FUBAR

FUBAR.

A military acronym that stands for ( lets use the sanitized version ) [Fouled] Up Beyond All Recognition. Apparently Fubar originated back in WW2 and is slang (mangled German) for the word "Furchtbar" which means terrible or horrible. When it comes to the current state of the healthcare system, terrible or horrible just don’t do it justice. The healthcare system is, in my opinion, FUBAR.

As a physio for almost 24 years I have been through the healthcare trenches, and seen many changes. I mean, when I started EMR wasn’t even thought of! We were scribbling notes out and writing out charges. In PT school I may have touched a computer once. I literally had to photocopy ( 10 cents a page) every article I wanted to read! In short, … I’m old!

We have made incredible progress over the years in our profession with some amazing clinicians developing and progressing the profession. However at the same time we, collectively (PTs, MDs, admins, politicians, insurance companies – the medical industry)  have completely failed our patients. Sure , there are amazing stories of innovation, we are saving more people from maladies that would have killed them years ago, we are transplanting organs, performing surgeries only once dreamed of, and many people are living healthy lives in the western world. Yet at the same time, when we look in at the experience of the patient, our client, the person right in front of us that has come to us for help it is a frightening tale of failure.

This really rang true to me this week with a couple of patient encounters. The saddest part is that these two stories are not rare in today’s system. I guess I should have written this earlier. I don’t know why it has struck me now to speak out… maybe I’m just getting into my grumpy old PT mode as I age…. Or maybe healthcare is getting worse.

Patient 1:  A middle aged gentleman. Referred by an orthopedic doctor with the diagnosis of “tennis elbow.” He tells me his pain started a month ago when he was turning a stuck valve and felt a pop. He has had increased pain since. He tried OTC meds without relief and it got to the point that picking up objects was painful and really affecting his work and home life. He saw an MD and, of course with NO alternate options on their mind for musculoskeletal pain, went through a month of NSAIDS, then injections- all with no relief.  After a follow up visit in a month it (for some reason) occurred to the MD that a referral to physiotherapy may be appropriate. If it persisted, imaging was the next stop (MRI).

On a brief evaluation he had pain and tenderness at the radio humeral joint and pain with resisted supination. No real pain with any resisted wrist motion, no radial nerve signs and an otherwise clean exam. After a manipulation of the radial head and soft tissue work and dry needling to the supinator he reported instant relief.   

   

Lets look at a few of the multiple problems here:

1) The same insurance paid the physician 4x as much as they paid for my service – TWICE. Then paid for medications, and steroid injections, and almost an MRI.

2) This man spent a month in pain affecting his work and family life all based on a diagnosis that really appears to be wrong.

3) Taking NSAIDS (which did not help) can have significant effects on the GI system and as was recently highlighted by the FDA heart attack and stroke risk increase even with short-term use, and the risk may begin within a few weeks of starting to take an NSAID. Furthermore, steroid injections are also not without risks and side effects.

Patient 2:  An 81 year old gentleman who comes for evaluation for chronic back pain. He has had pain on and off since his twenties which has become constant and severe. Reviewing the history I see that he has had an implanted spinal stimulator, injections, has been on opioids and has been followed by “pain management” for years. He recently had his opioids cut back. Sixty years of pain (30 of them bad by patient report), this wasn’t exactly an eval I was excited to be a part of. Yet when I went in the room I was met by a pleasant and kind man who explained that he was primarily frustrated because his pain is limiting him from caring for his wife who is suffering from dementia and needs almost around the clock care and supervision.

He had placed her in an assisted living center but when he went to visit found she was not receiving good care and he wanted better for her – thus bringing her back home. He is doing everything at home and even obtained a bed alarm that alerts him when she gets up at night and wanders. She had once wandered out of the house alone in a confused state. He also reports that he is no longer able to sleep well.

I went through my eval and did discover some issues I felt we could address physically - significant loss of hip and knee mobility, hypomobility through the lumbar spine and significant trunk and hip weakness to highlight a few. Along with the obvious need for pain neuroscience education I felt that we could definitely help this man, at least to some degree. The most shocking part of my evaluation is when he told me he had not seen PT before. He stated that he was “tired of going from medication to medication and having injections” and continuous procedures. He literally said, “I feel like exercise and moving is what I need.”

This gentleman had been stuck for decades in the medical industrial complex being pushed from one med to another, one intervention to another, and obtaining no relief. He underwent procedures that had risks and side effects and was taking numerous meds and opioids with all of their risks. At no point did anyone actually place their damn hands on the man and assess his movement. At no point in all these years was therapy suggested. At no point was he provided education on pain to decrease catastrophizing and fear avoidance behavior.

