On Track PT and Performance

Does Gaining Range of Motion Really have to Hurt?

Not all physical therapists are created equal. Nor does gaining range of motion have to be extremely painful! Unfortunately there is this idea among the public that physical therapy has to hurt to be effective. In most cases, nothing could be further from the truth. Sadly enough there are plenty of physical therapists out there who also believe "no pain, no gain" to be true.

Before we go any further, I need to clarify that pain is very different then a "stretch", "pull", "pressure" or "fatigue/workout soreness". Just because I don't believe in "no pain, no gain" doesn't mean I'll vouch for laziness or sub-par effort.

So here is why gaining range of motion does not have to hurt:

–  When the brain starts feeling ‘stress’ it goes into protection mode.  A pain response results in signals sent to muscles, fascia, and joint capsule to literally tighten down to protect the painful structure.  So the entire time your PT is cranking on your new rotator cuff repair, knee replacement, or you are cranking on it at home per their instructions. Your brain is busy fighting back.  The result is lots of pain and minimal progress.

– Pain fires up your sympathetic nervous system, the part of the system that handles ‘fight or flight’ situations.  To complicate matters, research has found that a lot of people are already in this sympathetic state even at rest. These individuals tend to exhibit increased stress hormone levels that result in poor sleep patterns and poor recovery from workouts and games (If you are coming off of surgery, I would argue that you are already in this state to some capacity anyway).  This elevated level of stress over the long term can have some serious effects and implications on rehabilitation.

Balance is good!

The moral of the story here is that increased pain levels correlate with increased stress levels which can delay healing and recovery.  Some pain is going to be present when you’re dealing with an injury or surgery, but your therapy should not be making you consistently feel worse! Increased pain is not an ideal situation for someone trying to gain range of motion, strength, and returning to work or athletics.

So how do we avoid the "no pain, no gain" philosophy! For starters, you still need to put forth maximal effort. Laziness will not get you out of pain. If you are post surgery then you should expect some type of "stretching" or "pulling". It is very important to distinguish between this and actual pain. The surgical limb has to move (when appropriate) and move frequently in order to start improving and building back up normal tissue resiliency. However, you want to avoid jamming your limb through further ranges of motion putting yourself into a further stressful (sympathetic) state then you already are post surgery.

Taking this a step further, in both surgical and non surgical folk we want to consider other areas which could be contributing to your overall dysfunction and pain on movement. This means looking at the joints above and below the injured area to make sure they are functioning optimally. Assessing the difference between active and passive movements also plays a role on distinguishing between actual soft tissue restriction or just lack of motor control or coordination in those end ranges of motion.  Muscle strength, endurance, work capacity, and timing are all important factors as well.

Next time you go through a physical therapy treatment, or any treatment for that matter, ask yourself if all these things are being assessed? If your program feels like a cookie cutter program then it probably is! Find a provider that understands pain and will take the time to assess/reassess movement. In most cases, there are better ways to gain range of motion and strength than trying to push through restrictions and pain.

Why am I doing this exercise?

Most patient's assume I hate answering this question. Just let me do my Job! Right?

Wrong.

In fact, I enjoy hearing this and really do not mind your curiosity.  A few things run through my head when I hear this question. 1) It usually forces me to take a step back and better educate the patient on what exactly we are trying to accomplish. If the patient understands where we are going, they are usually much more willing to actively participate in their rehabilitation, which in the long term provides much better outcomes.

2) (Along similar lines) Maybe the patient does not fully trust me and has not bought into the treatment program…..this is important for me as a therapist to realize and again educate. In the grand scheme of things, patients spend very little time in my office and much more time on their own working, competing, exercising, and just living life. Without trust, there is no carry over from my office to their daily life.

3) If I or any therapist cannot give you a detailed answer as to why, then it is probably not worth your time. If you ever get the feeling that a therapist hasn’t put any thought into the exercise selection or treatment, then you are probably being placed into a cookie cutter program.  That being said, there are times when a cookie cutter program does work.  However, I believe that if you are actively seeking out treatment then chances are you did not respond previously to a cookie cutter program or you are not looking for a cookie cutter answer.

At On Track Physical Therapy your treatment should never feel like a cookie cutter program, and we welcome the questions that start with “Why”!

