Unlocking the Secrets of the Pelvis Part 4

In this series of “Unlocking the Secrets of the Pelvis” we have discussed how asymmetries will affect lumbo-pelvic-femoral alignment starting with a chain of muscles on the left side with too much tone that include the diaphragm, illiacus, psoas, TFL, biceps femoris and vastus lateralis and is called the L AIC or Anterior Interior Chain. The diaphragm is important because the most common movement dysfunction is breathing and breathing dysfunction affects entire chains of muscles in the body. (1)

Assessing the ability to breathe in a functional manner needs to be part of our evaluation and education process for every patient. Combining breathing with a corrective exercise strategy will provide a powerful tool for expanding your clinical competency and providing more effective patient care.

What makes breathing so important is that the diaphragm, or “Big D”, is responsible for not only respiration but is a major player in stabilization and positioning of the lumbo-pelvic-femoral region. Big “D” has right and left leaflets as discussed in this series and the left side is notable since it tends to have more “tone” or tends to be more flattened in an over-activated state.

Patients with this Left AIC pattern present with too much tone in that entire chain of muscles and just want to relax them. (And with focused breathing the rest of their body as well!) When that polyarticular chain relaxes, other muscles as described in Part 2 of this series can be recruited in a way that restores a more functional pelvic positioning and alignment which then affects the entire musculoskeletal system.

The reason breathing with corrective exercise is important is that you need to start influencing the diaphragm, especially the left leaflet, if the rest of the Left AIC is going to be addressed. The left leaflet needs to relax and dome (Remember the ZOA or Zone of Apposition from Part 1 of this series and Part 3 of “Breathe Well and Breathe Often” by this author) during exhalation while you are activating the left anterior abdominal wall. The rest of the muscles in the L AIC will relax and help facilitate activation of inhibited of muscles that help to restore symmetrical pelvic alignment and position of the acetabulum over the femurs.

The dysfunctional Left AIC pattern has “tri-planer” consequences to the lumbo-pelvic-femoral region and our thinking and correction needs to affect the sagittal, frontal and transverse planes. The goal is to restore neuromusculoskeletal symmetry that provides a rotational shift of the pelvis back to the left providing for a more equal acetabular/femoral (AF) position on each side.

Many of the muscles that influence positioning and control of the pelvis were mentioned in Part 2 of this series. The following exercises are a beginning step to correct the L AIC pattern. The findings of the “Adduction Drop Test” and the “Extension Drop Test” from Part 3 will give you direction and proper sequencing of a corrective strategy as outlined by Postural Restoration Institute.

Let’s look at a few of the many exercises that combine breathing with myokinematic repositioning of the pelvis. If the patient presents with a positive left adduction drop test and a positive left extension drop test, we start with an exercise designed for lumbo-pelvic-femoral control quoted from the PRI Home Study Course on Myokinematic Restoration.(2)

I. 90-90 Hip Lift

1. Lie on your back with your feet flat on a wall and your knees and hips bent at a 90-degree angle.

2. Place a 4-6 inch ball between your knees.

3. Inhale through your nose and exhale through your mouth performing a pelvic tilt so that your tailbone is raised slightly off the mat. Keep your back flat on the mat.

4. Hold this position while you take 4-5 deep breaths in through your nose and out through your mouth.

5. Relax and repeat 4 more times.

II. 90-90 Hip Lift with Hip Shift

1. Lie on your back with your feet flat on a wall and your knees and hips bent at a 90 degree angle.

2. Place a 4-6 inch ball between your knees.

3. Inhale through your nose and exhale through your mouth performing a pelvic tilt so that your tailbone is raised slightly off the mat. Keep your back flat on the mat.

4. As you maintain a hip lift, shift your left hip down and your right hip up so that your right knee is slightly above the left.

5. Slowly take your bent right leg on and off the wall so that your right thigh comes toward your chest. You should feel the muscles behind your left thigh engage.

6. Perform 3 sets of 10 repetitions, 1-2 times a day.

III. 90-90 Hip Lift with Medial Hamstring

1. Lie on your back with your feet flat on a wall and your knees and hips bent at a 90-degree angle.

2. Place a 4-6 inch ball between your knees.

3. Move your left foot and ankle slightly outward while gently squeezing the ball.

4. Inhale through your nose and exhale through your mouth performing a pelvic tilt so that your tailbone is raised slightly off the mat. Keep your back flat on the mat.

5. Slowly take your bent right leg on and off the wall so that your right thigh comes toward your chest. You should feel the muscles behind your left thigh and left outer hip engage.

6. Perform 3 sets of 10 repetitions, 1-2 times a day.

The breathing component is essential and can be taught with the patient on their back asking them to take a full relaxed breath in through the nose then breathe out through their mouth in a long, relaxed sigh then holding it at the end of the breath for just a second before breathing in through the nose again. It helps to have the right hand overhead since this allows the right ribcage to expand more while the patient inhales and is still flattening their lower back with sacrum elevated off floor or table.

Any one of these three exercises is a starting place for a progression of more exercises (with pictures) by PRI that are designed to provide muscular realignment of the lumbo-pelvic-femoral region.

These exercises are designed to inhibit muscles that have too much tone, like the ones that comprise the Left AIC, and recruit muscles that have been reciprocally inhibited causing a chronic pelvic position asymmetry. We are simply reversing the roles of antagonist and agonist, lengthening tight muscles, shortening over-lengthened and weak muscles thereby providing more AF internal rotation on the left and AF external rotation on the right. You can help this process along with a standard L AIC pattern with a precise adjustment to the inominate bones that facilitate a balanced alignment and positioning.

These exercises should not be performed if they are creating additional pain or discomfort during or after the exercise. Also, these exercises work best if done in a relaxed fashion with the patient mastering the many parts of each exercise with breathing and gentle activation of muscles and position.

The purpose of this series of four articles on “Unlocking the Secrets of the Pelvis” is to introduce a basic overview of “Myokinematic Restoration” of the lumbo-pelvic-femoral region and describe common pathomechanics combined with a path to assessment and correction.

Mastery of any approach to patient care requires more than an overview and for a complete understanding of pelvic myokinematics attending a PRI course or studying their home courses is recommended.

PRI provides “power tools” that will make your adjustments more effective and provide lasting results beyond “That last adjustment was great Doc but it just didn’t hold very long!”

Chiropractic has been just like the basic landline telephone many of us baby boomers grew up with. That is, chiropractic has been safe, effective and reliable.

Today think of your practice like a smart phone or “Pad”. It is still like a phone and always will be but now you can add “app’s” or functions that enhance and make it more powerful. For your chiropractic practice, PRI is a critical “app” to include in your treatment toolbox.

References

1. Myokinematic Restoration Home Study Course, Anterior Interior Chain, Page vi.

2. Myokinematic Restoration Home Study Course, Myokinematic Repositioning Techniques, Page 2

Robert “Skip” George, D.C., CCSP, CSCS also owns La Jolla Sport and Spine where he integrates chiropractic, rehabilitation and sport performance training. He is also a Certified Functional Movement Screen Instructor. For questions or comments he can be contacted at dr.george@sbcglobal.net

 

 

 

Unlocking the Secrets of the Pelvis Part 3

In part one of this series we began to identify the many asymmetries that human beings are all born with and that these asymmetries, when they become excessive or unchecked, can create a cascade of imbalance in every system of our body resulting in dysfunction, pain, degeneration and eventually disease.

In part two we discovered that these asymmetries in the neuromuscular system can determine the position and movement of not only the pelvis but the entire skeletal system as well. Looking at the entire picture it becomes clear that every system is interconnected and can affect any or all systems including the neurologic, hormonal, digestive, cardiovascular, respiratory, musculoskeletal and even including the mental and emotional.

As discussed, one continuous group or chain of muscles are comprised of the diaphragm, psoas/illiacus, TFL, biceps femoris and vastus lateralis is called the “anterior interior chain”. Most commonly, the left “AIC” is the group of muscles that has too much “tone” or activation and affects pelvis and skeletal alignment and position.(1)

When the left anterior interior chain of muscles is over-activated, an asymmetry will occur affecting the position of the pelvis which creates an orientation to the right of the entire pelvis in the transverse plane. All of the other muscles in the pelvis respond in a compensatory fashion (as described in Part 2 of “Unlocking the Secrets of the Pelvis”) in a “tri-planer” fashion creating pelvic misalignment and ultimately dysfunction, pain or even decreased athletic performance.

So how do you know if you have a basic Left AIC pattern of too much tone? This starts with simple observation of gait and the presenting shape of their right vs. left lateral abdominal wall. Individuals with a Left AIC pattern are stuck in a right mid stance phase and have difficulty getting off their right foot and onto their left. One of the compensations is that they have to swing their foot forward by laterally flexing their right abdominal side wall. This can present with a mild concavity on the right side as compared to the left because they are always “hiking” that anterior/lateral abdominal wall to achieve more swing phase on the right to get onto the left leg. You may also observe during gait that the left hemi-pelvis orients more to the right in transverse plane rotation and doesn’t rotate back to the left as much or symmetrically.(1)

There are several tests to determine if a Left AIC pattern is present. One of the old stand-bys that we have all used for years is simply the Ober’s test. Commonly, this test is used to determine tightness in the fascia lata or the ITB. As a “Postural Restoration Institute Test”, it is known as a modified Ober’s or Adduction Drop Test. The Adduction Drop Test is a starting point to determine pelvic position and if a Left AIC pattern is present. The set up and performance of this test is as follows and is quoted from the home study course of the Myokinematic Restoration notebook by PRI and taught by James Anderson, P.T..

“The patient lies on his or her side with the lower leg and hip flexed (90 degrees). Stand behind the patient and passively flex, abduct and extend the hip to neutral while maintaining 90 degrees of knee flexion. Passively stabilize the pelvis from falling backward and allowing femoral internal rotation to occur. Make sure the top inominate is positioned directly over the bottom inominate so the frontal plane starting position does not give any false positives ((top inominate too cephaled) or false negatives (top inominate too caudal). A positive test is indicated by a restriction from the anterior-inferior rim, transverse ligament and piriformis muscle or impact of the posterior inferior femoral neck on the posterior inferior rim of the acetabulum that does not allow the femur to adduct: possibly secondary to an anteriorly rotated, forward hemipelvis. Usually seen on the left especially if the left Extension Drop Test is positive in a Left AIC oriented patient.”