I was dumbfounded. We, collectively as a medical system and as a society, have failed this man. I believe that even after all these years he can improve. However, think of the possibilities if he had been managed differently all these years. How would that affect his life now? How would that affect his wife’s life now? We will never know what could have been but I do know it could have been better.

I want to be clear that I do not write this so as to place blame on other providers and elevate my abilities. I mess up on a daily basis. I don’t make the right decisions on treatment every time I see a patient. I don’t always address psychosocial issues as much as I should. I don’t always progress and develop my treatments as well as I should. We are all human. Almost all medical providers have nothing but the best of intentions. However they are often stuck in a system that is FUBAR.

I know I can do better. I know we can all do better. We need to do all we can to get our voices out there and let everyone know that we are the alternative to meds, imaging and surgery. I am so grateful for so many voices in our profession that have begun to speak over the noise and bring forward thinking solutions and promoted the profession like never before. @timothywflynn , @jeffmooredpt, @theaphpt, @dr.mitch.dpt, @ryansmith.dpt, @updocmedia, @theducklegs, and of course @physio.praxis  (Just to name a few)

Physical Therapists are the answer to so many of our systems issues. We owe it to our patients to work on being a solution and not another cog in an out of control system.                                           

Assessing and Improving the Hollow Body Position w/ Dr. CJ DePalma PT, DPT

Intro & Simplified Kendall Leg Lowering Test:

#MondayMusings:
From @the_movement_dr:

This week I teamed up with Doctor of Physical Therapy candidate, CrossFit coach, #CWCC & @clinicalathlete student forum member, @physio.praxis to use the reliable and valid #KendallLegLoweringTest as an objective measure to determine where your athlete or patient is on the #HollowBody spectrum.

Scoring is as follows:

3 - From 90 to 45 degrees: These athletes will compensate through the hip flexors, extending the lumbar spine when asked to hold a hollow just off of the ground. They will build upon dysfunction in an effort to get into appropriate position.

2 - From 45 to 15 degrees: These athletes maintain control throughout most of the movement, but begin to lose that control at the end range of movement - say on a heavy-ish shoulder to overhead or after a few toes to bar.

1 - From 15 to 0 degrees (or to the ground): These athletes exhibit good strength, endurance, and control of the anterior core and are well prepared for loading and dynamic movements.

Here @dani.f.baby would be on the border of 2 & 1. 

Over the next few weeks we will be providing exercise progressions and suggestions to build upon where the athlete currently stands. Keep in mind, core strength and endurance can be subjective—but this system aims to provide a starting point for you, your athlete, and/or your patient. Tune in next Monday for the first progression, or for the full series, follow the link in @praxis.physio's bio! 

Cite:

Staniszewski B, Mozes J, Tippet S. The relationship between modified sphygmomanometer values and biomechanical assessment of pelvic tilt and hip angle during Kendall’s Leg Lowering Test of abdominal muscle strength. Proceedings of the Illinois Chapter of APTA, Fall, 2001.

Level 3 First Progression: Single-Leg Active Leg-Lower:

#MondayMusings:

This test is a good starting point for those athletes who have difficulty getting into the hollow position. By taking a limb out of the equation, we reduce the force demand of the core and the difficulty of the task.

Many athletes make a common fault when “contracting” the deep core, or transverse abdominus (#TrA), where a hyperactive or excessive contraction is produced. This in turn engages the lumbar parapsinals -- creating over extension of the lumbar spine.

Points of Performance:

-Exhale the entire downward motion of the exercise while keeping the lumbar in contact with the ground.

-Once 15 degrees is reached, the athlete will isometrically hold—inhale and exhale—then bring the leg back up to 90 degrees.

-Avoid External Rotation of the leg, focus on keeping the leg linear throughout the full movement.

-Repeat 8-10x

Progressing from Level 3 to 2: Dead Bug Upper Extremity Isometric Variant

#MondayMusings:

The #DeadBug against the wall is a good starting point for those with a score of 2, or as a warm up/ramp up for athletes who score a 1 prior to lifting or gymnastic movements. This variation employs the use of upper extremity isometric firing to light up the central nervous system (#itsLIT), which in turn increases neural firing to the deep core musculature.

Points of Performance:

-Forceful exhale prior to initiating the movement followed by a quick inhale to breathe into the created tension while pressing into the wall or weight.