Exercises for Athletes #3 - Single Leg Box Jumps

Single Leg Box Jumps - This exercise is a mid-level explosive jump or plyometric that is great for athletes to develop explosive power. This is a great exercise for athletes, and can be easily implemented into a youth athlete's strength and conditioning program Find a box that comes up to your kneecap or one that is appropriate to skill level. Explode off of one leg, and land on the opposite foot as softly as possible. Knee should stay in line with your middle toe upon landing.

Prior to implementing this exercise into a youth athlete’s program, be sure they have developed competency to jump and land under control from a two footed jump first.  This way the athlete can properly demonstrate the ability to adequately decelerate from two legs prior to progressing to a single leg explosive activity.

It also acts as a great preventative exercise because it teaches the athlete to decelerate dynamic forces under control. This is why the athlete should focus on trying to land as softly as possible absorbing forces on their opposite leg.

Be sure to keep the reps fairly low here 3-6 reps per leg to allow for recovery, maximal exertion during exercise, and solid technique. The amount of sets will be dependent on the athletes fitness levels and the goal they are trying to accomplish from the particular workout.

ACL Prevention. The Importance of Youth Coaches

For top notch ACL rehabilitation in Ann Arbor, Mi contact On Track PT and Performance.

Calling all you coaches, athletes, therapists and trainers out there, it's time for us all to face facts; we've failed as an industry in protecting our clients from ACL injuries.

Even with all the BS "ACL Injury Prevention" programs specializing in reducing the incidence of non-contact injuries, the most recent statistics show an INCREASE in ACL injuries in active populations.

Time to stop patting ourselves on our backs (coaches and researchers) and realize that what we've been doing over the last two decades to combat this monumental problem is just not working.

You know what will work and has been a proven track record for hundreds of years? Old school, traditional strength and conditioning. Maybe try and master that, ingrain some sound movement patterns in your athletes and just maybe then they can stay on the field long enough to make a dent in their athletic potential.

Full article available  via DrJohnRusin.com by Dr. Greg Schaible.

Exercises for Athletes #2 - Goblet Squat

The Goblet Squat is a great lift to teach proper technique to a youth athlete or beginning lifter while still eliciting a training effect.  Due to the anterior load of the weight, it allows the lifter to better obtain a squat position as the weight will act as a counter balance. For this reason, a Goblet Squat will actually start to improve squat mobility by gaining control over deeper ranges of motion in the squat position while still maintaining a neutral spine. Once optimal squat depth is obtained with a neutral spine you can then start to focus on increasing load and time under tension. The amount of load you can perform with this lift is limited. However as youth athlete or beginning lifter, ultimately your main goal is time under tension.  In other words, performing set/rep ranges of 3-5 sets x 8-12 reps will give you a baseline level of strength needed to then progress to a lift that will allow for greater loads such as a box squat. As the athlete progresses in his strength and lifting technique, the Goblet Squat will remain a great tool for warm ups or accessory lifts. 

Stix and stones may break bones but words CAN hurt you

Interactions between health care providers and patients have a huge impact on a patient’s recovery. Unfortunately not all Doctors, Physical Therapists, Chiropractors, Insurance company’s realize how their words positively or negatively can impact a patient.  How a musculoskeletal or physical problem/injury is described to a patient has a great impact on how much pain is perceived. Pain is ultimately the body’s output to a perception of threat.  The way an injury is described to a patient often has a profound impact, either increasing the perception of threat or decreasing the perception.  Countless times I have heard patients say that Doctors have told them their MRI or X-ray is the worst they have ever seen.  Countless times I have heard patients say that a Physical Therapist told them that my “nerve is pinched” or “bending forward is terrible for the back.” Countless times I have heard patients say that their chiropractor told them their spine was out of alignment. What do all these conversations do? Increase fear of movement and increase avoidance of activity.  Never once do I hear a patient tell me that anybody actually took the time to explain to the patient what pain actually is, and how it relates to their injury.

pain-bear.jpeg

First understand that all musculoskeletal injury has the capacity to heal no matter if it’s bone, muscle, tendon, ligaments, discs, etc. These are all human tissues that physiologically heal in time. Much like when you were a kid and scraped your knee outside playing, physiological damage to tissue occurred and the skin healed in time.  Inflammation is normal, it is how the body starts to heal itself. The nerves being sensitive is a GOOD thing. If you stepped on a rusty nail, wouldn’t you like to know about it?  The nerves are just doing their job. The increased sensitivity to movement is only because the nerves are “pre-warned.” Much like sunburn on the shoulder increases the sensitivity of the skin when you get in the shower. The water is not actually burning the skin, it just feels that way because the skin is very sensitive at that point in time during the healing process.

