exhaustive list.  They're just a few of things that I find myself teaching people every day in the clinic. Or they are nuggets of information that I've picked of from experience and through reading and watching folks smarter than I.  Hopefully you'll find one or more helpful. 

1)  If you sit for most of the day, aim to stand up at least 3 times an hour.  If you can walk away from your desk for a minute, even better.

2)  With any exercise you're doing, check your alignment, posture and form.  Without these in check, your sets, reps and weight don't matter so much.

3)  If you feel the need to stretch a particular part of your body constantly, it may not be due to tight muscles or restricted joints.  There may be a reason that your muscle keeps going back to providing you tension after you've found temporary relief from stretching.  Do yourself a favor and find out why, or you'll be barking up the wrong tree indefinitely.

4)  Try to sleep on your back or side, if possible, for optimal spinal alignment.  Stomach sleeping forces you to hold your cervical (upper) spine in rotation in order to breath.  That's 6-8 hours of asymmetry a day that could take a toll on you.

5)  Movement and exercise opportunities are all around you every day.  "Exercise" does not have to involve an expensive gym membership and an allotted time.  Just keep moving, and your most valuable asset (you!) will keep serving you well into the future.  Take it for granted, and down the road it may only give back what you put in.

6)  If you want to help your balance, rather than standing on a wobble board or a BOSU, try taking your shoes off.  Allow all the rich proprioceptors to feel the floor.  If you were going to thread a needle, you wouldn't put thick gloves on, would you?

7)  If you ever experience plantar fasciitis (sharp pain on the undersurface of your foot primarily felt back by the heel), don't ignore your big toe.  You can roll out and stretch the undersurface of your foot and Achilles tendon all you want.  But if your big toe doesn't extend (bend upwards) well, then you may be missing something.

8)  Squat every day.

9)  Get down to and up from the floor every day.

10)  Have somebody take a picture of your full body in profile.  Musculoskeletal dysfunctions that are partly driven by poor posture can only be addressed by starting with awareness.  I see raised eyebrows every day when I show people their "before" pictures, which demonstrates their sense of "normal" posture.

11)  Pain is VERY complex and involves way more than tissue damage.  If it lasts more than 3 months (chronic), there's a great chance that more variables are at play.

12)  The most important thing that I can offer my patients is educating them and teaching them how to take control over their health situation.  It's not some modality that I "do" to them.  They play a part, but teaching folks how to optimize their healing environment and allowing time to do its thing matters more.  Empowering patients is the answer.

13)  If you ever experience pain in one of your limbs, know that the source might not be where you're feeling it.  You need to check the spine to rule it out first.  Otherwise, you may be futilely chasing pain and wasting your time.

14)  Don't ever be afraid to ask your healthcare providers questions.  Nobody is going to care about your health more than you.  Be your own biggest advocate.

15)  Be leery of the healthcare provider who seems to have an answer to everything.  It's impossible.  Rather, value those who are confident enough to say, "I don't know" but who get you an answer in a timely manner.

16)  If you're a runner, watch yourself do a single leg squat.  If your leg is wobbling all over the place and your knee is diving inward, you have some work to do if you want to make yourself a more efficient, less injury prone runner.

17)  MRIs shouldn't been the first stop when you're not feeling 100%.  If everyone with abnormal MRI readings was in some level of corresponding pain, I wouldn't say this.  But that just isn't the
case.

18)  In my field (and any, for that matter), there's really no excuse for not improving myself every day as a practitioner.  The barriers to learning are practically nonexistent with virtually everything accessible in the palm of our hands.

19)  There are no "magic bullet" solutions.  If you want meaningful, long lasting results, you've got to put in the effort.

20)  Beware of those who make declarations such as "Never do this" or "The best way to do that." (e.g., all the Crossfit haters out there).  The human mind and body are just too variable to speak in such absolutes.

21)  Life is too darn short.  Don't overthink everything.  There are many miles between caring and obsessing.  If you find yourself knocked off your plan, don't sweat it.  As long as you're pretty disciplined about your heath most of the time, you'll be alright. 

Again, random thoughts.  If you'd like any further explanation or clarification,  I'm happy to expand on any of the above.

Lacrosse Ball Shoulder Release

Here is a brief video that demonstrates a technique to address limited overhead reach due to tightness and/or pain.  There may be several reasons why this movement would be limited, but this specifically addresses tightness in the pectoralis major and minor (chest) muscles. 

