Find Ease Part 1 – Making Peace with Posture and Pain – Including Application video

, , ,

I would love to believe that the abundance of scientific research regarding a lack of relationship between posture and pain would be an open-and-shut case so that we can move on to really helping people with the complexity of pain. However, world wide false belief of a “perfect posture” and a “bad posture” continues to be spread. A slight glimmer of good news occurred as some international news circuits have picked up on a recent study which nicely demonstrates that the fear-mongering “text neck” does not cause pain. For those of you unfamiliar with the literature, please check out Ben Cormack’s Definitive guide to Posture & Pain in 3 minutes flat post for a brief abbreviated overview.

Beyond the literature, take a moment to look at life around the world and recognize how what many perceive as “bad postures”, are in fact, a normal variation in the demands of daily living, the body is remarkably resilient and designed to take on the stresses of daily living:

Part of the problem in interpretation of “good” or “bad” posture is the illusion that somehow, we are all keeping certain postures during the day. The truth is, we rarely keep the same posture for long. Dreischarf et al. looked at 208 adults with no current low back pain and monitored their lumbar spinal postures via electronic sensors for 24 hours. They found that the average range of change during the day was 8-33 degrees of lumbar lordosis! What we think of posture is just a tiny snap shot in the motion picture that makes a person’s day:

Another problem is that what we perceive as a “bad posture”, may simply be representative of an unconscious protective behavior. If you introduce a noxious stimuli to someone’s back, IE: inject a high concentration saline in their back, they will change their posture. As shocking as it may sound, our body wants to protect itself and it will change its behavior with, or without, your input. What the body perceives as threatening is more than simply nociceptive input, your emotions influence your posture as well. Moderate to severe depression is associated with classic “poor postures” and fear of pain reduces lumbar flexion to provide just a few examples. If you combine fear of pain with minor injury such as a workout which produces normal “muscle soreness”, your body may avoid lumbar flexion. Furthermore, if you have an episode of back pain, even if you do not have fear about it, your body will change you trunk musculature to behave in a more protective manner.

So where am I going with this?

I think we are looking at posture too much like a stand alone “thing”. Rather than being a cause, or a victim, it seems posture itself is a biopsychosocial representation of human needs, experience, and expression. It is reflective of a moment in time (or series of moments) and a person’s relationship to posture in that moment. Biologically, our nerves may need blood, movement, and space and posture change may be needed for that to occur. Culture and society may deem certain postures necessary, or conversely, inappropriate, and this may conflict with the needs of the physical body at the time. Emotions could be drivers and/or expressions of posture, ideomotor expression is a fascinating phenomena. Are we at peace with our body, avoidant and ignorant of our needs, or does it appear like it is is constantly on alert for a possible threat? If we are stuck in state of threatened existence, how do we find ease? Is it enough to tell some just to “relax”, do some breathing, move more, or do they need a little more guidance?

Below is the first of a series of “finding ease” guided experiences I wanted to share regarding how I believe we can use physical, cognitive, and emotional strategies to find ease in a posture for a moment. I must give a massive shout out to Joe Witte, a local physical therapist who is also a Feldenkrais practitioner, who cued me into these strategies for laying down, sitting, and standing. However, I will acknowledge I have essentially butchered the original non-verbal guided beauty of how he introduced me to this approach, but this is intentional. My belief is that simple experiences, such as this example of laying down, are ideal opportunities of effective therapeutic neuroscience education that may be helpful to unravel beliefs and open a person to new options for potential change in their life. Combining education, with an experience, body awareness, postural and movement variation, and re-assuring human contact has offered a number of my patients life changing insights into the complexity of their pain and a very real sense of hope that they did not previously have. Many of my patients cannot find comfort in a laying posture, and it is often the easiest place to build awareness and introduce change for other positions and movement, so this is where we start:

 

There and back again

, ,

This post is far more personal/autobiographic in nature than anything I have previously posted. I hope it does not detract too much from my intentions for this blog, but I have found that reading and hearing other clinician growth/life stories has tremendously helped my professional growth. I hope that perhaps this post may be meaningful for someone else.