If this test is positive on the left side but not on the right, that is the femur does not drop below midline in adduction, then we begin to identify a Left AIC pattern. If both sides are positive, that is called a PEC (posterior external chain) pattern but will be discussed in a future article. Suffice it to say, underneath every PEC pattern is a L AIC so proceed to the next text anyway!

This is a good place to introduce the capsule-ligamentous structures concerned with femoral acetabular (FA) joint dynamics.

Iliofemoral: the fibrous capsule is reinforced anteriorly by the strong Y-shaped iliofemoral ligaments (of Bigelow). The iliofemoral ligament prevents hyperextension of the femoral-acetabular (FA) joint during standing by forcing (twisting) the femoral head into the acetabulum.

Pubofemoral: The fibrous capsule reinforces inferiorly and anteriorly by the pubofemoral ligament. Key function is checking over-abduction of the hip.

Ischiofemoral: The fibrous capsule is reinforced posteriorly by the ischiofemoral ligament. It tends to hold the femoral head medially into the acetabulum preventing hyperextension of the femoral-acetabular (FA) joint.(1)

Integrity of these ligaments is critical for movement and position of the femoral acetabular joints. Assessing the integrity of these ligaments will determine the course or algorithm of a corrective strategy for pelvic dysfunction as outlined by PRI. If ligament integrity is diminished or absent, corresponding muscular activation must be applied to support pathologic ligamentous structures that have been weakened by time or trauma. The “Extension Drop Test” is also quoted from the PRI course notes as mentioned and is used to determine ligament integrity of the femoral acetabular (FA) structures.

“The patient is positioned in supine with both thighs on the table. Both hips and knees are flexed to the chest. Passively lower one leg over the edge of the table while helping the patient hold the untested knee close enough to the chest to maintain the low back against the table. Do not allow hip abduction to occur past zero degrees on the tested extremity while passively dropping the FA joint into extension.

A positive test is indicated when the tested lower extremity ( usually the left) is restricted in hip extension because of the forward orientation of the tested side compared to the other. If both femurs do not approach the edge of the mat or table the patient is tested on, the innominates are rotated forward bilaterally and the psoas muscles are on slack. Placing the femur in “neutral” is actually placing the patient’s femur in external rotation. This tightens the TFL and VL and restricts hip extension.

There is also a rotary component to this issue, especially seen with limitation in hip extension on one side. Since the forward, anteriorly rotated pelvis accompanies sacral rotation to the contralateral side(right rotation on a right oblique axis or left rotation on a left oblique axis) the iliofemoral ligament will also limit extension when the femur is externally rotated by the therapist/doctor, through testing with the femur in a “neutral” position.

The femur in this case will not approach the patient support surface without femoral internal rotation and or through luxation (ie.”click”) of anterior superior femoral head moving forward under the superior anterior condyloid labral rim of the acetabulum.”

That was a mouthful but what does it mean? Simply, if that femur extends all the way to the table especially on the left side, you need help from specific muscular structures to help stabilize that FA joint since those femoral acetabular ligaments are shot! Stabilizing the FA joint is part and parcel to stabilizing the pelvis and the corrective strategy for that will be discussed in the next article.

One of the most fascinating tests to determine dysfunctional myokinematic patterns in the pelvis is the “Hruska Adduction Lift Test” developed by Ron Hruska, P.T. . This is a progression of movements and is graded at how many of the positions in the test the patient can achieve with movement/stability competency. This is a detailed test that requires a specific starting position and grading criteria for five levels of movement testing. (This is the “tease” section of the article and you will have to order the home study course from PRI or attend a workshop to become proficient at this test! And no, this practitioner receives no royalties from PRI!)

Other tests for Femoral Acetabular (FA) extension include the Thomas Test and Modified Thomas, Thomas Test (with rectus femoris differential). For Femoral Acetabular (FA) flexion there is Ortolani, Fabere-Patrick and the “Snapping Hip” Maneuver.(1)

It is observation of gait, pelvis and abdominal wall positioning, the Adduction Drop Test, the Extension Drop Test and the Hruska Adduction Lift Test that will give you direction for your corrective strategy and a way to determine if you treatment is effective or not in restoring alignment, position and function to the pelvis.

These tests help to determine if your patient is stuck in a Left AIC pattern and which course of treatment is needed to restore more balanced and symmetrical neuromuscular function of the pelvis. These tests can also aid in how effective you treatment is. Simply test, treat and test again to see if your patient is really getting and maintaining the correction they need beyond walking to their car in your parking lot!

In Part 4 of “Unlocking the Secrets of the Pelvis” we will explore how breathing with corrective strategies will provide effective and lasting correction of pelvic dysfunction.

 

Reference:

1.Myokinematic Restoration, An Integrated Approach to Treatment of Patterned Lumbo-Pelvic-Femoral Pathomechanics by Postural Restoration Institute (PRI), Home Study Course taught by James Anderson, P.T.

 

Unlocking the Secrets of the Pelvis Part 2

Whether we like it or not, the times are “a changin’” and the healthcare consumer is demanding more while insurance reimbursement is decreasing. Expanding our clinical competence by adding more tools to our toolbox will be the best remedy to not only meet these challenges and strengthen our profession but to provide long term satisfaction to our careers as well. The model for healthcare is evolving and “lifestyle enhancement” will be the focus especially for an aging population.

One of those many tools comes from the Postural Restoration Institute (PRI). Their work on myokinematics is the study of movement regarding position of muscles and their influence on structure. “Myokinematic Restoration” is an especially powerful tool for the treatment of pathomechanics especially in the lumbo-pelvic-femoral region. (1)

In part one of this series, “Secrets of the Pelvis”, the many asymmetries we are born with as human beings were discussed. These asymmetries affect the neuromusculoskeletal, cardiovascular and lymph systems.

It is a marvel that we are born with a compensatory system that most of the time self-corrects or maintains a close enough balance that we don’t notice until there is pain, obvious dysfunction or disease that develops if and when those asymmetries become excessive.

As with any skeletal structure, ligaments play a pivotal role in position of the lumbo-pelvic-femoral region. However, it is the relationship of muscles to reposition, retrain and restore function that will be discussed in this article regarding the biomechanics of the pelvis and spine.

One of the most important considerations with pelvic position and alignment is the position of the acetabulum over the femur.(2) We usually think of a femur swinging underneath our pelvis when we walk. Or, we think of range of motion of the femur in terms of seated internal or external rotation measured with a goniometer.

A key concept to understand is that the position of the pelvis actually dictates movement of the acetabulum over the femur during gait cycles. This movement positioning is called acetabular-femoral or “AF”. Conversely, if we are talking about the femur moving in an acetabulum that is fixed or stable then it is femoral-acetabular or “FA”.(2)

For description sake, let’s just stop for a moment and put your hands out in front of you on your lap. Make a shape of a pelvis with your hands and move them in opposite directions as if you were walking. With hands in a somewhat neutral position and thumbs up each wrist should be moving in opposite directions just a bit to simulate movement of each inominate with acetabulum over the head of the femurs. (That is ulnar deviation on one side and radial deviation on the other of the wrists.) This is AF movement.

As mentioned in the last article, most of us have a dominate left anterior interior chain pattern or Left AIC as described by Ron Hruska, P.T., founder of PRI. This chain of muscles typically has too much activation or “tone” and has a major role in creating a flexed hip on the left, extended hip on the right and “rotated to the right pelvic” girdle or a right orientation. So just move your left elbow out to the side a bit, move your left hand slightly forward and angled to the right with both hands moving in a clockwise direction slightly if you are looking straight down at them. This is rotation in the transverse plane that is characteristic of a Left AIC pattern as described by PRI.(4)

The sacrum and lumbar spine develop torsion and a right orientation as well, but then as compensation, the thorax and shoulders can develop rotation to the left creating rotational and compressive forces in the spine. Often a right SI distraction or gap will form on the superior portion of that joint causing the common “top-of-the-butt-on-the-right- side” pain as one example of symptoms caused by this position. (3)

Now remember that “AF” position is relative to the pelvis and there will be an internally rotated femur on the right and an externally rotated femur on the left relative to each inominate. With the Left AIC pattern, we are stuck in “AF-ER” on the left side and “AF-IR” on the right side. As a result, we are also stuck in a right mid stance phase. This asymmetrical compensatory pattern occurs because of the inability of muscles to maintain the pelvis in a neutral and balanced position. Remember, if we are looking down at our hands, we want them to be symmetrical with the ability to move AF-ER and AF-IR on both sides equally. However, our first priority is to achieve more AF-IR on the left side and more AF-ER on the right to overcome this dysfunctional pattern. (3)

What makes symmetrical IR during gait so important? Our propulsive power really comes from the ability to externally rotate and extend the hip effectively but this doesn’t occur without adequate symmetrical internal rotation. As James Anderson, P.T. states “you must first load (IR, or internally rotate) before you can explode(ER, external rotate the hip).”