One of the key elements of full pain-free shoulder movement is the ability of the scapula ("wing bone") to move  freely on the ribcage.  Sitting in a slouched position all day in front of a computer might hinder that freedom of motion.  Check out below what to do about it.

The Powerful Yoke of "Can't"

"You miss 100% of the shots you don't take."  ~ Wayne Gretzy

One day when I was in physical therapy school, my class took a trip to Blythedale Children's hospital in Valhalla, NY.  We broke up into groups and were assigned to observe various children.  My particular group sat with a young child of about two years of age.  He had a diagnosis of agenesis of the corpus callosum, which means that the bridge connecting the right and left hemispheres of his brain was not properly developed.  

After our morning of observation, the class gathered in the parking lot to discuss the child whom my group had observed.  She asked us what we thought the future held for this kid.  A few of us ventured forth with some answers, but were chagrinned to hear the professor offer her own grim analysis.  I remember experiencing a sense of helplessness hearing her words.  I'm sure many of my classmates were feeling the same way.

A few years later, I bumped into a former classmate of mine at a New York Board of Education event.  I was pretty shocked to hear what he had to say as we caught up.

"Do you remember the child at Blythedale who we discussed afterwards?  Remember how little our teacher expected of his future?  Well, I'm working with him now.  He's walking with assistance, speaking, and doing several other things that we were told he'd never do.  It's pretty amazing."

What resonated with me after my conversation with this classmate was how a negative prognosis could have hindered this child's progress.  But somehow, despite the opinion of our experienced professor, he was able to achieve.  Would not and could not had turned into can and does.

A couple of years ago, I had a patient who wore a similar yoke of negativity around her neck as she struggled with a "bad" back.  Just the term "bad back" alone had this early 40's patient believing that her body had betrayed her for life.  As I worked with her for the fist couple of weeks, I'd often hear the refrain, "My former therapist told me I can't do that."  Or, "My other PT told me that that will hurt me."  She had built up a wall of negativity and fear that was preventing her from making any progress.  She had allowed her current condition to completely dominate her, rather than finding a way to positively effect her own well-being.

My cousin John Leder and his wife Emily are two fantastic parents to their 5 year-old twin boys, Owen and Charlie and 2 year-old Maeve.  When the twins were born,  Owen developed complications.   John and Emily were told that Owen would be deaf, mute, and likely non-communicative due to his brain injury.  They were told that he would have spastic quadriplegia which would require him to be strapped into a wheelchair to prevent his limbs from flailing.  Potentially devastating news for newly minted parents.  

My Des Moines cousins were unbowed.  Over the past five years, I've witnessed from afar via video and email updates as Owen broke through barrier after barrier.  Here is a clip of Owen graduating from preschool with Charlie, where he says that he wants to be a doctor one day:  

Here is one of Owen playing soccer:

Had John and Emily listened to the can nots, will nots and never wills, perhaps they wouldn't have engaged Owen in all of his therapies and activities.  Perhaps they would have let him fulfill the low expectations set by the "experts" by simply keeping him "strapped" into a chair.  But they didn't.  They want Owen to do everything his brother Charlie does.  Whether he does remains to be seen.  But his parents are giving him the opportunity, which is all that matters.

I am not naive to think that by simply willing and wishing something, it will come to fruition.  What I am suggesting is that by planting seeds of doubt and negativity, you'll surely limit your opportunities for progress and success.  

Stop listening to all the "can nots" and ask "why not?" instead.

"Small Bite" Goals

Yesterday morning,  one of my patients was sharing his stresses with me.   He is burning the candle at both ends and therefore is feeling like a failure at all his endeavors.  He is especially resenting how much his work is pulling him away from his family.  I'm sure you've all been there yourselves.

I listened to him as we worked on his shoulder rehab and offered a suggestion. This morning,  I woke up to a "Thank You" email from him.   He told me that he felt much better after leaving work a bit early to go home to have a catch with his son. 

My advice was simple.  I told him to set a reasonable goal for himself.  Perhaps that is one night a week where he goes home early enough for dinner with his family.  Even if he has to work until midnight the other nights, he'll know he'll have his dedicated time set aside.  It'll ease his anxieties and enable him to work more efficiently.  Most importantly,  he'll get his time with his family.  Conversely, if he sets a loftier goal of being home every night for dinner, it will likely lead to greater work stress and possibly even resentment towards his family.