Movement stimulates blood flow. Movement done frequently, in a non-threatening manner reduces sensitivity. Threatening descriptors such as “bad back”, “blown disc”, “bone on bone”, or “torn a muscle” increases sensitivity.

Here is a link to a post by a colleague. It also does a great job of explaining everything mentioned above. The post also contains a very interesting MRI photo demonstrating how words can impact pain. Take a look HERE!

 

Low Back Pain - Ann Arbor, Mi

Ann Arbor Physical Therapy Low back pain is one of the most common ailments in the United States. A number of contributing factors can play a role in this type of dysfunction. One of the most common reasons that your back may hurt is due to your hips. More specifically the lack of range of motion in your hips. In a study published by the Institutional Journal of Sports Medicine titled Passive hip range of motion is reduced in active subjects with chronic low back pain compared to controls. The authors found that typical range of motion in the hip lacked -4 degrees of extension from a neutral position. In those subjects without low back pain, they had 6 degrees of hip extension available beyond neutral. All totaled, this is a 10 degree difference in hip ROM. These findings are common in individuals for a number of reasons. One in particular is the tendency for people to sit for long periods at work, school, or home which puts your hips in a flexed position (opposite of extended). This is a video of one technique we use at On Track PT and Performance to help improve hip extension through neurological inhibition.

Sports Specialist Physical Therapy Clinic| Ann Arbor, Mi | FREE Discovery Session|

About the Author: Dr. Greg Schaible is a physical therapist and strength coach specializing in athletic performance. He attended The University of Findlay as a student athlete. As an athlete he competed in both Indoor and Outdoor Track & Field where he earned honors as a 5x Division II All-American and 6x Division II Academic All-American. In 2013 he completed Graduate School earning his Doctorate of Physical Therapy (DPT). Greg is the owner of On Track Physical Therapy in Ann Arbor, Mi. Follow On Track PT and Performance on Facebook.

Pain, Productivity, and Happiness

Understanding your brain and how it operates can impact your health on multiple levels. The video below talks about how our mindset should match how the brain operates. Watch it! It's comical and you'll thank yourself for listening to it. http://www.ted.com/talks/shawn_achor_the_happy_secret_to_better_work

In case you are lazy, here are some quotes.....

“90 percent of your long-term happiness is predicted not by the external world, but by the way your brain processes the world.”

“25% of job successes are predicted by IQ, 75% of job successes are predicted by your optimism levels, your social support and your ability to see stress as a challenge instead of as a threat.”

“If I work harder, I'll be more successful. And if I'm more successful, then I'll be happier.” “Every time your brain has a success, you just changed the goalpost of what success looked like. You got good grades, now you have to get better grades, you got into a good school and after you get into a better one, you got a good job, now you have to get a better job, you hit your sales target, we're going to change it. And if happiness is on the opposite side of success, your brain never gets there.” “But our brains work in the opposite order. If you can raise somebody's level of positivity in the present, then their brain experiences what we now call a happiness advantage. Your brain at positive is 31% more productive than your brain at negative, neutral or stressed.”

My Two Cents.....

We know from pain science that our brain is naturally attracted to negatives or threats, this is a primal/survival mechanism that humans have developed. All inputs that the brain receive are either positive inputs or negative inputs. From a survival standpoint, positive inputs are seemingly useless to the brain. For example: Let’s say I’m camping in a tent in the middle of the jungle. I look around and I don’t see a tiger (positive input from visual system). I’m happy, I feel safe, there is no tiger.  However, if I listen to my previous knowledge (negative inputs). Which are telling me hey dummy, your in the jungle, there is probably a tiger around somewhere. This negative input then becomes a survival mechanism because I can now prepare for the life threatening scenario of meeting a tiger face to face.

As a protective mechanism your brain prioritizes negative inputs over positive inputs. When your body is in pain, the brain feels threatened from one or more likely a series of negative inputs. The body then becomes sensitive or highly altered of other potentially negative inputs.  The only way to reduce the sensitivity and break the cycle is to apply a positive input for the body. However because a positive input is not as significant as a negative input, this means we must bombard the body and brain with positive messages so the system no longer feels the need to prioritize all the painful experiences of the past.  If this is not accomplished, it can often be the reason why pain lingers around much longer than it takes for tissue to physiologically heal.