In this brief overview, we need to look at a few of the major muscle players and their role in dictating the position of our pelvis. On the left side there is an overactive illiacus/psoas that contributes to pulling us into flexion and external rotation. The TFL is short and strong and is compromising the left “anterior” glute medius’ ability to internally rotate the femur. (Remember, we are trying to get IR back on the left side.) The rest of the muscles in that chain including the vastus lateralis and biceps femoris are over-active as well.(4)

When the left anterior glute medius becomes long and weak do to pelvic AIC positioning, it has a hard time trying to get the left femur into internal rotation. The posterior part of the G-Med is firing mightily creating abduction and external rotation. This is fine for the right side but not so much for this left side! Again, we need to get into internal rotation on the left and external rotation on the right. (5)

The “King of the Pelvic Floor and Pelvis” is the gluteus maximus and two of its main roles include hip extension and external rotation. On the left the extension fibers are long, weak and out of position for optimal extension of the hip. Those fibers need to be shortened and activated while on the right side the external rotation fibers of the glute are long and weak and need to be shortened and activated for optimal pelvic position from that side. (5)

There are two functions of the adductors we have to consider. The adductor magnus and longus actually externally rotate as well adduct but it is the ischiocondylar portion of the adductor magnus that we want to focus on because that distal attachment is the portion that is concerned with internal rotation on the left side. Remember “IR” on the left is hard to come by with a strong Left AIC pattern and a key will be to remember to feed internal rotation on the left and external rotation on the right to correct this pattern!(4, 5)

To help control the pelvis requires controlling the obturator foramina because that is where the obturator internus and externus live as they attach to the femur. These muscles have great control and influence on the position of the pelvis because they control the orientation of the obturator foramina. The obturator internus and externus have “hole control” or dictate the position of the obturator foramina which controls and maintains position of the pelvis especially during walking or running.(5)

Included in this asymmetry the hamstrings on the left will be long and weak with longer attachment points because the position of the left hemi-pelvis is in flexed position. How often do you run into a tight left hamstring and try to stretch through it? Could it be that it is already stretched but because of pelvic positioning the attachment points are lengthened relative to the right?

So, the right side musculature will have opposite muscular length and activation to the left contributing to a compensatory dysfunction that feeds into the entire asymmetrical positioning of the pelvis! The key to think about this is what ever side is long, weak, short or strong will be the opposite on the other side. The trick is understanding that the position and length of muscles on each side will determine what is required to correct the pelvis and help maintain your chiropractic adjustments far longer. In addition, your patient becomes an active participant instead of a passive recipient of care. This type of patient/doctor cooperation makes your treatment and craft much more powerful and effective and only contributes to your healing philosophy.

Chiropractic icons like Dr. Clarence Gonstead and Dr. Major DeJarnette were very observant when it came to pelvic positioning. Dr. Gonstead came up with listings or a system for defining pelvic alignment and a logical formula for correcting misalignment or subluxation.

Dr. Major DeJarnette, a chiropractor as well as an osteopath, saw the relationship between the cranium and sacrum and that each affect the entire body through the kinetic chain. Both doctors developed very effective techniques that we still use today and can be built upon with new discoveries in today’s emerging fields of pelvic and spinal functional biomechanics like PRI. (This practitioner utilizes both of these techniques as well as the latest approaches to spinal biomechanics including this work from PRI)

In Part 3 of “Secrets of the Pelvis” we will be exploring several tests to determine the position of the inominate bones in relation to the femurs and how breathing affects not only the entire kinetic chain but the autonomic nervous system as well.

 

 

 

References

1. Postural Restoration Institute(PRI), Myokinematic Restoration, Home Study Course, James Anderson, P.T., Instructor

2. PRI Myokinematic Restoration, Home Study Course, Pages 4-8

3. PRI Myokinematic Restoration, Home Study Course, Pages 8-12

4. PRI Myokinematic Restoration, Home Study Course, “The Left Anterior Interior Chain Pattern”, Page vii

5. PRI Myokinematic Restoration, Home Study Course, Pages 18-20

 

Dr. Robert “Skip” George practices in La Jolla, CA where he integrates chiropractic, rehabilitation and sport performance training. He has lectured nationally and is an instructor for the Functional Movement Screen. He can be reached at Dr.George@sbcglobal.net for questions or comments.

 

 

 

 

 

 

 

 

Unlocking the Secrets of the Pelvis Part 1

Treatment of pelvic dysfunction that is effective and lasts just beyond our patients walking out to the parking lot to where their car is parked requires observing and thinking about tri-planer movement of the pelvis.

To understand balanced and symmetrical movement of the pelvis we need to understand “myokinematics” or the study of motion produced by specific neuromuscular forces.(1 ) The pelvis, as well as our entire body, needs to have as close to symmetrical muscle flexibility, strength and length as possible. Asymmetries in muscle strength, length and endurance with agonists and antagonists can eventually create dysfunction in movement and alignment patterns. Our rehabilitative goals need to include addressing these asymmetries effectively. (1)

We are born with asymmetries that the body usually deals with effectively for the most part but does need our help when those asymmetries form dysfunctional myokinematic patterns that lead to pain, decreased performance and ultimately premature degenerative changes.

Lets explore some of the many asymmetries that we as humans possess and need to integrate and balance every minute of every day. For starters, we have a left and right sided portion of our brain with the left side being associated with motor skills and analytical thought while the right side more with abstract thought and creativity. The autonomic nervous system with sympathetic and parasympathetic portions can often be out of balance and asymmetrical. Would you agree that in this day and age, there is too much stimulation or “tone” on the sympathetic or fight or flight side? The lymph system is asymmetrical with drainage on the right side clearing the right arm and chest and the rest of the body being drained on the left. Most of us are right hand dominate over the left and if you take a picture of your face, split it in half, use a mirror image and combine right to right and left to left side and you may not recognize yourself!

One of the most significant asymmetries our bodies has to integrate is with the diaphragm or “Big D” and respiration is key when considering effective treatment of musculoskeletal function .

There are two leaflets of the diaphragm with the right side having bigger and more muscular “crura”. The left side is smaller and has less muscular crura and attaches 1 to a1 ½ half lumbar vertebra higher than the right. On the right side of the abdominal cavity is the liver which helps “dome” the diaphragm on that side. There are also three lobes of lung on the right side as opposed to two lobes on the left with the heart and aorta orienting more towards the left. To help balance this asymmetry is a small muscle in the anterior chest wall called the transversus thoracis or triangularis sterni. (2)

The diaphragm may be the most important muscle in the body. Obviously it is the key muscle for breathing but it also must stabilize the lumbar spine and torso as well. Breathing, stabilizing and even walking are just some of the functions connected to Big “D”. Typically the left side of the chest wall “flares” because of inactivation of the anterior lateral abdominal muscles together with a flat or over-activated diaphragm on the left side. Remember, it doesn’t dome like the right side does and full exhalation does not commonly occur on our left side unless we are trained to do so.

The inability to exhale completely and coordinate the diaphragm with the abdominal wall results in a faulty “Zone of Apposition”(ZOA) that results in pelvic misalignment as well as thoracic misalignment. (Please refer to my article: Robert “Skip” George, D.C. Part 3 of Breathe Well and Breathe Often, Dynamic Chiropractic, Sep. 9, 2012 ) This connection and potential asymmetry of the diaphragm has a profound effect on alignment of the lumbar spine!

Understanding ZOA is fundamental to the understanding the close relationship with the diaphragm as well as the sequence of muscles that create a “polyarticular chain” that effects all neuromuscular skeletal movement and function.

To understand pelvic dysfunction and how to restore balanced biomechanics, we need to look at groups of interconnected muscles and how they interact in three planes of movement. Ron Hruska, MPA, PT and director of Postural Restoration Institute, describes the “Anterior Interior Chain (AIC)” composed of muscles that form a polyarticular connection starting with attachments to the costal cartilage and bone of rib 7 through 12 then terminating at the lateral patella, head of the fibula and lateral condyle of the tibia. These two tracts of muscles, left and right side, are comprised of the diaphragm to psoas muscle then with the illiacus, TFL, biceps femoris and vastus lateralis combining a chain of muscles that have significant influence on balanced pelvic motion, breathing and gait.(3)

(This left and right AIC has a profound effect on another polyarticular set of muscles called the brachial chain and will be described in a future article.)

“Tone”, either too much or too little, can have a profound influence on an asymmetry and whether or not that asymmetry will affect us in terms of function, athletic performance or chronic pain in the spine, pelvis or an extremity. It is important to remember that asymmetries, anatomical or neurological, are not usually a problem or issue because our bodies have a system of homeostasis that help us adapt, balance and adjust to those asymmetries. It is only when those asymmetries become too excessive and we are unable to restore balance that they are a problem. One of the goals, as James Anderson states in the Myokinematic Course, is that these patients with too much tone just want to relax!

The side that usually has too much tone for most human beings is the left anterior interior chain unless you are born with liver and three lobes of lung on the left side. (“Situs Inversus” is a condition where the organs are flip flopped on opposite side and is rare.) The reasons for this are many but lets just start with the diaphragm being flatter or less domed than the right side. Remember when the diaphragm contracts, the central tendon drops and the diaphragm flattens to create negative pressure in the chest cavity so the lungs fill with air. Typically, most people have a dominate left anterior chain pattern because if the diaphragm doesn’t completely relax, neither will the rest of those muscles mentioned in the left polyarticular chain. (In fact, the muscle fibers of the diaphragm and the psoas are so closely interrelated that upon dissection it is nearly impossible to distinguish between the two.) (3)

This excess tone or inability to relax the left anterior chain of muscles has many consequences anatomically. Typically there is an “orientation” of the sacral region pelvic to the right with an anterior tilt and flexion of the hip on the left side if you are viewing from above in the transverse plane. In addition, with the above mentioned rib flare especially on the left, the thorax tends to rotate to the left creating the opportunity for scoliosis, rotational/compressive forces to the discs and excessive stress to the facet joints of the thoraco/lumbar spine because of a rotational/extension alignment and movement pattern. (1)

In Part 2 of “Secrets of the Pelvis” I will be describing specific muscles and the myokinematic pelvic patterns they influence. I will also describe the importance of the diaphragm and breathing with every one of our patients. And ultimately in this series on the pelvis I will describe corrective treatment strategies that help evolve our patients from purely passive and dependent care to being a more active and independent participant in their well being!