Preparing for the journey:  Pain and Movement

I was exposed to the experience of persistent complex pain early in life. Shortly after birth, my family started to question why I was in near constant distress. Countless medical care visits later, I received my first pain diagnostic label; chronic cluster migraines, at age 2. This made for a challenging childhood, I missed many typical school age experiences and averaged ~50 days of lost school a year. I know it was a terrible burden on my family, and the physicians didn’t help the problem by telling my family to watch out for possible suicide efforts, as historically, cluster migraine was labeled the “suicide headache”, now that is nocebo!! Imagine as a parent, or a sibling, how that felt to think about? I was thankfully oblivious to this information until later in life. I can relate with the social implications of persistent pain quite closely. I can also relate with my patients on how pain negatively influences your relationship with movement. I wanted to move, I was a kid, I wanted to go out and play and hangout with friends, but the fear of triggering a cycle of pain sometimes prevented you from wanting to try to move. Despite this, I had this intense inner desire to move, and by grace and with the resiliency of youth, I was able to find a movement experience that fit my needs, falling in love with martial arts, and later stunts and movement choreography. With martial arts, I progressively, yet unconsciously, found a balance between intense physical training and rest though a 7-year sedentary career in information technology during the dot.com boom in the 90s. Perhaps this paced rest-to-work ratio was part of what made such a profound dent in in the frequency and intensity my headaches in those years. Likely, these effects were combined with the reduction of social pressures by dropping out of high school at that time… Regardless, all other medical interventions had failed prior to that point to improve my pain.

Another important observation to note about that time was when I instinctively recognized there was something more to human movement than the physical domain. Movement at times would resonate with me emotionally, it stimulated me cognitively, and as I explored different martial arts styles, I found the cultural  variations of essentially the same movements fascinating. Long before I knew the science, or what the words meant, there was this unconscious awareness that movement and pain was bio-psycho-social in nature.

The Journey There

In 2002, I was training and teaching at a kung fu school which decided that they wanted to expand their strength and conditioning offerings for their San Shou (Chinese Kickboxing) program. The school owner invited me to join him in attending a Perform Better seminar that year. I gladly accepted the opportunity because at that time only thing I knew about “Conditioning” was working yourself into the ground combined with traditional “Chinese torture” conditioning methods. There were several great speakers at that seminar, and being blissfully ignorant to the world of performance enhancement, made me feel like a kid’s first experience in a candy shop. I cannot recall all the speakers for the seminar, but I was most influenced by Mark Verstegen and Michael Boyle that day. Michael made a statement during his presentation that finalized my decision to become a physical therapist. It was the early days of the joint-by-joint, correctives, and of course, “core stabilization.” We had previews of the Gray Cook Movement trend to come and looking at the landscape today, it is shocking how little has changed in the last 16 years. I was also introduced to the idea of mobility work with various tools and rollers and this magical “fascia” and phenomena called “Trigger points.” I had dabbled with manual therapy before then, in particular with “trigger points”, having received treatments which had given me some short-term benefits for aches and pains from time to time. It made sense to me that hands on care had some value. If I’m honest, it didn’t take much to sell me on the dream of being a manual therapist to “fix” and train people, I still had aspirations to grow up to be the legendary martial artist and Chinese Medicine “bone-setter” “Wong Fei-hung.”…

I remember the thrill of the experience of being at that seminar clearly to this day. It created that feeling of the days of learning that “secret” technique in martial arts. I was enamored by all of it; I loved the “structural” thinking and the “healing” potential of the concepts of the biomechanical/pathomedical model. Being an IT guy at the time, the idea that there was some sort of “ideal” motor control and motor pattern for all sorts of movements that every person should be adhering to avoid “dysfunction”  seemed so logical, people had to be fixed! This started my first “binge phase” of learning. Before I went back to school to become a physical therapist and athletic trainer, I already had purchased the red tome of Travel and Simons, picked up a copy of Florence Kendal, and memorized Netter’s musculoskeletal pages, excluding the nerves of course, what good were those to fascia?! I bought a treatment table and lined up my “victims” to develop and practice my new-found skills using hands and other modes of manual therapy combined with my growing collection of “correctives”.

Doubts on the Journey

Fast forward through the roller coaster of information and skills I explored between the years of 2002 to 2010. It was a head first dive into a wide variety of manual techniques, Thomas Meyer Anatomy Trains, FMS and SFMA, Vladimir Janda, Stuart McGill, Pavel Tsatsouline, and countless other concepts and “thought leaders” at the time. No questions asked, if the pros were using it, I had to learn it. Besides, there must be evidence for these things somewhere right…? All I knew was, I wanted to be a movement expert and a highly skilled manual therapist, I had no concerns about the tens of thousands of dollars I invested in these resources along the way, or thousands of hours exploring them. But some tiny doubts started to creep up as I started to realize how much of my own training time was used for preparation and mobility work, and it was beginning to cut into skill training. Plus, I started getting frustrated because none of it was really helping any of my body aches and pains, instead, it seemed as though they were starting to become more frequent and persistent…