When I give patients a home exercise program, it's not more than a few things at a time.  I want the goals to be reasonable and achievable so that progress will result.  The same goes for other areas in life.  Lay down one building block at a time.  Feel good about it, and then build on it.  Don't feel as though you have to do it all in one day.  Otherwise, you'll inevitably end up disappointing yourself time and again.

When setting goals, consider taking "small bites."  While not only more digestible, they'll leave you feeling exponentially satisfied.

Mental "Scar Tissue"

Two weeks ago I evaluated a patient who had recently undergone surgery to repair a ruptured quadriceps (above the knee) tendon.  It was readily apparent to me that despite his physical impairments, his biggest road block was fear.

"I'm scared as hell," he told me.

This patient came in with a strict protocol from his surgeon, which allows for a certain amount of knee flexion (bend) each week.  He is also required to wear a protective brace for a specified period of time, progressively "unlocking" it as he gains motion, bears more weight, and heals.

On the first day of treatment, my patient would hardly allow me to assess his leg.  Just this past Friday, after only three visits, he had achieved 40 degrees of knee flexion.  This was already pushing the limits of his protocol, so I shot his surgeon a quick email.  He authorized us to progress past the protocol based on my patient's current state, which we were both excited to hear.

My patient's physical progress and change in attitude in one week were profound.  I'm convinced that the the biggest reason wasn't because of the techniques I used or the exercises prescribed.  It was because I listened to his concerns, answered all of his questions, and provided a ton of assurance.

What is my point?  Your body is pretty darn good at knowing how to repair itself and adapt.  But don't underestimate the role you mind plays as a gatekeeper in the process.  While physical healing involves an amazing cascade of events, you can also simultaneously lay down mental "scar tissue" along the way.  It's simply about allaying fears through education.

When you go see your health care professional, demand to be heard as well as listened to.  In today's break neck pace of health care delivery, it's often a difficult task.  But remember, you are more than just a body part or a symptom.  You are a person with worries, fears and anxieties often overlaying your symptoms.  Just a little bit of compassion, patience and education will help pave your path towards wellness.  Everyone deserves that.

Lacrosse Ball for Knee Pain

In my opinion, the best way that I can help my patients is to educate them regarding their condition, and then provide a simple and realistic treatment plan for them to follow.  A KEY component of the plan is a home exercise program.  Effective home exercise programs must not only have to target the issue, but they also must be doable.  With simplicity in mind, I am also a big proponent of using as little equipment as possible.  One of the least expensive and most beneficial "tools" that I use in the clinic and encourage people to buy is a lacrosse ball.

Here is a quick demonstration of how this three dollar implement can be used to help treat a painful condition:

I hope you find this useful.  I plan on sharing more lax ball self-myofascial techniques in the future.

Normal vs. Unusual

This past week, I was struck by how often I was asked the following question by patients in the clinic:

"Is that normal?"

Most typically they are asking this regarding pain that they are experiencing.  It's a very logical question, whereby patients are seeking assurance or direction about their condition.  I've probably been asked this question hundreds of times over my 13 years practicing physical therapy.  Recently, I've been answering with the following response:

"No, it's not normal, but it's also not unusual."

What do I mean by that?  It may seem that I'm splitting hairs, but I believe there is a distinction between "normal" and "unusual".

I recently came across a simple definition that I think eloquently sums up physical therapy:  The restoration of painless, thoughtless movement.  By this simple description, pain is not "normal".  Most (not all) of the patients whom I see present with unilateral (one sided) complaints of pain and dysfunction.  That makes for a very simple testing approach.  If you can move one side freely without pain but not the other, then this is not normal.  Pain is a subjective symptom that is trying to get our attention for some reason, which may be directly related to tissue damage, or perhaps something even more complex.  It's not "normal" to be in pain.

But is it unusual?  When people ask me if their pain is normal, it's typically not during the first visit.  Rather, it's usually after a period of rehabilitation has gone by, and pain or swelling pops back up.  Unfortunately, progress in rehabilitation is not always linear.  You may go two steps forward, and occasionally one step back.  Or you may find that you have plateaued to some degree.  The reasons for this could be many, but a common one is that as folks progress, they become more active and/or perhaps less mindful, leading to slight set-backs.  It is those times when I'll explain to someone that what they are feeling is not normal, but it's also not unusual.