References:

1. Myokinematic Restoration, Postural Restoration Institute, Home Study Course, Pg. 1, Pg. 8

2. Postural Respiration Seminar Notes Pg. 11, May 18-19, 2012 James Anderson, MPT, PRC

3. Postural Respiration Lecture Notes May 18-19, 2012, Brachial Chain and Anterior Interior Chain- Pg. vi, The Left Anterior Chain Pattern- Pg. vii, Zone of Apposition, Ron Hruska, MPA, PT -Pg.viii

 

Dr. Robert “Skip” George owns La Jolla Sport and Spine in La Jolla, CA where he integrates chiropractic, rehabilitation and sport performance training. He has lectured nationally on prevention and treatment of sports injuries as well as coaching chiropractors on how to evolve their practices to adapt to rapidly occurring changes in the healthcare system. He is also an instructor for the Functional Movement Screen (FMS) and can be reached at dr.george@sbcglobal.net

 

 

 

 

 

 

 

 

 

 

Survival of Fittest: Integrating Chiropractic, Rehabilitation, and Sports Performance Training – Part 1

Part 1:  Move Well and Move Often: Introduction to The  Functional Movement Screen

By Robert “Skip” George, DC, CCSP, CSCS

As chiropractors, we diagnose and treat conditions of the spine and extremities.  In addition, many chiropractors refer to themselves as sports or rehabilitation specialists.  The chiropractic diplomate programs for sports and rehabilitation take comprehensive steps into integrating rehabilitation, sports performance training and “on the field” first aid/ injury management to provide a specialized approach for our patients and athletes.

When an injury occurs the focus of our attention is on the region of pain.  It then needs to shift and expand into seeing that pain can also be a messenger or signal not related to the location of symptoms.  Gray Cook mentions that the potential exists to become myopic on one body part as being the problem versus thinking in terms of movement patterns for the entire body and prescribing specific corrective exercises or treatment that address a significant dysfunction .  He also states that movement, especially moving well and often, is at the heart of not only our early growth and development but remains a central issue throughout our lives.  This is true especially for aging athletes and patients.

In rehabilitation, sports medicine and sports performance training much is talked about “functional” and “core” training.   Often the “What comes first: The chicken or the egg?” question arises when defining the topic of functional/core training and how it relates to determining what is a priority, mobility or stability.  One of the most valuable tools in addressing  this question and  assessing “weak links” in the kinetic chain  is the Functional Movement Screen developed by Gray Cook, MSPT and Lee Burton, PhD.     The Functional Movement Screen, or FMS, grades seven different movement patterns to assess mobility, stability, balance, symmetry and proper movement sequence or patterns.

One way to look at how we function and perform is to visualize a three layered  pyramid that separates first function, then strength/ power performance, and finally sport specific skills.  Think of the rectangular base of a pyramid that defines how well the patient’s or athlete’s  body functions in terms of mobility, stability, balance, symmetry  and movement sequence. This base is the widest part of the pyramid and upon what all else is built .  In the middle is a layer of strength and power performance and on top of the pyramid  are specific sports performance skills.  Many a gifted athlete has had a season or career cut short because of durability problems that may have been addressed if their functional base was assessed, corrected, reinforced and maintained.

Often fitness is “piled” onto dysfunction  without addressing the functional base of the athlete’s “pyramid”.  This is where potential trouble begins and is a reason patients enter our offices.  Many talented athletes can perform at a high level because they are such good compensators. However,  they  are an injury or accident ready to happen because they are working around a pre-existing problem and simply are  not aware or neglect to train their functional weaknesses before beginning their strength and conditioning programs.  As Gray Cook says in his book Movement: Functional Movement Systems,  “Movement is how we survive, communicate, recreate and thrive.”  The performance pyramid applies to us all if we are to function well not only in sports but for our daily activities.

For doctors, therapists and trainers that work with sports teams, the FMS can be part of the pre-participation assessment and used as a baseline with re-checks during the season.  The following tests are brief descriptions of the Functional Movement Screen.  The screen takes about 10 minutes to perform and is easily integrated into your treatment schedule  with your patients.

The seven tests  of  the FMS are graded 0-3 with a total score of 21 possible.  If during any of the movements there is pain,” 0” is the score and that particular issue is addressed with appropriate treatment modalities after the entire screen is performed.  If one of the tests is performed perfectly, it is graded  a “3”. A score of  “2”  is given if the movement is done “well enough” or with minimal compensation.  And, a score of “1” is given if the patient or athlete is unable to either get into position to do the test or unable to perform adequately. A minimum of “2” points for each of the seven tests for a total score of 14 is used as a as the baseline to participate in strength training or athletics.  A score under 14 increases probability of injury and decreased performance.

The first screen is the Deep Overhead Squat Movement Pattern.  It demonstrates fully coordinated ankle, hip and thoracic spine mobility and core stability with the hips and shoulders functioning in symmetrical positions. By the way, this test is critical especially for your golfers!

The second screen is the Hurdle Step Movement Pattern Test.  It is designed to challenge the body’s proper stepping and stride mechanics as well as stability and control in single leg stance.  This is really helpful in determining symmetry left and right side while assessing hip mobility and balance.  This test also determines how well we can stabilize during acceleration.

The third screen is the In-Line Lunge Movement Pattern Test.  This provides a quick appraisal of left and right function in a basic pattern and is intended to place the body in a position that will focus on the stresses as simulated during rotation, deceleration and lateral type movements.  This one is done balancing on a 2x 6 inch board with feet in line and maintaining perfect posture. This test also demonstrates how well and athlete stabilizes during deceleration.

The fourth screen is a Shoulder Mobility “Reaching” Movement Pattern Test. This test demonstrates the natural complimentary rhythm of the scapular-thoracic region, thoracic spine and rib cage with reciprocal upper extremity shoulder movements. In other words, you are really testing thoracic spine mobility  in addition to gleno-humeral  movement and scapular stability.

The fifth screen is the Active Straight Leg Raise Movement Pattern Test.  This is an “apparently” simple test that has the patient supine on the ground and identifies active mobility of the flexed hip and  initial and continuous core stability while the opposite hip remains extended and flat on the ground.  Don’t be fooled by the simplicity of this test as it also demonstrates the ability to disassociate the lower extremities while maintaining stability in the pelvis and core.

The six screen is the Trunk Stability Push-Up Movement Pattern Test .  It is used as  a basic observation of reflex core stabilization and is not used as a measure of strength since only one repetition is required.  The goal is to initiate movement with the upper extremity without allowing movement of the hips or pelvis.

The seventh and last screen is the Rotary Stability Movement Pattern Test and it is a complex movement requiring proper neuromuscular coordination and energy transfer from one segment of the body to another through the torso.  It has roots in the basic creeping pattern that follows the crawling pattern in the developmental sequence of normal human growth and locomotion. It looks like a birddog, horse stance or whatever you want to call getting on all fours!

The purpose of the FMS is to find the weak links in your patients and alleviate them with specific corrective exercise strategies.   When this occurs, the individual or athlete will have greater movement efficiency which will lead to  improved performance and a decrease in injury potential.

The Functional Movement Screen is designed for the individual that is not in pain or has an obvious injury. The Functional Movement Screen  can be easily integrated for all patients to provide a continuum of care and rational reason to continue with treatment even when  pain or injury has resolved.

The Functional Movement Screen has been shown to predict and reduce the likelihood of injury.  This has been tested in the NFL and the FMS is now part of the NFL Combine.  The United States Marine Corps utilizes the FMS for specialized communities within that branch.  It is also used in several college football programs and with many professional golfers.   Titleist Performance Institute uses the FMS to assess golfers and their unique movement dysfunctions.  It is taught as part of the Titleist Certified Provider program that many chiropractors and therapists have participated in.

The Selective Functional Movement Assessment (SFMA) is a different and complimentary screen  designed for the patient that has pain and requires a more in depth treatment protocol.  The “SFMA” will be described in a future article of Survival of the Fittest: Integrating Chiropractic, Rehabilitation and Sports Performance Training.

Robert “Skip” George, DC, CCSP, CSCS  co-owns Optimum Fitness and Health in La Jolla, CA. and integrates chiropractic, rehabilitation, and sports performance training in his practice.  He can be reached at Dr.George@SBCglobal.net

References:

1.The Functional Movement Screen Professional Training Manual by Gray Cook, MSPT, OCS, CSCS,  Lee Burton, PhD, ATC, CSCS and Keith Fields, MS.

2.MOVEMENT: Functional Movement Systems, Gray Cook, MSPT, OCS, CSCS, with Dr. Lee Burton, Dr. Kyle Kiesel, Dr. Greg Rose, and Milo F. Bryant

Survival of Fittest: Integrating Chiropractic, Rehabilitation, and Sports Performance Training – Part 2

Part I1: Move Well and Move Often: Introduction to the Selective Functional Movement

Assessment (SFMA)

By Robert “Skip” George, DC, CCSP, CSCS

In Part One of this series, I discussed the Functional Movement Screen (FMS) as one of the critical components of the Functional Movement System created by Gray Cook, MSPT and Lee Burton, PhD..   The FMS uses a standardized process using seven tests basic to testing fundamental movement patterns   with a scoring system providing the means not to only assess injury risk and discover pain, but to rate and rank movement patterns that include weaknesses, imbalances, asymmetries and limitations.

If there is one primary motivator that initially brings patients to our offices, it is pain!   For example, one typical case we see is the patient who presents with lower back pain and is given spinal manipulation with or without some kind of therapy and corrective exercise.  Our pain relief success rate is legendary with this approach for many of these patients but for many others their problem can be stubbornly persistent and complex with chronic re-occurrences that frustrate the best efforts of doctor and patient.

A step further beyond the FMS into clinical considerations of movement patterns is the Selective Functional Movement Assessment (SFMA).  There are similarities and differences in the two screening procedures.  Both the FMS and SFMA provide a complimentary means to assess cause and effect in addition to providing a rational for continuing care beyond the treatment of symptoms. The purpose of the FMS is predictive in assessing risk and discovering pain in movement patterns. The purpose of the SFMA is to assess the patient already in pain and to discover regional movement dysfunctions that cause local symptoms.  The SFMA addresses the critical issue defined as regional interdependence.

Regional interdependence is seen throughout the interconnection of the myofascial, neural and even circulatory systems as described by Thomas W. Meyers in his book “Anatomy Trains”.  He states” The muscle-bone concept presented in standard anatomical description gives a purely mechanical model of movement.  It separates movement into discrete functions, failing to give a picture of the seamless integration seen in a living body.  When one part moves, the whole body responds.  Functionally, the only tissue that can mediate such responsiveness is the connective tissue.”      Tom Hyde, D.C. is quoted in a previous Dynamic Chiropractic article describing spinal dysfunction.  He stated “Today there is more complexity with the description of subluxation.  Now it can be defined as a more complex set of issues called spinal dysfunction”.  And Gray Cook, MSPT lists subluxation as part of a joint mobility dysfunction classification that contributes to pain and dysfunction caused by faulty movement patterns in addition to soft tissue and motor control components.