In 2008, I started to wonder why it was so hard to find research to support all these amazing outcomes we believing we were seeing in the field. So, I did what any other sane person would do, I decided I should start learning how to “science this shit of this” and begin adding to the literature myself. As is classic me, I fumbled my way into learning the scientific method with whatever resources and mentorship was available to get the job done. I chose something simple at that time which was the “hot topic” of dynamic vs. static stretching and chose to look at their roles in agility performance because nothing had been published at the time in that area. You can see the results of that experience here.  There are many things that can be learned in the process of developing, conducting research, writing, peer-review, and publishing a research article. The most important thing I learned was to be very systematic/procedural about literature review and begin to question my biases. By no means am I saying somehow I have succeeded in completely overriding my biases, but it was enough for me to start questioning some of my core beliefs about movement, manual therapy, and pain. The literature review process for stretching also brought me into the world of the nervous system and how it would be impossible for me to truly know about movement if I didn’t understand the nervous system better. Up to this point, my understanding of ROM and mobility was based on traditional biomechanics and the stress strain curve, so this was eye opening to be learn non-mechanical properties had a more profound role in available ROM. It was also when I first time was exposed to the idea that nociception does NOT guarantee pain, nor was pain it’s only role, but that it had other important biologic purposes. Of interest to me at the time, nociception’s role key role in stretch tolerance, the cornerstone of ROM and mobility. I didn’t realize how important that bit of learning would be in my current growth, because I still had my blinders on and had a fairly structuralist based mindset, but my curiosity was increasing.

Fast forward two more efforts to contribute to scientific literature, both of which had their own positives, negatives, and flaws (here and here). After completing these, I decided to take a break from being involved in active research to focus just on clinical practice with my new thinking in place. I have no doubt I will revisit the role of being a researcher again in the future.

Finding Ground

From movement and manual therapy came the opportunity to learn about pain science. I figured a good part of my life I had experienced some form of pain, sometimes finding relief for short periods of time, but I wondered why no treatments or magic trick seemed to have lasting benefits. So naturally, it was time to learn more about pain. Between natural curiosity, expanding available literature, and the “hivemind” that is internet social media (filled with its own opportunity and pitfalls), there was a great deal to learn. The constant feed of people smarter than myself on Blogs, Twitter, Facebook, and sites such as SomasSimple forced me to constantly question my interpretations of literature. There were times I felt my beliefs and interpretations were under constant threat and the ground beneath me was going to give way, but I knew that struggling with these ideas were vital toward my goals. It was a challenging time but my own struggles with pain made me realize the biomedical model was woefully inept at addressing the Complexity of Pain and I finally had to embrace the biopsychosocial framework.

It is hard for me to make a single list of all the people who inspired me and helped me understand pain better and how to implement it into clinical practice, but I must at the very least mention Adriaan Louw, Lorimer Moseley, David Butler, Louis Gifford, Diane Jacobs, Greg Lehman, Peter O’Sullivan, and Todd Hargrove. I owe Adriaan for not only helping me connect some important dots in pain physiology, but for changing my life in a short conversation he had with me about the fears I had about my own pain problems. His approach resonated with me and greatly influence my education style a great deal. I recommend anyone who works with people in pain consider taking part in the Therapeutic Pain Specialist program at the International Spine and Pain Institute.

With my foundation and framework somewhat stable, I began to nearly exclusively treat complex and persistent pain problems. The demand was so high in my community, I could not keep up with the number of referrals myself. To meet these needs, I developed an outpatient pain treatment division for Generation Care. This meant beginning to develop a curriculum and a system to start sharing my ideas with other clinicians. Through 2017, I had 10 clinicians suffer through my attempts to get ideas out of my head and try and making meaningful applications to their clinical practice. I can proudly say we have made a successful team to take on extremely challenging cases in our community and I look forward to new additions joining this year as the demand is not slowly down.

Back again

This brings us to 2018. Before the start of this journey, there was pain and movement. When I started the journey, it was about movement and manual therapy. As the journey continued, I reconceptualized pain and realized understanding pain meant understanding movement and manual therapy better. Now, the realization is there is a person behind all these things, which is an amazing conversation in and of itself. But in the meantime, I have a new-found love for all things movement, manual therapy, and pain.  Having realized how valuable it was for me to take a multitude of perspectives and interpretations of science and clinical experience, I felt it was my turn to give back by sharing my interpretations. This year, I will officially offer my first full course: Pain Science, Movement, and Manual Therapy. This course work is designed for Physical Therapists, Athletic Trainers, Occupational Therapist, Chiropractors, Physical and Occupational Therapist Assistants, Massage Therapists, and physicians who work in rehabilitation settings. The course work is designed both for those new to these topics, but also to offer some twists for those who already have experience, and are familiar, with these topics. These will be offered in 2018 with live classes and by 2019 I will hopefully have the online with live lab hybrid classes ready to go as well. By 2019, I also hope to expand to offering courses dedicated toward my physician colleagues as their needs are truly unique compared to the movement based rehabilitation profession. I am teaming up with a fantastic advisory board to make these products with the goal of improving communication and patient care through shared understanding of pain and science based interventions across multiple disciplines. Every effort will be made to keep the courses current with the evolution of research and changes in my own thinking. Change and improvement is inevitable, this will be reflected in revisions of the course as the years move forward. I look forward to the process and I hope I can be a small part of helping someone else in their journey.