I find that most people are tough.  Sure, nobody wants to cope with the unpleasantness of a pain.  But in general, they are adept at coping and soldiering on.  What I do find that people are really seeking (along with pain relief) is assurances that they are taking the correct measures to allow for optimal healing and avoiding making matters worse.  It might not seem like much, but when you consider that one can experience pain for reasons far more complex than tissue damage, addressing the psychological component of pain is tremendously valuable.

***One final note on pain.  As I've written in the past, pain that wakes you an night, is unremitting, and does not respond to positional changes is a red flag.  This is certainly NOT NORMAL and requires a trip to your doctor to rule out anything systemic.

Interview With a Personal Trainer

One of the things I like about my job is the collaboration I get to do with other professionals in the rehabilitation and fitness world.  I'm always learning new things and expanding my knowledge base, sometimes shedding old ideas for new ones.  It keeps my job interesting, but most importantly, helps provide my patients with better outcomes.

Over the past several months, Johari Mayfield of Johari Fitness has been coming into the clinic for some hours of observation and collaboration.  A few weeks ago, Johari asked if I'd like to be interviewed for her website.  I thought it sounded like fun and was happy to participate.  Here's the clip below, in which I answer a few questions and offer some insights regarding movement skills, rehabilitation and collaboration:

http://vimeo.com/100241583

What's Up With "Up"?

Last June, I purchased an Up band by Jawbone, one of the many fitness trackers on the market.  My main motivation was to get a read on my sleep patterns.  I was also hoping that my patients would ask about it out of curiosity,  perhaps providing some inspiration for others to move more.

Has it been worth it?  It's difficult to offer a ringing endorsement for this particular product because it had a tendency to break down.  A lot.  In fact, I'm wearing my 7th one as I write this. Fortunately, their warranty policy is excellent and getting replacements was a snap. But nonetheless,  the Up certainly wasn't built to last. 

The band is easy to use.  You just plug it into your phone and a program provides you with all sorts of stats and health tips.  It can be a nice motivator if you find that you're someone who tends to forget to move much. 

Just a couple of days ago, I received a message saying,  "Congratulations!  You just hit 4,000,000 steps over the past 361 days!".  That's roughly 2,000 miles of walking/running, or 12,500 steps per day.

I'm not writing this to pat myself on the back.  I'm sharing this because even though I like to lift some weights and run, I'm convinced that my decent health is largely owed to the walking I do, the general cumulative moving around rather than the directed, focused exercising.

My desire to walk and take stairs rather than look for shortcuts is twofold.  First, it just feels more natural and gratifying.  And secondly, after having the good fortune to have worked with kids with special needs for ten years, many of whom were wheelchair bound, I told myself that I would walk and take stairs simply because I'm blessed to be able to do so.  I don't take it for granted.

This is not rocket science.  Move more now while you can, and you'll improve your chances of moving on your own well into the future. 

Avoid "Tech Neck"

If you sit all day staring at a screen, do yourself a favor.  Don't follow that up with a commute home spent staring at an even smaller screen.

Sometimes it feels as if all of our advances in technology are leading us on a backward evolutionary slide.  We came out of the womb small, but gained the strength to be tall.  Unfortunately, our gadgets have done a great job pulling us back into that fetal position.  Don't let them.

If you find that your neck and shoulders are sore and painful, don't hit the panic button right away.  Rather, try the simple practice of putting your phone away, getting the crown of your head as tall as possible, and letting your shoulders sit back in a relaxed position.  You may find that a simple postural "re-set" is all you need to alleviate your discomfort.  If that is the case, then try to work in more resets throughout your day until you restore the naturally good posture that you likely once possessed.

Good posture can help minimize unnecessary and annoying aches and pains.  It starts with awareness.  Try giving your electronics a rest, get your head up, and see what else is going on.  Your neck and shoulders will thank you.

Less (But Better) is More

"How many?"

That's often the question I immediately get when I teach someone a new exercise.  It tells me that the patient's focus may be on "getting it over with" rather than doing it correctly.  I would much prefer the latter to the former.

With that concept in mind, I've attached this video to provide an example of how you can use an external cue to help "coach" you to use good form.  The exercise is called the birdog, and it's an excellent way to improve posterior chain (back side) strength.  But to do it correctly requires good core control and stability.

Keeping the foam roller balanced on your lower back requires control and stability in both the sagittal (front/back) and transverse (rotational) planes of movement.  It's also hard to race through the repetitions without knocking it off your back.  The roller is a simple external "coach" to get your to focus on your form rather than getting to the last rep.