Several questions need to arise when facing all of our patient treatment needs.    Are we too focused on chasing painful symptoms vs. addressing a more complex regional issue that  relates to the location of pain?  If a corrective exercise is given, how do we know that it fits the specific needs of the patient?  Why do highly trained athletes experience non-contact injuries or patients seem to have chronic re-occurrences?  Are we piling fitness onto dysfunction?

Planning effective care needs an accurate starting place. A functional diagnosis that demonstrates posture and movement patterns is crucial. The SFMA is an excellent tool for this task.  With practice evaluating a patient and discovering dysfunctions takes about 10 minutes.

There are seven movement assessments that comprise the SFMA.  Caution!  If these tests look simple or basic to you, you are right!  However the interpretation and the meaning is not so obvious and will be revealed at the end of their brief descriptions.

The first is the Cervical Spine Movement Assessment with three components —flexion chin to chest, extension face parallel to ceiling, chin left and right to shoulders.

The second is the Upper Extremity Movement Pattern of the shoulder.  Pattern One assesses internal rotation, extension and adduction of the shoulder and Pattern Two assesses external rotation, flexion, and abduction of the shoulder.  This also includes a pain provocation test ie: Yocum’s impingement test.

The Third is the Multi-Segmental Flexion Assessment starting with patient standing erect and bending forward at the hips attempting to touch the finger tips to the toe tips.

The fourth  is the Multi-Segmental Extension Assessment and tests for normal extension of the shoulders, hips and spine.

The fifth is the Multi-Segmental Rotation Assessment  and it’s objective is for testing normal rotational mobility in the neck, trunk, pelvis, hips knees and feet. All of these look just like part of a standard chiropractic/orthopedic evaluation, don’t they?

The sixth is the Single-Leg Stance Assessment and it evaluates independent stabilization of each leg with dynamic leg swings used as part of the test.

The seventh and last is the Overhead Deep Squat Assessment for bilateral symmetrical mobility of the hips, knees and ankles.  With arms overhead, it also tests mobility of the shoulders and extension of the thoracic spine.

Unlike the FMS which uses a 0-3 point grading system, the SFMA places each movement assessment into one of four categories.  These are Functional Non-Painful (FN), Functional Painful (FP), Dysfunctional Painful (DP), and Dysfunctional Non-Painful (DN).  Since the SFMA is a tool for assessing patients with pain, which would be the most significant category for a given finding?  This is where the significance and meaning of an apparently simple testing or assessment tool is revealed!  If you are thinking Dysfunctional Painful (DP) or Functional Painful (FP), it won’t be the significant finding in regards to regional interdependence and discovering the source of pain and dysfunction.  Of course when painful findings are discovered, stop and treat the pain with the best means possible.

It is the Dysfunctional Non-Painful (DN) pattern that will most often lead us to the source of a regional problem causing local pain.  This is our starting place that takes us through a flow chart to “break-out” corrective exercise and treatment strategies.  For example, the nagging lumbar pain that persists as mentioned at the beginning of this article may have its genesis in an asymmetry in an extremity pattern, postural and alignment issues outside of the lumbar spine or lumbar spine stability and motor control issues which may include inappropriate lumbar flexion instead of hip hinging.

The SFMA is for licensed healthcare providers only including chiropractors, physical therapists, medical physicians and athletic trainers.   Combining the SFMA and FMS for a Functional Movement System gives you a more comprehensive and effective tool for risk assessment, injury prevention and treating pain caused by movement dysfunctions.  In addition, your patients will experience a reason to continue with care beyond pain relief as it gives them a place to go with a road map from which to work from.

What could be better than providing lasting pain relief and corrective exercise care for a patient while progressing them to be more functional and stronger than when they entered our office?

In Part Three of this series I will discuss the practical clinical applications of the FMS, SFMA, and the “Turkish Get Up” as a part of a continuum of care for your patients.

Robert “Skip” George, DC, CCSP, CSCS  co-owns Optimum Fitness and Health in La Jolla, CA. and integrates chiropractic, rehabilitation, and sports performance training in his practice.  He can be reached at Dr.George@SBCglobal.net

 

 

References:

1.The Functional Movement Screen Professional Training Manual by Gray Cook, MSPT, OCS, CSCS,  Lee Burton, PhD, ATC, CSCS and Keith Fields, MS.

2. The Selective Functional Movement Assessment (SFMA) Training Manuel, An Integrated Model to Address Regional Interdependence,  by Dr. Kyle Kiesel and Dr. Phil Pliskey

3.MOVEMENT: Functional Movement Systems, Gray Cook, MSPT, OCS, CSCS, with Dr. Lee Burton, Dr. Kyle Kiesel, Dr. Greg Rose, and Milo F. Bryant

4. Anatomy Trains, Thomas W. Meyers

A Candid Interview with Gray Cook, Founder of the Functional Movement Screen – Part 2

RG-There seems to be revolution right now in “physical medicine” where there is a potpourri of treatment applications and practitioners like personal trainers that perhaps aren’t diagnosing back pain but certainly treating back pain and other physical ailments. The information age is upon us and many different practitioners from many disciplines are treating these ailments.  Can you speak to that?

GC-Treatment without diagnosis, in my opinion is irresponsible.  It’s almost like going to a pharmacist and asking for a medication.  That pharmacist does not have the clinical ability to diagnose you but right behind them they can dispense a “potpourri” of things to make you feel different.  Now, don’t get me wrong I truly appreciate for example what a massage therapist can do.  I think that they have skilled hands and can get in there and work the tissue like nobody else.  But, you and I have been trained to find the driver of bad movement, to find the source of the pain.  Sometimes rubbing on the sight of discomfort distracts you from making an appropriate diagnosis.  You know, we have innovative, aggressive ways to treat soft tissue.  Dry needling and A.R.T. (Active Release Technique) are on the forefront of aggressively treating soft tissue so you don’t have to go to a massage therapist for a year  to get rid of unnecessary tightness for instance in the “traps”.  So, literally think that just because somebody may have had previous success getting people in shape or whatever, the treatment does not justify the lack of a  diagnosis.  I can give you morphine right now and you will feel significantly better but it does not mean I have diagnosed you or you have a lack of morphine in your system!  (RG Note: Chiropractors have said the exact same thing since day one!) So I am a proponent, that is if I had to dedicate myself to expert diagnostic abilities or expert treatment abilities and you could only pick one, it would be expert diagnostic abilities.  This is because I would soon figure out and how to change the baseline.  If all I had was treatment, then I would try to force every patient into my treatment zone.  So if you are good at diagnostics, one of the first things you will figure out is that you may not have the skill set to fix the person if front of you but I am a phone call away from being able to network that and I have never found a patient yet or a referral source that didn’t appreciate a well diagnosed, well managed referral and it usually comes back to me ten-fold.    I do think that diagnosis is a lost art and movement screening and movement assessment are sort of my contributions to get us back to that critical thinking.

RG-So talk to me then about the use of the FMS with organizations, professional sports teams and some of the people you have personally worked with.

GC-I’m very honored that the FMS has made it into the special populations of the military, the NFL and many other professional sports.  And I think there is a certain “dogma” that surrounds the movement screen.  It is either the savior of everything or it is the worst thing that ever happened!  And it is neither.  It is simply a tool that did not previously exist in our toolbox.   Once you introduce a new tool it doesn’t mean you lose all of the other effective tools.  It lays right beside the other tools.  And, I’m not saying that there are some tests that we should probably delete.  As a matter of fact, there are a lot of innovative orthopedic books out that say some of those tests we used to do are either unreliable or not valid.  So if we were to delete at least those, and not based on my opinion but current evidence, then we have plenty of space to add a new tool or “app” into what we do.

RG-It seems to me that that is the revolution Craig Liebenson, D.C. spoke about in a course he was teaching a few years ago when he said that everything in rehab and the functional approach to patient care changes every 5 years. Could you talk about that and where you see all of this going with the FMS and all of the new approaches in health, fitness and movement ? 

GC- Well, the first thing I see is that as soon as the FMS gets a little more popular than it already is, you will see a lot of “movement screens” come out.  You will see a lot of copy cats.  You see exercise videos, exercise equipment and protocol get copied.  So I would say we will see some new screens come out.  And I would at least throw down the sword out front and say listen, if you are going to beat me, then beat me.  But copying me ain’t gonna beat me.  I see people doing that, they take the movement screen and delete two tests, add one and then brand it as something else.  I think that is closer to seeking popularity instead really trying to change the baseline.  I am absolutely sure that we will have a better way to screen movement one day.  Until we had a GPS we had to be good at using a compass.  That GPS isn’t available now and until it is, lets use the compass and wear it out so as not to get lost!  I think the one thing we have to be vigilant for is a lot to copycats that are going to come around just because screening is popular.  And what will happen is that the pendulum will swing.  First of all, people will take the simple screening concept that we have offered to the exercise profession and do exactly what you talked about in terms of getting into assessment and diagnosis.  That is the pendulum swinging too far, taking irresponsible liberties with a skill set that is not designed to be clinical.  Secondly, we could swing the other way and say we should not do any screen at all and all we should be doing is counting “reps”.  I think that is irresponsible as well.  As time goes on and the FMS gets more popular it may polarize people saying it is too invasive or not thorough enough.  The movement screen is here to categorize people in both function and dysfunction.  And if we can at least agree that we shouldn’t lump a bunch of fitness on top of dysfunction, then it has done its job.

RG-Gray you have worked very well with other professions, especially the chiropractic profession.  Given our respective profession’s competition with each other, you even have chiropractors as FMS instructors.  Tell me about them.