-Raise the tailbone slightly off of the ground and lower one leg slowly. Make sure that the pelvic positioning is maintained during this eccentric motion

-Repeat for 5-6 breaths per side.

Tune in Monday for the next progression with @the_movement_dr, or head over to #MusingsOfMills -- link in bio. 

Level 2-ish: Plank to Pike on Rower:

#MondayMusings:

Our 3rd installment for the #KendallLegLoweringTest is the Plank to Pike on Rower. This exercise is for those who scored a high-level 2, moving closer to a 1 during the test.

The starting position of this movement is opposite to the starting test position and the previous two exercises. We begin in a bottom up fashion: starting in a plank then working towards a Pike. By doing so, we are able to increase our initial lower core engagement in a concentric fashion.

We need variance to create change, and this movement fulfills just that.

Points of Performance:

- ROM may become an issue, just pike as high as you can and the exercise will still maintain the benefits.

- Exhale as you pike up

- Hold for 1 to 2 seconds at the tope

-Slowly lower the body back down

-Repeat 4-5x 

Levels 2 to 1: Bar-Supported Leg Raise:

#MondayMusings:

In our second to last exercise, again for those on the border of 2 & 1, we use a barbell (or heavy resistance band) to externally cue the athlete (@dani.f.baby) to maintain a #hollowbody position while perform an active leg raise.

Points of Performance:

-Begin by exhaling and elongating your spine, while gently hollowing the low back into the bar or band

-Brace the core, squeezing the feet and quads together synchronously.

-Initiate the movement with your lower abdomen (focusing on engaging the internal obliques and TrA) similar to how you did with the #pike.

-Only lift so high as you can maintain the position without compensation, i.e. beginning position.

-Repeat for 5-6 reps/breaths or until fatigue

This can be paired with a #hollowarch to begin working on the movement specificity needed to perform all #kipping movements, especially if you turn into a #FloppyBaby as soon as you attempt full speed. Tune in next for the final exercise - or visit #MusingsOfMills -- link in bio .  

Level 1: Strict Hollow Body to Arch

#MondayMusings:

For the athletes who have made their way through the progressions or for those who scored a 1.

The Hollow Body to Arch Strict Transitions are the ideal precursor to any kipping Bar or Ring movements.

Focused and controlled transitions will help engage the #Lats and #Trunk in the free-hanging #HollowBody position, as well as improve our bodies kinesthetic awareness as we engage in movement towards an arched position.

Points of Performance:

-Do not swing. Stay as still as possible. Synchronous, co-contraction.

-Keep your body elongated and your feet touching.

-Each transition from Hollow to Arch should take roughly 3-5 seconds

-Repeat 8-10x

     

Improving the Split Jerk: A Self-Case-Study

#MondayMusings:

Ever since tearing my ACL 3 years ago everything that resembles a lunge has given me problems. They feel uncomfortable and weak in comparison to squatting motions, and have since formed a mental block that has always made me nervous to go heavy – especially on the split jerk. Ever since the @cwcseminar, @elisbad7 has been programming them regularly, and I’ve been using what I knew before, along with cue’s and drills that I picked up from both @quinn.henochdpt and @ricky_redus to work towards evening out the weight with my power jerk.

Step one was to incorporate bottoms up kettle bell presses with a focus on maintaining a stacked spine to work on the strength deficits from one shoulder to another, along with a bias towards keeping my core controlled, spine stacked, and rib cage down. Here is a simple progression and self-cue that I find helps facilitate this by both keeping the ribs down and palpating the serratus anterior. I will be piecing together a review of current literature that speaks on current evidence of unstable load training for unilateral strength improvement and as a rehabilitation tool over the next few weeks.   

#MondayMusings:

There are varying opinions amongst researchers on whether or not training with an “unstable load” is effective or not. Some researchers say there is no striking difference in shoulder activation using a #barbell vs. a #dumbbell at the same weight, some say that training with an unstable load offers no additional benefits for force and power production, and some say that co-contraction of the musculature around the joint is always a good thing.

I follow the train of thought that there is a give and take between what the research says and what has been used as an effective tool in varying settings. I have not stumbled upon a prospective study on the ongoing effects that a majority bilateral training program has on the body, but I know #CrossFit has a lot of it. If you are only using an evenly loaded barbell for the majority of your training chances are your strong side is getting stronger, and your weak side is getting weaker.