The next time you're doing an exercise, slow it down and focus on your technique before worrying about how many repetitions you will execute.  You'll likely find that the slower, more deliberate movements are even more taxing than the high-speed, sloppy method because you won't be masking your compensations with speed.  Give it a try.

The Demand of Sand

While out for a run in my hometown last Sunday morning, I noticed how much sand was in the streets.  It looked like the beach was brought to Garden City, the remnants of a long winter and a pleasant reminder that spring and summer are, at long last, on the horizon.

It also got me thinking about what a great natural resource we Long Islanders (and all folks within driving distance of a beach) have at our disposal.  Miles of sand are within our reach, and can be used as both a rehabilitative and a training modality.

This article in last week's New York Times discusses neuromuscular training and its benefits towards reducing the risk of ACL (anterior cruciate ligament) knee injuries.

http://well.blogs.nytimes.com/2014/03/19/how-a-warm-up-routine-can-save-your-knees/?_php=true&_type=blogs&emc=eta1&_r=0

What is neuromuscular training?  Think of you body as a computer, with the muscles, bones, ligaments, tendons and fascia acting as the hardware, and your nervous system acting as the software.  Our movements are dictated by, among other things, the continuous interplay between these systems.  And this system needs to be maintained, trained, and honed if we want to get maximal performance from our bodies.

When we get injured, our neuromuscular system can get thrown out of whack.  Our motor control is altered when pain is present.  Even when pain dissipates, we may still be devoid of an optimal level of communication between our software and our hardware.  This can be remedied by retraining the system.

Injuries often occur when an unexpected force demand is placed on our body, and our tissues (bone, muscle, ligaments, tendons, etc.) are not up to the challenge by being able to reflexively adapt.  In addition to maintaining strong and flexible muscles and tendons, as well as mobile joints, neuromuscular training can help your body learn to expect the unexpected.  By training this system, you will be more likely to withstand these unexpected demands on your body.

So, take advantage of the abundant local natural resource that is sand.  Whether you are in the more advanced stages of rehabilitation, or if you are preparing yourselves (or your kids) for the spring sports season, do yourselves a favor and get down to the beach.  Take your shoes off and go for a walk on the sand.  Walk on the packed sand by the water's edge, in both directions so that you take advantage of the slope on both sides of your body.  Then be sure to walk on the softer sand.  This activity, while not only enjoyable for the very act of being by the ocean, will do wonders for your neuromuscular system.

It's been a long winter here in the northeast.  Aren't you all ready for a little beach time right about now?

Part-Time Maintenance

"Get in shape in time for the summer!!"

This was posted in the front window of my gym this morning.  I can understand why the management would use such a tactic to temp people to sign up for a membership.  But I sure hope that the people inside were working out for more than the aesthetic appeal of looking good in a bathing suit.

Why should exercising only be a part-time pursuit, whereby effort is ramped up as temperatures rise and layers are peeled off?  Would you only take care of your car in the summer time?  Would you only sock away money into your 401(K) during the warm months?  The answer, hopefully, is NO.

I have stated before that taking care of your body, the only one you've got, is an investment in both the present and the future.  We all know that eating well and exercising are keys to feeling good and staying healthy, yet current statistics reveal just how challenging that's proven to be for our society.  Rather than tackling your health in spurts of effort tied to the calendar, strive for consistency.  Take the tortoise rather than the hare approach.

If you care about how you look in a bathing suit, fine.  But don't make it your focus.  That shouldn't be upon what gym memberships are based.  A healthy body with functioning systems that will stand a better chance of offering you longevity and QUALITY ought to be the objective.  That way, you will be able to enjoy that pot of gold that you've diligently and methodically invested in throughout your work life.  As a side benefit, you'll probably end up feeling just fine in your summer clothes.

Grateful For Pain

I'm a big fan of analogies when it comes to explaining things in the clinic.

Today, my 8am patient expressed disappointment that her thus far linearly progressing improvement had been derailed.  For the first time since commencing therapy following a fracture of her humerus (long arm bone), she experienced an increase in pain and assumed something was wrong.  From the outset, this patient had openly expressed her apprehension and fear of pain.  I had to work to build her trust, and today we had a good discussion about pain.