The Complexity of Pain

Teaching people about the complexity of pain is extremely challenging, you must meet each person where they are at. It is not cookie cutter, there is no script, what is meaningful for one person may not resonate with another. You can provide too much information and you can provide too little. While we cannot predict what every patient needs to help them take the next step forward, themes and patterns of information that patients are missing that help connect the dots for them do arise. The late Louis Gifford is one of the pioneers who had a knack for this. Louis has made countless contributions to our understanding of pain. His development of the Mature Organism Model (MOM) was an extremely valuable contribution to both our understanding and education of patients regarding pain. Below is an effort to bring the “Complexity” of the MOM to the patient.

 

 

Confident Ambiguity

I currently work with a large percentage of patients who experience “complex ” and/or “chronic pain”. Many have multiple surgical intervention histories (most repeat surgeries), every known non-invasive treatment (multiple episodes of PT/chiro/body workers), and every known pharmacological intervention known to man. All of these patients share a similar story, they were all told that “X,Y,Z” would resolve their pain or dysfunction with absolute certainty, everyone told them it was a simple fix. Yet, here they are continuing in pain, or in worse pain, in front of me.

As I sit back and review many of these cases, the most consistent theme I see of why they continue to suffer is that the traditional differential diagnosis has failed them. Many were told they had a specific diagnosis and were given a specific treatment. Differential diagnosis is based in the contemporary utilization of “Occam’s Razor”, which is the principle that “Among competing hypotheses, the one with the fewest assumptions should be selected.” (Side note: Historically it has been argued this  statement is an inaccurate reference to Occam and was created by later philosophers) . Utilization of Occam’s razor is critical to many aspects of healthcare, in particular emergency medicine. However, regarding pain, it is a principle which falls far short. Pain is complex, not simple.

The absolute, “this tissue/disease is the issue”, which is both culturally and healthcare driven, is why we are in a chronic pain epidemic.When it comes to pain and movement, physical medicine and rehabilitation professionals need to come to terms with the complexity of pain. It is never a single factor, even if there is a single predominant source of nociception. This also holds true for acute injury, you must account the environmental factors and the processing, as well as the outputs:

 

Gifford Scrutinise Image

Louis Gifford’s Mature Organism Model – 1998

This understanding makes pain and movement complicated, it makes things a bit gray, there is no absolute. You must make a clinical decision to guide the treatment, you need to be able to identify red flags quickly, you need to identify some important tissue issues, but you also must be able to confidently proceed with fair degree of uncertainty with a great deal of grace and skill.  I call this skill, “Confident Ambiguity”.

Confident ambiguity allows a clinical decision to be made in the absence of an absolute diagnosis, and the absence of absolute certainty. Classically, you would look at it as a list of possible diagnosis, within your differential, but now you are asked to not just identify the possible biomedical diagnosis but also the psycho-social factors and assume for all of them to be present concurrently with a constant dynamic shift, as well as combined presence, in any given moment (Louis Gifford calls it the “Shopping basket”).

Research and clinical prediction rules help, but they need a larger framework to address all the concurrent layers of a biopsychosocial model. Personally, I, as well as many others, have been drawn to Ronald Melzack’s work on the neuromatrix at face value to help with developing a constant confident inventory of inputs/outputs  in the biopsychosocial model. At all times, while interacting, assessing, and treating, in the back of my mind I play the “input/output” game, which at first appears challenging, but over time is very re-assuring both for yourself and your patient based on the dynamic nature of the interaction. This same approach has been beneficial with performance enhancement.

Neuromatrix

Melzack, Ronald and Joel Katz. “Pain in the 21st century: The neuromatrix and beyond.”Psychological knowledge in court. Springer US, 2006, 129-148

Every pain experience and every movement dysfunction cannot simply be broken down to single tissue damage, single disease, length tension relationships, muscular imbalance, tissue restriction, or any other musculoskeletal emphasized diagnosis. You must learn to accept the fact that the tests you delivered ,which you so confidently felt were reproducible to a specific tissue or movement pattern, may at least in part be a “neurotag”, a pain and/or movement memory that is driving everything you see and feel.

Microsoft Word - Figure 5

Furthermore, lumping the patient into a primary “psychosocial” driver of pain is a also problem, one cannot ignore sensory input, regardless of whether it is nociception or any other sensory input perceived as a threat.

Pain is complicated, pain is messy, if we don’t treat it as such, you will be lost and you aren’t give the patient everything they need.

Todd Hargrove’s: A Guide to Better Movement

, , , ,

I haven’t updated in a while due to time devoted to opening a new clinic called Generation Care Performance Center.