GC-I think it is a breath of fresh air because the one thing that I think about chiropractors, and I am going to speak specifically about the chiropractors that help us, is that they seem to be significantly more “fitness savvy” than a physical therapist would be that work with us.  Unless a P.T. has a previous athletic background or sports medicine background, they don’t really feel comfortable in a fitness environment.  I think it is because P.T.’s come out and they don’t go into independent practice.  They work under the umbrella of a hospital or large clinic.  Whereas chiropractors come out of school and realize “ I’ve got to be a community resource right away.  I‘ve got to distinguish myself right away and if that means I have to give all Pilates and yoga instructors a discount for care so I can educate them about the service I might provide to their clients, if I am going to work with the local tri-athlon club or be a resource for personal trainers and maybe even offer them continuing education twice a year, then I am going to become a resource in my community that appreciates fitness and wants to keep the active population moving ”.  I mean, it’s a good business model.  Active people are going to get hurt more by the simple fact that they do more.  If you can position yourself to be there and make that injury a temporary inconvenience instead of this long term issue requiring medication, then wean off of it and all that.  The chiropractors we have had had not all just been competent clinicians but somehow in their communities have become a role model that this how you manage a clinic and fitness side-by-side.

RG-What value would the FMS bring to a chiropractic practice today?

GC-I mentioned before about being a community resource.  Often the sports medicine specialist or the orthopedist show up on sports physical day at the local high school and they do their thing and they are looking for medical contraindications for participation in sports.  Where as if the chiropractor teamed up with the school’s athletic trainer and did movement screening, it will not interfere with the pre-participation physical conducted by the medical physician.  But the chiropractic physician, the P.T. and athletic trainer can collaborate on the screen.

RG-You talk about this in your lectures that we all have been told to ”see your doctor before starting an exercise program”.  You follow this with how many people are told to “see you movement specialist before starting exercise” and who better than chiropractors and physical therapists to assess and be the “go to” professionals for movement?

GC-I just spoke at the International Federation of Orthopedic Manual Therapy in Quebec and said isn’t ironic that dentists look into your mouth for prevention once or twice a year.  They demonstrated they can prevent costly care just with an ounce of prevention.  Wouldn’t you like it if chiropractors could do a yearly musculoskeletal checkup?  We would love that, especially if insurance gave us about a hundred bucks to do it!  I’d crank them out about every 20 minutes!  And, I would uncover some stuff that I would go into clinic to treat.  The deal is, every dentist has a standardized, accepted checklist.  Here is the disappointing thing.  We are a long ways from getting that wellness checkup because everyone of use does something different.  We need to standardize that procedure.

Robert “Skip” George owns La Jolla Sport and Spine in La Jolla, CA where he integrates chiropractic, rehabilitation and sports performance training.  He is also a Functional Movement Screen instructor.  He can be contacted at dr.george@sbcglobal.net

A Candid Interview with Gray Cook, Founder of the Functional Movement Screen – Part 1

By Robert “Skip” George, D.C., CCSP, CSCS

On Oct. 26, 2012 I had the pleasure of speaking with the founder of the Functional Movement Screen, Gray Cook, MPT, OCS, CSCS, at the annual Perform Better/FMS Seminar in Los Angeles regarding what the purpose of the FMS is and its potential role in the healing arts especially in chiropractic. 

RG-Gray how did you come to settle in Danville, VA?

GC-We moved there in 1975 when my dad became a Methodist minister.  We moved from Virginia Beach where my dad was a V.P. of a paint company and was successful.  Then he got called into the ministry.  Actually we initially moved to a small town called Dryfork in rural Virginia where my dad was minister at a church nearby in Chatham where Lee is from (Lee Burton, Ph.D is the co-founder of the FMS).  Lee’s family had been going to that church for two generations and that is how I got to know Lee.  Ultimately we became friends and business partners each “team teaching” the FMS.

RG-What motivated you to create the FMS and would you define its purpose ?

GC-I realized early in my career that every big paradigm shift or how we view the human body or big changes in medicine was not because of a treatment protocol or medication.  It was because we identified something.  We’ve known for some time that we are not functional and especially we have known that from the late eighties and early nineties.  We have known that from what we have observed in the military for example regarding lack of fitness and function.  We have also known that from guys like Gary Gray, Vern Gambetta and even Janda goes back and talks about what happens when this dynamic wonderful body is made to work in an industrialized office environment.  So there has been this cry that we need to make out bodies more functional and move more authentically.  Many of the contemporary things we do in fitness have been influenced by body building.  Even though body building didn’t try to influence conventional fitness many assumed that if that is the way they train it must be good for us.  We have grown dysfunctional because of our culture and we compounded that with a skewed view of training someone away from that process (of being functional).  I could see that we had to hold up a mirror to show us how dysfunctional we have become instead of just coming up with new exercises alone that would help somewhat.  But we lacked an accurate assessment.  So if I didn’t create a “metric” that rates and ranks functions then none of us could really understand what changes function.  Without an objective metric, we are just being our own referee.  I am not saying that other functional approaches aren’t good.  I am saying that if we don’t have a baseline we will never know.   So, I had to decide if I wanted to put my effort and energy into creating a good baseline or do I want to just come up with some “neat” exercises.  I realized that many of my contemporaries were very innovative in coming up with exercises but my whole thing is when is the exercise applied, what is the progression and where do we go next?  Without having a good baseline or metric of what is good function we really don’t know where we are working.  So when my original concept of the movement screen was forming in my head I said you know what be a wonderful thing to do?  To go to a school in a community in the U.S.A. and run them through a battery of absolutely simple tests to see how well they do.  If I went to a martial arts studio or a dance studio in Russia or a gymnastic studio in Brazil and showed the FMS, they would say what do you mean people can’t do these tests because they could do them easily.   What I wanted to  demonstrate is what we have significant difficulty in doing today that  somewhere in a different time zone, or two generations before us, and because of culture they are more mobile, stable and they actually function better.

RG-So, this doesn’t sound like traditional physical therapy .

GC-I think traditional physical therapy literally helped me embody this because the one thing I got from traditional physical therapy was not just my orthopedics background but my neurological background to where I could appreciate the developmental “stuff”.  When someone falls victim to a stroke we don’t do bicep curls and triceps presses.  We literally have to re-integrate that limb to a part of the brain that is going to have to take over a new role.  So, you never really know motor learning until you work with someone who has a truly compromised motor system.  And, if you can help someone with small partial brain death to walk again, then helping someone with a bad ankle is no big deal.  I went into P.T. school feeling pretty good with a sports medicine background and athletic training background.  The thing that knocked my head off was the neurological stuff so my master’s thesis at the University of Miami was on the vertical leap, the leap being the undisputed test for human power.  I reference this in my book “Movement”.

RG- I want to ask you about the “ Movement” book in a moment.  You have written countless articles, you’ve written “Athletic Body in Balance.”  Your latest is the book “Movement” and describe your collaboration with Dr. Greg Rose, a chiropractor.  Would you also describe your professional relationship with Greg? (Greg Rose, D.C. is the co-founder and clinical director of Titleist Performance Institute in Carlsbad, CA)

GC-Greg is an “outside-of-the-box” thinker.  Greg has not only been looking how to integrate exercise into rehabilitation and especially into golf.   Greg is not stuck in one dimensional thinking and it was he who brought me into the world of golf and bio-mechanical analysis.  Greg thinks like an engineer and that is a breath of fresh air for us because as we are constructing a thought process and schemes for evaluation, the whole breakouts (algorithm) of the SFMA (Selective Functional Movement Assessment) could not have happened without Greg.   We had the breakouts but Greg and Mike Voit took it to the next level and it was an unbelievable contribution.

RG-Speaking of each our professions, chiropractic and physical therapy, our professions continue to have turf wars over competing for patients and scope of practice but you don’t seem to adhere to a specific practice methodology or philosophy that excludes or fights against another profession.

GC-No, I practice very eclectically but I haven’t really left my “tribe”.  I got here through physical therapy but I was reading Craig Liebenson’s work(Craig Liebenson, D.C.) the same time I was reading Vern Gambetta, Gary Gray, Cyriax and Janda.  So, I dispense with all of that (turf wars, etc.).  I think many of the things we do in physical therapy are because we have always done them that way and I have the same criticism for chiropractic.  Saying that, I am very blessed to give a workshop where chiropractors and physical therapists are in the same room.   The chiropractors are more aggressive with manual therapy and I appreciate that because I think it is a lost art in physical therapy.  For a long time there, physical therapists had great hands.  In countries where there are less chiropractors on hand, the P.T.’s are doing more joint work and our clinicians here in the states unless they get training out of school don’t get as good of training as they should.  Likewise, I don’t think the chiropractors get the motor learning, the developmental model and the exercise stuff.  So I see the therapists being creative on the exercise end and the chiropractors very, very creative on the manual end and I don’t see it working without both.   I need good manual therapy to “bump” or reset the system but then we need to reload it would some good movement patterns.  If I have a therapist that is reluctant to do aggressive manual therapy, I say hey listen find a chiropractor to get that neck moving for you and then get back on your exercise model.  Feel free to refer out if you don’t have the skill set.  Likewise, if a chiropractor appreciates manual work but doesn’t have the staff or time, make the referral and work together with a physical therapist or adopt the skill set to do both and more.   

Survival of Fittest: Integrating Chiropractic, Rehabilitation, and Sports Performance Training – Part 3

Part III: Move Well and Move Often:  Introduction to Kalosthenos and the Turkish Get Up

By Robert “Skip” George, D.C., CCSP, CSCS

Recently Craig Liebenson, D.C. and Charlie Weingroft, P.T. teamed up to teach a seminar called “Bridging the Gap: Rehab to Performance Training”.   I had the privilege of speaking with Craig and Charlie regarding the changes in chiropractic, physical therapy, the fitness industry and our healthcare system as well.  The blend of rehabilitation, training and lifestyle coaching is becoming an effective approach in not only the fitness industry but in many of our clinics as well.   Whether we like it or not, personal trainers are treating back pain with powerful assessment tools and corrective exercise —and they are getting results!  

Strength and conditioning associations as well as companies in the fitness industry, like Perform Better, are doing an excellent job of teaching doctors, therapists and personal trainers about the role of muscles, joints, and the nervous system in painful conditions of the spine and extremities.  As an example, over 5000 doc’s, P.T.’s, ATC’s and trainers are now certified FMS providers.