Pain is a GOOD thing.  Without its perception, staying alive and healthy becomes infinitely more challenging.  Imagine how difficult it would be to keep from harming yourself if you could never feel a hot stove with your hand or a rusty nail in your foot?  For the sake of simplicity, I will avoid bogging you down with the details of the neurophysiology of pain perception.  Rather, I'll use the following analogy.

If your body were a car, imagine pain playing the role of both the steering wheel and the brakes.  If your car were cruising down the road at 65 miles per hour and all of a sudden it began to veer out of your lane, you'd use the steering wheel to adjust and compensate.  If you were driving in the dark and a deer ran out into the road, you'd instinctively hit the brakes to avoid a collision.  Pain can both steer as well as limit or stop your movement.

A common concern that many people have is the fear of "doing more damage" if they continue to perform such-and-such behavior.  I think most folks can tolerate a certain degree of pain, as long as they are assured that nothing "serious" is wrong, and that it is only temporary.  The simplest advice I can offer my patients is to use pain as a guide when it comes to movement.  Don't be afraid to move.  Rather, explore movement in the affected area.  If that's too intolerable, then try moving the surrounding joints in a pain-free manner.  Never barrel ahead with a "no pain, no gain" mentality.  Rather, tease the edge of your pain tolerance with gentle repetitions until you edge that barrier back towards normal functional limits.  This is likely what occurred with my patient this morning.  Her body is diligently healing itself at a normal pace.  Perhaps her progress lead to some over exuberance, and she pushed herself too far.  Not to worry.  We simply dialed it back and used her pain to steer her back into a safe lane.  

If your drifting car didn't have a steering wheel, then you would be liable to end up going off the road.  If your car wasn't equipped with functioning brakes, then you might hit that deer head on.  Disaster in both cases.  Thankfully, functioning cars are equipped with these vital features.  If not, the only safe bet would be to never remove the car from the garage.  The resultant disuse will cause all of its other moving parts to begin a slow, steady decline.  Eventually, your car would never be able to go anywhere.

Don't be like that car sitting idly in the garage.  We were born to move.  Rather than fear pain, embrace it for its protective role and be grateful for it.  Recognize its power to keep you alive and regulate your movement as your body heals itself.  When it's finally gone, get back to moving well.

IMPORTANT FOOTNOTE ON PAIN:

Not all pain is the same.  Should you ever find that pain WAKES you up at night, or that you have pain that is unremitting and unresponsive to positional or activity changes, go seek medical attention.  You must rule out that anything serious and systemic is going on in this case.  In addition, please don't misread the above to suggest that anyone should SEEK pain.  Pain alters motor control (meaning it will cause movement compensations).  We don't want to move for too long with poor movement, because our brains will record these aberrant patterns.  The quicker we can rid our bodies of pain, the faster we can get back to restoring healthy movement.

Where Have You Gone, Mrs. Robinson (and Mr. Philips)?

Things seemed much simpler in the 70's and 80's.  There were no 7-point harness car seats.  We just slammed around the back of the wood paneled station wagon like air hockey pucks.  Gluten and GMO food wasn't in the vocabulary.  Kids played an hour or two of organized sports on the weekends, and then played with their friends and families the rest of the weekend.  Not anymore.

My kids are too young to have hit the sports insanity full force.  As much as I'm excited to watch and coach my kids on the sports field, whichever one that may be, I have some trepidation about the current sports landscape out there.  Kids are specializing in sports at such a young age, with camps and select teams that seemingly suck up every free moment of their lives, not to mention their parents'.  It's a highly competitive environment, with big money stakes by way of collegiate scholarships in the offing.  While I'm all for esteem-building competition and team camaraderie, I wonder if the pendulum has swung too far?

I just read an article in Sports Illustrated about Roy Hibbert, the 7'2" center for the Indiana Pacers.  He's in the midst of a breakout season, and his team is seriously challenging Lebron James' Heat for Eastern supremacy in the NBA.  One thing that I found interesting in the article was the fact that while a freshman at Georgetown University, Hibbert was unable to execute a single push-up or stand up from a chair without using his hands.  Here was a Division 1 college athlete who was too weak to move his own (albeit massive) body via fundamental movements.  Unfortunately, the article did not mention one thing about his current workout routine.  I happen to know that Hibbert spent the summer preparing for the season by working with Mike Robertson at IFAST (Indianapolis Fitness and Sports Training), a trainer whom I follow online.  It would have been nice for readers to recognize the relationship between strength and fitness and athletic success.