However, I felt compelled to make a quick, blunt, review of Todd Hargrove’s: A Guide to Better Movement: The Science and Practice of Moving With More Skill And Less Pain. Simply put, this book is the most important book on movement in the last 20 years, possibly in existence up to this point. It will become a required reading for every movement professional to truly understand movement and pain. I have made pitiful attempts to touch on some of the concepts of this book in the past, but Todd has so elegantly written words which convey a clear understanding of the integration of movement in the Neuromatrix, that  I don’t know if I could ever add to it (but will foolish try at some point!). This book is fully accessible to both the clinician and the patient/client. Thank you Todd for your efforts, your clarity, and how incredibly affordable you have made this knowledge in an age of academic inflation. If you don’t buy this book, you are doing a disservice to your patients, and yourself. Buy it now!

Don’t Blame the Structure – The Role of Belief and Movement in Orthopedics

**Updated 2/16/14**

The purpose of this post is to have a central link on this blog which will contain brief summaries of the growing evidence demonstrating a continued need for us to examine the role of belief and movement interventions prior to pursuing surgical interventions for many common orthopedic conditions.

Please let me be clear that there are certainly clear need for surgical intervention for the management of symptoms, even in the absence of medical necessity. In fact, the structure may be involved and may have initiated the output from the brain, but may not necessarily be responsible for continued symptoms. However, the emphasis on structure has resulted in a growing trend towards excessive, unnecessary, expensive, and risky surgical procedures for the management of pain and movement dysfunction. These procedures are occurring despite clear evidence indicating that just because a “damaged” structure innervated with nocioceptors is removed or “repaired” and the patient feels better and/or moves better, the structure itself does not fully explain for the existence of the symptoms, nor does it fully explain for improved symptoms. The advent of placebo surgeries and increased number of true randomized controls for surgical intervention have opened a whole new realm of understanding of the role of structure in the human body.

This post is incomplete as it stands and will be constantly updated. I welcome any and all recommended additions to it, with the hope that it will grow into a stand alone section of the blog itself:

Arthroscopic Debridement for Knee Osteoarthritis
First, the landmark study by Moseley et al. which started it all in 2002 which showed that both  arthroscopic debridement (‘cleaning up”) and lavage (‘washing out’) were no better than placebo surgery for moderate to severe osteoarthritis: http://www.ncbi.nlm.nih.gov/pubmed/12110735

Second, Kirkley et al. addressed some the questions brought about from critics about the pain measures from the Moseley et al. This study compared arthroscopic debridement and lavage to physical therapy and conservative medical therapy and found again that  neither arthroscopic debridement nor lavage provide any additional benefit over physical therapy and conservative medical therapy: http://www.ncbi.nlm.nih.gov/pubmed/18784099

Third, Herrlin et al. found that arthroscopic debridement with physical therapy was no different than physical therapy alone: http://www.ncbi.nlm.nih.gov/pubmed/17216272

Fourth, Katz et al. looked at individuals with a meniscal tear and evidence of mild-to-moderate osteoarthritis on imaging found that arthroscopic partial meniscectomy with physical therapy had no better outcomes that physical therapy alone: http://www.nejm.org/doi/full/10.1056/NEJMoa1301408

Finally, the 2nd edition of the “Treatment for Osteoarthritis of the knee” from the American Academy of Orthopaedic Surgeons officially states “We cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.” and their first recommendation in this association statement was “We recommend that patients with symptomatic osteoarthritis of the knee participate in self-management programs, strengthening, low-impact aerobic exercises, and neuromuscular education; and engage in physical activity consistent with national guidelines.” with the following clarifying statement written within the recommendation that “The exercise interventions were predominantly conducted under supervision, most often by a physical therapist”.

Arthroscopic Meniscectomy
Most recently (December 2013), Sihvonen et al. compared  arthroscopic partial meniscectomy for patients age 35-65 with degenerative meniscal tears without knee osteoarthritis with placebo surgery and found that their outcomes were no different: http://www.nejm.org/doi/full/10.1056/NEJMoa1305189?query=featured_home

This is in agreement with earlier studies which also showed that arthroscopic partial meniscectomy followed by supervised exercise was no better than supervised exercise alone:
http://www.nejm.org/doi/full/10.1056/NEJMoa1301408 – (May 2013)
http://www.ncbi.nlm.nih.gov/pubmed/17216272 – (2007)

Spinal Fusion for Low Back Pain
A study which followed up on previous randomized controlled trials of spinal fusion versus exercise and behavioral therapy for chronic low back pain found that there no difference in outcome after 10 years and there is no evidence for continued deterioration of symptoms in the absence of surgical intervention. Making strong suggestion for avoiding fusion due to the increased risks of surgical intervention for spinal fusion: http://www.ncbi.nlm.nih.gov/pubmed/24200413