The Half Kneeling Landmine Press is a unilateral movement, which some would call intrinsically unstable, and has been shown to cause greater recruitment of the local core musculature, specifically the internal obliques and transverse abdominous. I have found that the specificity of training in this position gives a foundational and simple awareness of what you should be feeling in the feet, hips, core, and shoulder during a #splitjerk. Also, try adding in neuromuscular re-ed because your lock-out is slow, soft, and self-limiting. 3x8-12 with a two second pause at the top, 3 seconds on the way down, explode up.

Cites:

Behm D, Colado JC. THE EFFECTIVENESS OF RESISTANCE TRAINING USING UNSTABLE SURFACES AND DEVICES FOR REHABILITATION. International Journal of Sports Physical Therapy. 2012;7(2):226-241.

Kohler J, Flanagan S, Whiting W. Muscle Activation Patterns While Lifting Stable and Unstable Loads on Stable and Unstable Surfaces. Journal of Strength and Conditioning Research. 2010;24(2):313-321. doi:10.1519/jsc.0b013e3181c8655a.

#MondayMusings:

When I was a freshman in high school I remember performing lunges for the first time in an exercise setting, and I hated them. I can picture the trainers face when I said something like, “Yeah, the lunges feel okay, but they really just hurt my big toe.” He seemed bewildered, and stated that in all his years of training, he has never once heard that. It was not until I learned of the Windlass Mechanism that my statement was validated.

Clinicians argue that you need between 45-60 degrees of big toe extension for proper walking mechanics, and 80 degrees for proper running mechanics. When I first goni’d my big toe in PT school I was rocking out at a lackluster 30 degrees, bilaterally. My entire big-toe-life had been a lie. The Windlass Mechanism utilizes the elastic properties of the bottoms of your feet to transfer energy at toe-off during walking and running, and I had utilized virtually none of it for years.

The #WindlassTest is traditionally used as diagnostic tool for ruling in plantar fasciitis, but can also be used to determine hallux rigidus, or a really stiff toe. Here, @djhousebrother and I use it to determine the latter in the first clip.

The stretch performed in the second clip can be utilized both dynamically for a warmup, or held for a prolonged, static stretch. Current evidence suggests that a stretch must be sustained for ~20 minutes to truly add length to the tissue. Tune in Wednesday for exercises and points of performance to solidify positive outcomes. 

#MondayMusings [Extended Edition]:

We’re going to Tarantino this and give you the end first: turn your sound on and listen as @djhousebrother breaks down what your back foot needs to be doing in the #SplitJerk.

If your big toe doesn’t extend, your body will compensate – when walking or running, you may push-off on the outsides of your feet, or your arch will just collapse. In a lunge/split jerk position, that uncomfortable feeling of your big toe slamming into the ground will, in turn, cause the body to move away from that uncomfortable position through compensation – whether that be in the other joints of the foot – or the ankle, knee, and hip. Some can get away with it, others cannot – but if you are not getting into the optimal position, you may not be reaching your maximum potential.

In the second clip, Josh demonstrates a simple Step-1 to gaining motor control in that new range we got from the previous video, all the while focusing on weight bearing through that first ray of the foot. Step-2 increases specificity of the movement in the #lunge – work in a pain-free range as a warm up and work on optimal hip and foot alignment. Then begin to load the movement with 3-4 sets of 10-15 reps, first by increasing depth, then by adding weight to make it a strength training accessory movement. Step-3 is the Bulgarian Split Squat – follow a similar fashion as the lunge by working into depth and tolerance, followed by load, depending on the goal of the athlete.

Clip three, and Step-4 puts it all together in the #JerkBalance – here focus on technique and timing before loading the bar, as the timing of a jerk may be just as beneficial as loading it, especially for beginners. The jerk balance is a great drill to perform between your initial warm up sets to hammer out any inconsistencies.   

A Case Study w/ [sl]Amber

Intro: A Case Study w/ [sl]Amber:

A few hours prior my friend @amberm88 was a Cranky-McCranky-Pants, mopping around the gym with a whole lotta low back pain. She had been unable to pick up a barbell without pain for the past two weeks. Want to see what went into these clips coming to be? Then PAY ATTENTION.

Amber was training hard for a competition. Amber moves a lot of weight frequently. Amber is a proficient and fluid mover. Amber is athletic and knows how to compensate really really well, almost to the point that you probs wouldn’t even notice that something is wrong. WRONG: Amber has a really stiff thoracic spine, or, upper back.