Get PT First

Often times when a patient walks through the door, I’ll ask them “How are you doing today?”.  Many times I’ll get the response “fine”, “feeling better”, or something else that leads to a nice conversation. Sometimes the response is much more blunt however “Well if I was good, then I wouldn’t be here.”Touché! Hopefully your medical professional has some sense of compassion and empathy toward your situation.

We’ve all had those moments when things just don’t seem to be going right.  It doesn’t always have to be a health related issue.  Maybe it could have been that your car broke down and you had to take it into the shop.

Is it convenient? No

Do you need your car? Yes

If your check engine light comes on, you have two choices. Ignore it and hope for the best, or address the problem. If you have a leak in your plumbing, you find a plumber.  If you have a toothache, you go see a dentist. If you want to win a bobsled race, you need a good driver.

Do you dig where I'm coming from?

As a Physical Therapist we have the expertise and knowledge to treat a variety of musculoskeletal disorders.  Pain is much like a check engine light, it’s signaling to your brain that your body is perceiving a threat to the system.  The cause of this threat is often related to multiple different reasons. The underlying issue could be big or small, and if ignored it could lead to much greater problems.  As a Doctor of Physical Therapy, we are uniquely trained to assess and treat many of these issues. We are also trained to recognize red flags which may signal to us that we need to refer to another medical professional with a different expertise.  Your body is the vehicle that drives you, and I encourage you to pay attention to the “signals” that your body is sending.  Unlike a car, you cannot trade your body in for a new one when it breaks down.  Find a health professional that you trust and be proactive in your health.  Take care of your body.

 

“Don’t Put Fitness on Dysfunction”

"Don't Put Fitness on Dysfunction." This is one of my favorite sayings from Gray Cook (physical therapist,). What he’s getting at, is we need a solid movement base – meaning joint mobility and stability, muscle flexibility, and balance – prior to training for strength, power, speed, and so on. Or before just going out and participating in a given sport or taking up something like jogging. Here is the Functional Performance Pyramid he came up with.

What this basically says is we need to move well before we should begin any training program or athletic endeavor. The purpose of this is not only to get better results from our training, but also to prevent the injuries that seem to go hand in hand with training and athletics.

The research is now clearly showing that the movement skills we once possessed as children, are vital to our health and performance as teenagers and adults. Research done in professional and collegiate sports, as well as in the military, is demonstrating that a base level of movement competency is necessary to prevent injuries. Not only that, but training and performance are enhanced in athletics. In the military it has been shown to correlate to drop out rates in basic training.

Here are two factors from the research that relate how well you move to injury risk:

1) Previous injuries 2) Right-Left asymmetries

These are the two biggest predictors of injury in athletics and in those that train, run, bike, ski, etc. Previous injuries we have experienced often create compensatory strategies to allow us to continue to perform our desired activities. Something as simple as an ankle sprain provides a great example. To continue to run, just in this example, the calf muscles tighten down to protect the ankle and you lose ankle joint motion. This requires compensatory motions from the knee, hip, and up the chain into the spine. This is meant to be a short term adaptation but often becomes chronic – a new way of doing things. Over time the accumulating microtrauma can lead to overuse type injuries such as plantarfascitis, achilles tendinopathy, knee pain, or back pain. Occasionally it can lead to bigger, more devastating injuries.

Right to left differences in movement (asymmetries) can create a similar scenario. Often our work, school, and athletic activities create these side to side differences that will have much of the same affect. We move well one direction, but not the other. Repetitively moving in our more mobile direction creates excessive wear and tear on our joints and muscles. When forced to move in our not-so-mobile direction repetitively or with great force (a.k.a sports), serious injury can result.

45 degrees of hip rotation on the Left and 20 degrees on the Right = Not Good!

This is just the tip of the iceberg when it comes to movement quality and injury prevention. The research is showing that we’re playing with fire by just jumping into training programs or athletics without first assessing how one moves, determining base levels of strength, conditioning, etc. I prefer using the Functional Movement Screen and Y Balance Test with all athletes and those who want to train hard, but it can be any system that takes a good hard look at how you move prior to putting you under the bar or out on the field or court.

I think this quote by world renown physical therapist Diane Lee (who has worked with the Canadian Olympic team) puts in all in perspective: “Don’t run to get in shape, you must get in shape to run”. If you move well, you can train hard. If you have a ‘weak link’ then we must address that to help you meet your goals.