A meta-analysis of  666 patients (402 cases) over 4 randomized control trials demonstrated no benefit of spinal fusion over conservative treatment. The authors concluded the evidence was so strong that no further research was necessary: http://mobile.journals.lww.com/intjrehabilres/_layouts/oaks.journals.mobile/articleviewer.aspx?year=2014&issue=03000&article=00002

No different in outcomes between conservative treatment and lumbar fusion after 10 years:
http://www.ncbi.nlm.nih.gov/pubmed/24200413

Vertebroplasty
Multi-center trial which compared vertebroplasty to a simulated procedure (placebo) without cement for OSTEOPOROTIC SPINAL FRACTURES. The capital letters are for the fact that for the simulated procedure, those vertebrae are still “not secured” or “healed”. Despite this, outcomes between groups for pain and pain related disability were similar at 3 months. The authors did an excellent examination of cross over effects, well worth reading the full text: http://www.nejm.org/doi/full/10.1056/NEJMoa0900563

A similar study design was performed which also confirmed that the fractures were unhealed via MRI and expanded the follow-up to 6 months. Similarly no benefits for vertebroplasty over sham was noted: http://www.nejm.org/doi/full/10.1056/NEJMoa0900429

Miller et al. discuss verbroplasty and the placebo response here: http://pubs.rsna.org/doi/full/10.1148/radiol.11102412

A meta-analysis of these two studies concludes that the hypothesis of the possibility of a specific subgroup benefiting from vertebroplasty is unlikely to have unique benefits from vertebroplasty: http://www.bmj.com/content/343/bmj.d3952

Inappropriate imaging, excessive specialist referral, and lack of physical therapy referral for Low back pain
A recent study on trends in the management of back pain examine the treatment of back pain from January 1, 1999, through December 26, 2010. The researchers found a worsening trend in the management of back pain inappropriately referred for imaging and specialists when they should have been referred to physical therapy first: http://archinte.jamanetwork.com/article.aspx?articleid=1722522

Non-surgical intervention of atraumatic full-thickness rotator cuff tears
A multicenter study of 452 patients who are treated with physical therapy first rather than initiating surgery for full-thickness (complete) rotator cuff tears found that 75% of the patients after 2 years opted not to have surgery due to a satisfactory outcome from physical therapy alone: http://www.ncbi.nlm.nih.gov/pubmed/23540577

Achilles Ruptures treated non-operatively have equivalent outcomes to operative interventions
A randomized study of 144 patients with an average age of 40 revealed that non-operative treatment of achilles ruptures had no difference in functional strength, range of motion, calf circumference, functional scores, or re-rupture rate between groups. In addition, a greater number of soft tissue complications were noted in the operative group: http://www.ncbi.nlm.nih.gov/pubmed/21037028

Is ACL reconstruction the best management strategy for ACL rupture?
A systematic review and meta-analysis of ACL repair versus non-operative repair demonstrates poor available evidence for ACL interventions as a whole, but that current evidence appears to indicate that a non-surgical intervention should be attempted prior to considering surgical intervention. http://www.thekneejournal.com/article/S0968-0160(13)00199-3/abstract

MRI detection of disc herniation has no indication on outcome and is associated with lesser sense of well-being
In a study which examined both surgical and conservative treatment of sciatica and lumbar disc herniation, the presence of disc herniation on MRI after 1 year had no association with the outcome. 85% with the presence of disc herniation after 1 year of treatment still had a favorable outcomes: http://www.ncbi.nlm.nih.gov/pubmed/23484826

This is in agreement with previous research which revealed that not only was MRI findings not representative of the patients symptoms or outcomes, but that knowledge of the MRI findings resulted in a lesser sense of well being: http://www.ncbi.nlm.nih.gov/m/pubmed/16244269/

Surgical Scraping for Achilles Tendinopathy
In a study of patients with bilateral chronic achilles tendinopathy, surgical scraping performed on one side (the most painful side). Despite having expected to need a second surgery for the opposite side, 11 of the 13 patients had full resolution of symptoms bilaterally after unilateral scraping. Many already had full satisfaction bilaterally within the first 6 weeks. The authors make a good discussion why they believe these improvements were centrally mediated, not mechanically oriented: http://www.ncbi.nlm.nih.gov/pubmed/23193327

No difference in outcomes between arthroscopic acromioplasty and supervised exercise for shoulder impingement syndrome
A randomized control trial of 140 patients with shoulder impingement syndrome showed no differences in pain or function at any point over a 5 year follow-up. Furthermore, surgical intervention was not considered cost effective and the recommendation was that structured exercise should be the treatment of choice for shoulder impingement: http://www.ncbi.nlm.nih.gov/pubmed/23836479

Shoulder Impingement Syndrome and Central Sensitization
A trial which compared 17 age matched patients awaiting arthroscopic subacromial decompression to a matching asymptomatic control group and identified a significant proportion of these patients presented with notable central sensitization. Those with the most pronounced levels of central sensitization had significantly worsening outcomes at 3 months post subacromial decompression than those with lower levels: http://www.ncbi.nlm.nih.gov/m/pubmed/21464489/