This recent availability of skill development has enabled personal trainers to provide a more clinical approach to their clients.  And, with all of the changes and uncertainty in healthcare, clients return to personal trainers over and over without insurance reimbursement.

Perry Nickleston, D.C. and Jeff Tucker, D.C have written numerous articles regarding rehabilitation and exercise including topics such as proper overhead squat mechanics, the kettlebell swing, and nutrition for patients and athletes.  They are leaders in one of the trends in many chiropractic practices that blend rehabilitation and sport performance training and utilize the Functional Movement System.

Teaching patients not only about chiropractic but how to move and function well is a needed approach for evidence based treatement. This integration is becoming a perfect match for the 21st century practice and defines a critical niche in the rapidly changing healthcare marketplace where trying to collect reimbursement from a third party is often more trouble than it is worth!

This article is the third in a series that I describe the Functional Movement System which includes the Functional Movement Screen (FMS), the Selective Functional Movement Assessment (SMFA), and the Y-Balance Test.  This system can help you determine which patient or athlete is at risk for injury, which movement patterns or regions are dysfunctional and what treatment or corrective exercise strategy is needed to address those issues in combination with your chiropractic treatment.

Just for fun, let’s examine what a typical American looks like in terms of posture, waistline and ability to function or move well.  Are we shining examples of form, function and fitness?  I think that most of us can agree that the typical hunched forward and rounded shoulder posture with moderate to severe de-conditioning is a significant reason patients enter our clinics.  It is not a stretch to observe that this de-evolution of sedentary human beings in a rapidly changing and highly stressful modern society is a major contributor to the unsustainable costs in our healthcare system. As chiropractors, we need to be at the “tip of the sword” when it comes to addressing what is needed to help heal our ailing healthcare system!

Regarding posture and patterns of movement, Mike Boyle and Gray Cook came up with what is known as the joint by joint approach that describes how our bodies move, stabilize and function.  Essentially, the ankles, hips and thoracic spine need to be predominately mobile and the knees, lumbar spine and scapulae need to be stable.  What contributes to or can cause dysfunction, pain and ultimately injury is the reversal of these patterns.  If we don’t recognize these patterns and deal with them effectively, we can actually contribute and prolong a painful condition vs. treating it effectively.

For example, not enough hip mobility will result in an excess lumbar spine movement compensation.  How many of us have treated a lumbar disc disorder or misalignment issues because of hip immobility and decreased lumbar stability ?  Shoulder conditions such as impingement, labrum or rotator cuff tears are often associated with unstable scapulae and decreased extension of the thoracic spine especially in athletes that use repetitive overhead motion.  Add rounded shoulders with forward head lean and headaches, cervical radiculitis or lumbo-pelvic pain can occur.

A must read is  Gray Cook’s book “Athletic Body in Balance” in addition to his new book, “Movement”.  He states that we are walking around like turtles, head sticking out forward and a big shell weighing us down.  What happens when we get put on our back and try to get up?  It’s not a pretty sight imagining we are flat on our back flailing to get up.  But this is exactly what happens to many overweight or elderly patients.  We will be seeing more and more aging “Baby Boomers” that want to live and function well and we have an important role in their healthcare outcomes.  Unfortunately, we will be seeing more obese patients unless this costly and destructive process changes.

So, we are then told to exercise and diet but what do we typically do for exercise?  How about going to the gym, sitting on a machine and pulling or pushing weights while hunched over with lousy posture.  Or, after sitting for 40-60 hours per week, let’s go out and put staggering amounts of rotational force on our lower back and a de-conditioned core with a round or two of golf or our Wednesday night softball league?  Sounds like a lot of fun to me just before the ACL goes or L-5 disc blows!

The public is told to “see your doctor” before starting an exercise program.  Most patients are cleared after history and vitals are considered “normal” enough.  But nothing is mentioned about seeing a doctor to determine how well you move before starting any exercise program.   How about see your “movement specialist” before even considering an exercise program.

The beauty of the Functional Movement System is that those regions that need mobility or stability can be addressed with a proper assessment and functional/strength training.  After a functional assessment, it just makes sense to reinforce functional patterns with functional exercise to build a foundation of proper movement, strength and athletic skill.  Now we are beginning to get somewhere to build form, function and fitness!

The word “calisthenics” appeared as a form of exercise that uses body weight or a hand held weight for strength and conditioning in the early 1800’s.  Ancient Greeks had a word called “Kalos” which means beautiful and “Sthenos” which means strength.  Kalos Sthenos means moving well or beautifully and possessing great strength and was a far cry from pushing or pulling on a seated machine.  Isn’t ironic that progress in developing fitness equipment could actually have the potential to do more harm than good and that an exercise created decades or even centuries before with a simple weight is more effective at helping us move and function more authentically?

One of the best exercises that personifies “Kalos Sthenos” by  integrating,  mobility, stability, symmetry(left, right, front, back), coordination, balance and yes, beautiful strength, is the “Turkish Get Up” or “TGU”, using the Kettlebell.

Kettlebell training has become popular in today’s fitness, performance and rehabilitation world and is an important tool for rehabilitation or strength and performance training because it reinforces  movement where movement is needed, stability where stability is needed, strength, coordination, symmetry and especially proper posture.

There are seven distinct parts to the TGU.  Starting from the ground is Step One: Roll to Press.   One of the most important parts of the exercise is gripping the kettlebell.  A straight or neutral wrist holding the offset weight is used as well as “crushing” or squeezing the grip very hard.  This crushing of the grip leads to a progression of hand, arm, shoulder and chest muscle activation that will provide greater strength and stability throughout the movement.  In addition, “packing” that shoulder down and away from the ears stabilizes the scapulo-thoracic joint to maintain proper and safe form throughout the exercise.

Step two: Press to Elbow.  It is simply rolling under the kettlebell to the elbow.  Force generation is required to overcome the inertia of being flat on your back.  Again, the shoulder is “packed” or retracted down and medially towards hips.

Step three: Elbow to Post. This is a continuation from the elbow to the hand and requires continual gripping, keep packing of the shoulder, extension of the T-spine, and mobility of the hips.  Can you see where each step is starting to reinforce the joint by joint approach while moving in a coordinated, multi joint pattern?

Step four: Post to high pelvis.  This illuminates the ability to extend the hips upward and forward creating a space to bring the leg back next to the hand.  Talk about taking bridging to a different level!

Step five: High Pelvis to Bend( a.k.a High Pelvis to Knee). This step requires coordination with strength.  Notice the mobility of the hips, extension of thoracic spine, stability and position of scapulae and lumbar spine.

Step six: Knee to Half Kneeling.   Keep shoulders packed down towards hips (note: ears are poison to the shoulders!) wrist and hand vertical, T-spine elongated and relaxed, drive straight up to half kneeling.

Step seven: Half Kneeling to Stand.  Continue with step six instructions for shoulders, hands, arms and spine then drive from the back foot to standing.

After each of seven steps are completed from the ground to standing reverse order all the way back to the ground.  Then, switch and perform the TGU on the other side.

This one of the most important exercises in rehab and sport performance training and is an important tool for the doctor who wants to integrate corrective exercise into their practice.  The TGU reinforces the functional movement patterns including stability, coordination, symmetry, balance and strength that allow us to thrive in how we work and in recreation.  It is  also an ideal exercise to restore function after an injury, augment sport and performance training, has a low financial cost for equipment and doesn’t require much office space.

The description and pictures are used for introducing you to the TGU. Only perform this exercise after you have been instructed by an “RKC” (Russian Kettlebell Certified) instructor, or become an “RKC”, and have a minimum score of 14 or more with no asymmetries on the Functional Movement Screen.  Without proper instruction and a proper movement assessment, there is a very real risk of injury and this exercise should be performed by fit individuals.  And, it needs to be learned without weight first and then only appropriate weight is added based on the patient’s age, fitness and functional level.

References:

  1. Kettlebells from the Ground Up/The Kalos Sthenos Manual and DVD by Dr. Mark Cheng with Gray Cook and Brett Jones
  2. Mike Boyle, Keynote Speaker, Notes from the April 2011 American Chiropractic Board of Sports Physicians Sport Symposium,  “Joint by Joint” Approach
  3. Movement by Gray Cook, MSPT, OCS, CSCS
  4. Rehabilitation of the Spine, Second Edition, by Craig Liebenson, D.C.
  5. The Selective Functional Movement Assessment Workbook, Advanced Clinical Integration by Phil Pliskey, DPT and Kyle Kiesel, P T

Robert “Skip” George, D.C., CCSP, CSCS  owns Optimum Fitness and Health, where he integrates Chiropractic, Rehabilitation and Fitness/Performance Training.  He is a certified Functional Movement Screen (FMS) and Selective Functional Movement Assessment (SFMA) provider as well as a Functional Movement Screen Instructor.  He can be contacted at Dr.George@sbcglobal.net

Mastering Your Craft: Soft Tissue Injury Treatment and Prevention

By Robert “Skip” George, D.C., CCSP, CSCS

As mentioned in my last article, sports science is evolving rapidly today as performance training, rehabilitation and sports medicine are “bridging a gap” to  increase performance, prevent injuries and more effectively treat injuries when they do inevitably happen to your athletes or clients.  Whether you are a personal trainer, athletic trainer, physical therapist or sports doc, soft tissue injury and effective treatment strategies need to be in your “tool box” for optimal performance and injury prevention.

Manual therapy or soft tissue work is utilized for the prevention of injury and treatment for acute or chronic painful conditions or just simple stiffness that is restricting movement.  If movement is restricted, performance will be reduced and the likelihood of injury is increased!

When do many of these initial injuries occur?  The answer is not only high school athletics but middle and grade school as well.  Since previous injury is the most significant cause of re-injury, are we providing the appropriate training and rehab to our younger athletes?  In our training programs, are we piling “fitness” on top of “dysfunction” or previous injury?