The training that goes into being an elite CrossFit athlete involves weightlifting and gymnastics. These two modalities of movement exist mostly in the sagittal (forward and backwards) plane, this is what one could refer to as a training bias. Considering her impressive athletic history, Amber used to ball on sucka’s in softball and basketball, both of which include frequent thoracic rotation. Now, not so much.

With the foundational idea of treating the athlete as a whole, I made a student-hypothesis: Make one segment move better to offload the other segment. This is what happened.

**Disclaimer**: I am a student, and this is not medical advice. If you are seeking medical advice refer yourself to a local physical therapist.

Testing, Testing; 1, 2, Rotate:

You can think of most joints that don’t move well as a stuck drawer. How do you open a drawer whenever it is stuck? There is a scientific approach to mobilizing joints, but for the sake of simplicity and wit, do you rip that beast straight out? NAH. You wiggle that thing. You wiggle it and then see what happens. More often than not that wiggle will grease the tracks and the drawer will slide right out.

Apply that to your thoracic spine. Amber had limited wiggle once you limited movement in her hips and lumbar spine (low back) on the bench. In my personal experience working extension on a foam roller is waste of time, because you can so easily compensate in other areas.

Not to mention a lack of thoracic rotation can negatively impact the relationship between our shoulder blades ribcage. And who wants their shoulder being codependent and whinny all the time? I certainly don’t. This being said, a hypomobile (doesn’t wanna move) upper back may have negative effects up and down the spine. In Amber’s case, the issue surfaced in her low back.

AAROM, Take a Breathe, Re-Test:

I once read that if you can’t breathe in a position, you don’t own that position. The statement holds true here. I apply gentle pressure opposite the direction that I want Amber to go, I use Active-Assisted Range of Motion (AAROM) to guide her in the range that is there, but dormant. I give her some assistance to hangout in her end range, and to take a few breathes (sped up here).

The same thing can be done by pressing up against a wall, or using a band to pull you in the opposite direction. Just make sure you are moving with your upper back, not your lower. Chances are you have the range of motion, but you don’t know what to do with it because it’s 2017 and everybody has a tight thoracic spine.

SPINE TIP (no, not the coccyx): if one segment is tight, another segment will reflexively “loosen.”

But do you Extend?

Ask a CrossFitter if they’ll get prone on the ground and extend. They’ll get down there, crush it, and look at you and say, “I can do this all day, I can do unbroken “Michael,” [a hero WOD: 3 rounds of 800m run, 50 back extensions on a GHR, 50 situps], duh.” But then you limit the degrees of freedom, and BOOM, #gnarwhale.

Exercisers are fantastic at global extension, but it’s really hard to extend your spine segmentally. I saw @unchainedphysio use this exercise to prevent mashed-potatoes’ing on front squats, but it’s also a great assessment.

Slow your roll, block the hips, and gain some control of how your back extends. I’d say if you can do 3x30 of these your upper back moves just fine.

Your Ribs Aren’t Moving and Your Diaphragm Hates You

The average human takes 12 breathes a minute. There are 60 minutes in an hour, 24 hours in a day…and so on and so on, you do the math. I don’t want to, that’s why I’m in physical therapy school. Did you forget that your ribs attach to your thoracic spine? Its in the name ya’ll.

Here’s a way to get the intercostals (muscles between the ribs) working double time to expand your rib cage. If you sit on one side of a seesaw, does the other side move? Yes, yes it does. This is virtually what is happening here, creating much needed movement around a bound down fulcrum.

Focusing on your breathing, and if you start to cough on your exhales that OK – it just means your diaphragm is moving for the first time in awhile. If you don’t have a wallball, just stack some sturdy pillows under your ribcage and give it a go. And if you fall off like Amber, at least you’re already right next to the ground.

Crawl Before You Walk

As infants, we spend most of our time on our back. Our baby-brains instinctually desire movement and exploration, so we rolled onto our side and then on to our stomachs (in prone). You hated it, and you cried – because your little baby neck was entirely too underdeveloped to hold up your disproportionate noggin.

You began to spend to more time here, then you pressed up onto your elbows, then you began to move around. Eventually beginning to pull yourself up on furniture, getting onto your knees, eventually making your way into standing. These concepts apply to learning exercises. It's easier to learn stuff on the ground, especially if you are like me and tend to be a floppy baby. Try 3x12-15 per side of these exercises to build up rotational endurance.

Stop extending solely from your low back and just hanging out on your passive structures. Please: Use your muscles. Progress yourself with these exercises. If King Soloman were a PT he would probs say something like, “Guard your low back above all else, for from it flows the innervation for everything downstream.” PTverbs 4:23