Examining peripheral and central mechanisms in shoulder pain
Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain: http://www.ncbi.nlm.nih.gov/pubmed/23429268

The pain of tendinopathy: Physiological or Pathophysiological: http://www.bodyinmind.org/wp-content/uploads/Rio2013.pdf

The central nervous system e An additional consideration in ‘rotator cuff tendinopathy’ and a potential basis for understanding response to loaded therapeutic exercise: http://www.ncbi.nlm.nih.gov/pubmed/23932100

Multiple abnormalities of the hip are normal imaging findings in asymptomatic individuals, including labral tears
In a random sampling for 45 volunteers (60% males) with an average age of 37.8 y/o, MRI imaging revealed “Labral tears were identified in 69% of hips, chondral defects in 24%, ligamentum teres tears in 2.2%, labral/paralabral cysts in 13%, acetabular bone edema in 11%, fibrocystic changes of the head/neck junction in 22%, rim fractures in 11%, subchondral cysts in 16%, and osseous bumps in 20%”: http://www.ncbi.nlm.nih.gov/pubmed/23104610

Cervical surgery with physical therapy versus physical therapy alone resulted in similar outcomes after 2 years
Although surgical intervention demonstrated a more rapid improvement in the first year, these differences were no longer present after 2 years. Due to the decreased risks and decreases costs, physical therapy was recommended prior to considering surgical intervention: http://www.ncbi.nlm.nih.gov/m/pubmed/23778373/

MORE TO COME..

Post-Antalgic Patterning – Part 2 – Quick Reference for Manual Therapy and the Nervous System

, , , , ,

*Note: This is part of a series of thoughts on the topic of looking at movement and movement related symptoms as influenced by the nervous system. These will be dynamic posts with additional content and references being added as time allows, but the primary purpose of the posts are to share my current thoughts on the influence of manual therapy and exercise on what we see and feel in our patients. I hope others will engage me in these thoughts and provide their perspectives and also criticism into the process.

In part 1, I wanted to provide the definition for post-antalgic patterning which I believe is important to understand before thinking about how we treat it (if it even needs to be treated), for which I lay the ground work here:

Post-Antalgic Patterning – Part 2 – A Quick Reference for Manual Therapy and the Nervous System

A little over a year ago Jason Silvernail released a great video summary on manual therapy and the nervous system called “Crossing the Chasm” which definitely had its intended effect on me. This discussion has been a “hot topic” for at least a decade. As I have attempted to share this same information with other clinicians, I have noted a trend towards wanting more “practical” connection between the techniques we use on a daily basis and the nervous system. As a result, over the last year I have started to formulate a way to bring a little bit of clarity to a very complex topic.

Mechanoreceptors – The elephant in the room

In most of our academic preparatory programs for various rehabilitation disciplines, our afferent and efferent sensory nerve fiber education has focused primarily on severe neurological conditions of the peripheral and central nervous system (stroke, spinal cord injury, CNS disease, etc.). However, when it comes to the role of the nervous system in musculoskeletal conditions, the focus tends to be on nocioception (note of importance: nocioceptors are NOT PAIN RECEPTORS!), chemoreceptors (in particular the relationship to inflammatory mediators), proprioception, muscle spindles, and the golgi tendon reflex. We might touch on some afferents when we talk about gate control, but in general, mechanoreceptors are a very minor part of “most” professional academic programming offerings. This is despite that fact that mechanoreceptors may be one of the bodies most densely dispersed points of interaction with our nervous system, in particularly in the tissues we commonly claim to be treating (joint capsules, fascia, ligaments, muscles, etc.).

I remember vaguely talking about Ruffini Endings, Merkel’s discs, Pacinian and Meisners Corpuscles, but I don’t remember much emphasis on them and I certainly didn’t see any value in even recalling their names at the time. Yet now I realize they are probably some of the most important structures I deal with on a daily basis, in particular when it comes to manual therapy interventions. We get so obsessed with the biomechanical properties of soft tissue and joints and the illusion that we can mechanically alter them through our hands and various tools despite growing evidence that this simply is not the case, or at best, has an extremely small role in the big picture. Yet we choose to ignore, or at the very least downplay, the one basic fundamental pathway, the cascade of neurophysiological events which occur every time skin is compressed. These events can result both in short term and long term tissue and movement quality changes which have the potential to explain every single “change” seen through the use of manual therapy. Furthermore, any inflammatory, fluid dynamics, or thermal responses which potentially could come about from an aggressive intervention could have chemical, thermal, and fluid interactions with mechanoreceptors, chemoreceptors, and thermoreceptors thereby compounding and/or altering an existing externally induced neurological stimulus. If the inflammatory, fluid, or thermal process remains active for hours or days, this could yield a sustained stimulus on mechanoreceptors, thermoreceptors, and chemoreceptors thereby influence the nervous system for an extended period of time (think of a “built-in portal e-stim unit” that already exists in all humans).