Back to the '70's.  Mr. Philips and Mrs. Robinson were my grade school gym teachers at Stratford Avenue School.  In hindsight, they really knew what they were doing.  I remember bear and crab walking across the length of the gym floor.  I recall climbing ropes and cargo nets to the height of the gym ceiling.  I remember playing hockey, softball, football and soccer.  I remember the annual "Olympics" which involved a myriad of events, from tire jumping, to softball tossing, to sprinting, to tug-of-war.  I remember early morning gymnastics.  We did it all.  And it was fun!  Sure, I didn't always love bearing walking back and forth.  But by having us do these exercises, Mr. Philips and Mrs. Robinson provided the building blocks to create successful future athletes.

I wonder if today's gym teachers are following in their footsteps?  I wonder if today's youth coaches are too focused on sport-specific drills rather than the fundamentals of foundational strength and movement?  I suppose I will find out over the next several years as my kids grow into the sports scene.  But I sure hope that the adults in charge of the sports programs don't foster the college version of Roy Hibbert in the pursuit of creating the next Lebron James.  I hope that coaches, gym teachers, and parents recognize that the basics always matter, and that keeping it simple will ultimately yield more healthy and successful athletes.

Next time your child scores the winning goal, touchdown or basket, give them the praise they earned.  But don't forget to check if they are still able to handle the basics.  Can the do a push-up?  Can they squat down and stand back up with ease?  Can they crawl a distance with their knees off the floor?  Can they stand up from a chair without using their hands?  Amid all the pressures of today's youth sports landscape, don't neglect the basics.

Resolutions With a "Why?"......Part II

I do not know everything about rehabilitation.  Not even close.  But I know enough to know what I don't know.  Sometimes I wonder about others.

Today, within an hour's time, I heard the following from two patients:

Scenario 1:

When I encouraged a 30-something year old man to strength train, he responded with:

"My martial arts instructor told me that I shouldn't lift weights with my arms, because having strong arms will take away from the strength of my legs."

Scenario 2:

While evaluating a three-month pregnant woman presenting with back pain, she said the following:

"My nurse practitioner told me that I shouldn't bend forward because I could break the baby's neck."

My female patient at least did her due diligence and Googled whether or not bending forward can harm her fetus.  Not surprisingly, she did not find anything to validate her healthcare professional's statement.

Reiterating my theme from a prior post, don't be afraid to ask, "Why?" when you are given advice about your (or your baby's) well being.  I'll admit that there is an overwhelming wealth of information on the internet, and finding trustworthy sources can be daunting.  However, I would recommend starting with a simple self-test.  Ask yourself, "Does this seem to make sense?"  Unless the answer is an unequivocal "yes" , then go find a second and third opinion.  Don't take every statement made by ''experts" at face value.  At a minimum, you might be depriving yourself of something.  At worst, you may be doing yourself harm.

Get informed.  Nobody cares more about your health and well being than you.

Don't Be "Creepy"

The below image was included in an article I was reading this morning about Superbowl ticket prices:

It's a pretty ordinary looking work scene.  However, the thing that jumped off the page at me is the poor posture assumed by the two figures in the foreground of the shot.  Look familiar to you?  Do you think that you spend most of your waking hours in a similar position, only to follow it up with a commute staring at even smaller ipad and cell phone screens?  If so, here's a simple piece of advice for you.

Try standing up every 20 minutes or so if you have a sedentary job.  The reason for this suggested time interval is because of a phenomenon called ligamentous creep.  After about 20 minutes, ligaments (connective tissue that provides passive support to your skeleton) begin to elongate and stretch out.  By simply standing up a few times an hour, you will help "reset" those ligaments.  Of course, there are many exercises that can help strengthen the dynamic (muscles/tendons) supports of your body, but this is about as basic as it comes in terms of interventions.

Many patients tell me that they simply forget to move during the workday because they are so engrossed in their work.  Here are a few simple tips:

-Drink plenty of water.  In addition to being just plain good for you, it will force you to go to the restroom frequently.
-Set your smart phone alarm as a reminder.
-Move your copier/printer away from your desk so that you are forced to get up.
-Stand up every time you receive or make a phone call.
-Use post-it notes on the corner of your monitor to remind you to get up.
-This is a more expensive solution, but many of my patients who work at Google have invested in adjustable sit to stand desks, so that they can spent part of their day working in standing.

If you spend most of your day in this flexed forward posture, commit yourself to getting extended.  You will minimize ligamentous creep and its potential uncomfortable consequences.