Assessment and treatment go hand-in-hand especially when it comes to the numerous soft tissue injuries that occur in athletics, especially contact sports.   Whether an athlete is in high school, college or is a professional, they are bigger, stronger and faster than ever before.  For many, training cycles are year round with intense strength and conditioning programs that lead into the season’s  schedule and perhaps playoffs beyond the regular season.  Injury prevention, injury treatment, and especially durability are crucial issues for your athletes.  One key player sidelined in any given sport for even a short period of time can make the difference between winning a game or winning the playoffs!  Effective soft tissue treatment with a “functional” movement assessment and specific corrective exercise is emerging as perhaps the best approach so far to prevention, treatment and performance.

Soft tissue is defined as muscle, ligament, tendon and nerve.  Surrounding the muscle like a slippery sack is an ultra thin but very strong membrane called fascia.  This may be one of the most important structures in the musculoskeletal system and forms a “fascial system”   that interconnects throughout the entire body and in many ways holds our muscles and bones together in a complex “functional” chain.  This fascial system contributes to posture and movement quality which ultimately results in the ability to generate power, speed and agility.  When damaged through direct contact, repetitive motion or traumatic injury it will affect movement and performance even when the pain is gone or the injury is “healed”.  This repetitive stress or tissue injury insult whether a single acute occurrence or one that happens over time affects the “plasticity” of connective tissue and affects movement patterns, player performance and durability of the athlete.

Injuries and pain to soft tissue can be classified as acute, sub-acute or chronic and refers to how long since injury occurred or the duration of pain.  Acute injuries go through three distinct healing phases which include the inflammatory phase, the repair phase and the remodeling phase.  Depending on the injury and joint involved treatment in the inflammatory phase may include managing the effects of the acute injury with rest, ice, anti-inflammatories and gentle movement with very light stretching, massage and/or isometric exercise depending on location and severity of injury.  In the repair phase, the time to promote healing and developing a “mobile” scar begins with soft tissue work while carefully adding exercise progressions.  Scar tissue forms initially in a random pattern and during this phase gentle alignment of scar tissue fibers with a soft tissue technique aids in the healing process.  In the remodeling phase, increased strength training and continued soft tissue realignment of scar tissue fibers aids in the healing of injuries and helps decrease risk of re-injury.  Ultimately, once an injury has healed, the “regional” effects on other areas of the body, especially through the fascial system, need to be addressed.

Soft tissue work has several benefits.  The first is biomechanical including the treatment of tissue adhesions, muscle lengthening and increased joint range of motion.  Physiological benefits include increased muscle and skin blood flow and circulation, increase of relaxation hormones and decrease of stress hormones.  Neurological effects include a reflex stimulation that decreases neuromuscular excitability, pain and muscle tension or spasm.   The psychological effects cannot be underestimated and include an increase in relaxation and decrease in anxiety.  Plain and simple, there is a healing effect with hands-on therapy!

Manual soft tissue treatment can include traditional massage for biomechanical, physiological, neurological and psychological effects.  For focused attention to specific structures there are several approaches widely used in sports medicine.

Today there are several excellent approaches to soft tissue management including the latest in fascial manipulation.  Several of these techniques are used in all major professional sports, Ironman competitions and the Olympics.   These treatments include Active Release Technique (A.R.T.), The Graston Technique (GISTM), Fascial Manipulation (FM), Functional and Kinetic Treatment with Rehabilitation Provocation and Motion (FAKTR-PM)  and Osteopath Guy Voyer’s work on treating fascia especially as it relates to sports.

Active Release Technique (ART) is a hands-on treatment that addresses muscular or soft tissue problems.  One of the key premises of A.R.T. and all of the soft tissue approaches mentioned in this article is to reestablish normal motion in and between fascial planes thereby reducing the adhesions that occur in the fascia and muscle while restoring the normal “gliding” and range of movement of these structures. The practitioner determines where the scar tissue or “adhesion” is located.  Then, he/she uses the appropriate amount of manual force to lengthen under tension in the direction of the fascia, muscle, tendon, or ligament.  Essentially, the muscle and fascia is first shortened then lengthened under manual tension slowly and held at the end of the movement for maximum therapeutic benefit.  The experience of the person treated is most often “That’s a good hurt, do it again!”.  This shortening and lengthening provides a free and complete movement of the structure treated, releasing adhesive tissue restrictions, increasing blood flow and restoring a more complete range of movement.  An example would be the treatment of Ilio tibial band syndrome that can cause pain into the lateral thigh region into the knee or a shoulder with scar tissue or limited movement.  Spinal pain and dysfunction can be treated in addition to tendonitis of the hand, wrist, elbow, shoulder, hip, knee, ankle and even plantar fascia.  A.R.T. was created by Michael Leahy, D.C..

Graston Technique is widely used in amateur and professional sports.  David Graston suffered a knee injury to several ligaments in his knee.  After extensive surgical reconstruction, he was left with limited range of motion and function.  He used a technique known as cross friction massage as described by Cyriax.  The problem cross friction massage or any hands-on technique is that it can be hard on the hands including being very fatiguing for the practitioner!   Graston developed specific stainless steel tools of different shapes that are used in many different directions over a fibrous “lesion” or scar tissue.  This soft tissue technique is designed to mobilize, reduce and reorganize fibrotic scar tissue or restrictions and can be very helpful in the repair and especially remodeling phase of inflammation.  Graston is also very effective for chronic or long standing soft tissue adhesions especially causing range of motion restriction for a joint.  Graston technique has been effective in clinical trials at Ball Memorial Hospital and Ball State University in Muncie Indiana.  It has been part of the kinesiology graduate curriculum at Indiana University for athletic trainers.

Fascial Manipulation (FM) is taught by Warren Hammer, D.C. and Antonio Stecco, M.D..   This work focuses on  treating what is known as individual “myofascial units” or trigger point locations along a “myofascial sequence”  or specific chain of trigger points.  These points are similar in location to acupuncture meridians.  Extensive research is continuing on this very effective technique that has been practiced in Europe for years and is now being taught in the United States by Dr. Hammer and Dr. Stecco.

FAKTR-PM also addresses the issue of once pain has occurred after an injury, what are the consequences to movement patterns of the athlete after the injury has occurred?  This technique uses hands-on therapy during corrective exercise to restore fascial “gliding” using functional movement patterns during treatment to restore proper timing and sequence to complex movement.  This technique was developed by  Tom Hyde, D.C., Greg Doerr, D.C. and Vince DeBono, D.C.  These sports docs also utilize the above mentioned techniques to complement their own unique approach to treat athletes.

Guy Voyer, D.O. teaches workshops on affecting fascia through specific stretches and is ground breaking in sports therapy and performance.

For specialized stretching, Stretch to Win is utilized by many professional athletes to maintain movement and function.

One of the most effective tools at your disposal in providing mobility is the “Stick”.  This popular tool is like a rolling pin for muscles and fascia.  In a blog by Joe Heiler, P.T., he recently mentioned Charlie Weingroft, P.T. and his use of the “Stick”.  How many clients or patients do you have with tight hamstrings?  Want to be an instant hero with that client or patient?  If they present to you with a tight hamstring stretch, use the stick on the back of their calves, hamstrings and lower back.  Spend about 90 seconds on each location then have them stretch again.  Nine times out of ten their range of motion will instantly improve and you get the well deserved credit!   The “Stick” is a must for every trainer, coach and doc working with athletes.

Remember that the biggest risk factor for injury is a previous injury.  After an injury or pain occurs, ligament, tendon, muscle and fascia need to be treated to restore normal function and movement at the location of injury.  But what happens to movement patterns to the athlete after an injury?  Studies have shown that even after the pain is long gone and tissues have healed, altered movement pattern is still a crucial issue and needs to be addressed.  For instance, studies have shown that once an injured ankle has been healed  function and strength of the gluteus maximus will be altered.  How important is this muscle for power production and speed?  With altered movement pattern on one side, an asymmetrical pattern can then develop in comparison to the other.  How prevalent are hamstring and groin injuries in your players?  Asymmetries are the second biggest reason athletes are injured and we are just talking about non-contact injuries.

For example, assessing injury risk and reducing that risk is one of the most important issues facing football players in high school, college and beyond.  Durability is a key component in this equation.  Of course, it is easier to prevent than to treat an injury and one of the most important tools to assess how well your player’s move and to address asymmetries and/or dysfunctions is the Functional Movement Screen(FMS) created by Gray Cook, MSPT.  In about 10 minutes and with seven basic movement tests, the FMS can predict the risk of injury in your athletes and provide a means to provide precise corrective exercise strategies.    The FMS is also an effective tool that helps you know when it is appropriate to refer out to a licensed healthcare provider.   The head strength coach of the Indianapolis Colts, Jon Torine, uses the FMS as the foundation for their training program.

A comprehensive and effective approach to training, playing and injury treatment including the use of assessment tools and soft tissue techniques that work hand-in-hand together is your best bet to provide that competitive edge that not only leads to a winning season but provides a solid foundation for your athletes to minimize risk of injury, fulfill their athletic potential to the fullest and provide durability now and in the future whether they continue on in competitive sports or not!   It never hurts having as many tools as possible in your toolbox for your athletes and this is a short list of the most effective tools for soft tissue treatment and functional movement available.

If you are a personal trainer you probably have limitations as to how much soft tissue or “hands on” work you can provide legally.  In the network of professionals you work with, make sure you know of at least one soft tissue expert or become one yourself. Spend the extra time and money by getting a massage therapy license or becoming an athletic trainer and then taking courses on the latest in soft tissue treatment.  Adding tools to your toolbox is not only professionally and personally satisfying but financially lucrative as well.  The competition is getting stronger in the fitness/training world.  Developing  competence and mastering your craft makes all the difference in the world for your professional and personal well being!  Good Luck and keep growing!

Dr. George practices in La Jolla, CA and integrates chiropractic care, rehabilitation and performance training.  He is a Certified Chiropractic Sports Practitioner, a Certified Strength and Conditioning Specialist and treats and trains amateur and professional athletes.  In addition, he has lectured to athletic trainers, physicians and strength coaches on the Functional Movement System it’s use in injury prevention and treatment.  He is also an instructor for the Functional Movement Screen.

He can be contacted at Dr.George@SBCglobal.net