Resolutions With a "Why?"

Earlier today at my gym I witnessed a man in his 50's working out with a trainer.  He was performing goblet squats with overhead presses using a kettlebell.  It appeared that the trainer was timing his client to see how many repetitions he could perform in a set period.  After a few reps, I heard the trainer say, "Come on.....I want your hips to bend more.  I want you butt down by your knees when you squat."  His client dutifully pressed on, no questions asked.

It's the beginning of a new year, and with that comes the inevitable spike in resolutions to get in better shape.  I'm all for that.  But the purpose of this post is to remind you that it's perfectly okay to ask your trainers, "Why" when they ask you to do a specific exercise.  After all, you're probably paying anywhere from $60-150 a session for the privilege of having someone make you sweat.  Don't be afraid to question the exercises you're asked to perform though.  In fact, I would think that the first thing that a good trainer would ask his/her client prior to commencing a program would be, "What are your goals?"  I would also hope that the trainer would put their new client through some sort of movement assessment prior to working them out, in order to determine that individual's red, yellow and green lights on the road to improved fitness.

I have no idea if the trainer in the above situation had already screened his client.  Perhaps he knew that his client possessed the requisite ankle, knee, hip and spinal mobility and motor control to squat deeply.  But if not, then asking him to "get deeper" in his squat with a weight in his hand doesn't make much sense.  Perhaps a better approach would be to work on a competent squat technique with no load first, and then load it up once that's achieved.  My guess is that it's the rare client who would stop to question their trainer.  The reasons for this may be myriad:  1) The trainer is the expert, and therefore "knows best"; 2) The client's ego drives them to finish the task, no matter what; 3)  The client is paying by the hour, and doesn't want to take time to discuss the "why".  These are just a few reasons why a trainer/client relationship may not reach it's full potential.

Again, I'm all for folks resolving to improve their levels of fitness.  But I also want people to do what's best for them, rather than simply following the latest exercise flavor-of-the-month trend.  It's your body, your time, and your money, and you should always feel comfortable asking the "experts" tasked with keeping you healthy, "Why?"

Prayers at Disney World

Over the past week, I have been fortunate to enjoy some fun times down in Disney World with my family.  There is nothing better than to see the smiles on the kids' faces derived from all the rides and characters.  It also hasn't hurt being down here during a week in which New York endures another deep freeze!

From a professional perspective, I enjoy being at a place like this for all the great people watching.  I have witnessed all sorts of body types, gaits, disabilities and ages wind their way through the various parks.  It's like a big, free laboratory.  So while my wife and older kids waited on long lines, I willingly offered to wait with my one year old so that I could just observe.

One thing that I witnessed yesterday got me thinking.  I passed three people who were knelt down in prayer while people passed by all around them.  I would guess that these three folks were in their 50's.  Each of their positions demonstrated full ankle, knee and hip mobility.  I didn't stick around to watch them get up from the ground, but my guess would be that they could do so with ease.

Seeing these people in prayer made me wonder if there is sociological difference in the prevalence of back pain.  I wonder about people who never stop practicing the task of getting up and down from the floor because daily prayer requires them to do so?  I wonder about people who never stop squatting, because squatting is how they eat or go to the bathroom?  I am curious if these people experience the same high incidences of low back pain as do typical westernized folks, ones who spend most of the day sitting?

Years ago, my grandmother fell and fractured her hip.  She spent 24 hours on the floor before my aunt discovered her.  As is the case with many such injuries with the elderly, my grandmother's hip fracture was the beginning of her physical demise, from which she never fully recovered before ultimately passing away.  Now, I'm not saying that my grandmother would have been able to stand up on her own to get to the phone with a fractured hip.  But I would bet that had she been asked to get down to and back up from the floor on her own the day prior to her fall, it would have been impossible.

So, here's a little test for you.  Grab two minutes of free time today and try getting down on the floor.  Then try getting back up.  Did you struggle?  Was it harder than you thought?  Did you find yourself having to use your hands to push yourself up from the floor?  Did you find yourself reaching for some external support to assist you (e.g., a piece of furniture)?  Where you able to get up with equal ease to both sides, or did you notice an asymmetry in the ease of the task?

For many of you with a million things going on in your life, I'm sure getting up from the floor is the last thing you are concerned about.  But if you practice this simple life skill now while still able, then one day when called upon, your body will be there to respond.  Just think of it as an investment in your physical future.