Perhaps more important than the external stimulus itself is the ability to modify, enhance, and/or guide the therapeutic outcome of the neurophysiologic response from the stimulus with an educational context provided to the patient, allowing for a profound impact on how they perceive touch and movement.

So what does the pathway for this manual therapy to mechanoreceptor stimulus to tissue quality/movement change look like? Dr. Schleip has perhaps best described this in his work on fascial plasticity, of which this diagram provides perhaps the most concise explanation of the relationship between manual therapy and the nervous system.

Schleip, R. (2003). Fascial plasticity–a new neurobiological explanation Part 2.Journal of Bodywork and movement therapies, 7(2), 104-116.

Schleip, R. (2003). Fascial plasticity–a new neurobiological explanation Part 2.Journal of Bodywork and movement therapies, 7(2), 104-116.

To further help solidify the connection between our commonly utilized manual therapy techniques and the nervous system, I put together a couple of acronyms to show the connection between groups of mechanoreceptors and various manual therapy technique:

“RuffMerks need tender care”

  • Ruffini Endings (End Organs) & Merkel’s discs are slow adapting mechanoreceptors which respond best to slow sustained and deep tension
  • ANS (PNS) & CNS interactions
  • General massage, myofascial release techniques, and possibly even ischemic trigger point releases likely preferentially engage these mechanoreceptors

“PacMeisners need action”

  • Pacinian and Meisners Corpuscles are fast adapting mechanoreceptors which respond best to fast & vibratory inputs and are key to texture discrimination (think edged/textured tools)
  • Predominantly CNS interactions although ANS (PNS) possible
  • Greater concentration subcutaneously are also more frequent on the tendinous site
  • IASTM style, cross friction (hand or tool), and oscillating techniques likely preferentially engage these mechanoreceptors
  • Also thought to play a role in high velocity manipulation

 “Free nerve endings do it all”

  • Some free nerve endings are intermediate adapting mechanoreceptors and can respond to any form of touch, or any modality (chemical, thermal, electrical) for that matter.

 “Ligamentous Mechanoreceptors – I got nothing”

  • 4 types, varying adaptability, primarily stretch mediated, although possibly facilitated through touch if the ligament is superficial enough to be compressed
  • Engaged primarily with mobilization/manipulation

Last but not least, how can so called “inert” soft tissue, or fascia, have tissue tension or “tonus”?

Smooth muscle fascia copy

More regarding the existence of smooth muscle cells within fascia can be found here.

To be continued in part 3..

Post-Antalgic Patterning – Part 1 – A Definition

, , ,

*Note: This is part of a series of thoughts on the topic of looking at movement and movement related symptoms as influenced by the nervous system. These will be dynamic posts with additional content and references being added as time allows, but the primary purpose of the posts are to share my current thoughts on the influence of manual therapy and exercise on what we see and feel in our patients. I hope others will engage me in these thoughts and provide their perspectives and also criticism into the process.

Post-antalgic Patterning – Part 1 – A Definition
Injury occurs either acutely or cumulatively. A threshold is reached and threat is detected, whether conscious or unconscious, the body wants to protect itself. As a part of the physiologic chemical cascade of events which occurs in an attempt to address the potential structural damage, the nervous system, both central and peripheral, protects the region through numerous responses including localized guarding or splinting. This guarding process involves contractile activation of muscle AND the CONTRACTILE activation of what has previously been defined as inert soft tissue, such as fascia, joint capsules, ligaments (1). As a result, kinematics, arthrokinematics, and tissue dynamics may be altered and movement may change. Some of it is subtle, some of it not (2). Regardless, it appears that occasionally, this alarmed state stays active long after the tissue has healed and the threat removed (3).

Steering away from the complicated matter of pain, better discussed in Explain Pain, I wish to focus on what I call “post-antalgic patterning”. This is the existence of an altered movement pattern that is most often an unconscious behavior that remains long after an injury has been healed, or possibly even perceived injury. It exists anywhere in the body with any movement, not just gait! This pattern is a chronic pattern, which begins as early as 2 weeks after an acute injury and remains a minimum of 6 months or for a multitude of years. It may be associated with patient symptoms through regional interdependence, or it may not. Post-antalgic patterning may resolve spontaneously or it may best respond to touch and/or movement coaching. In this definition, any clinician perceived “dysfunction” of the joint or soft tissue contributing to this movement pattern is propagated by the nervous system, not structural change and is minimally influenced by joint or tissue inflammation or swelling.

This pattern may or may not be mechanically inefficient, and it may, or may not, further propagate future episodes of threat elsewhere in the body. In truth, it may just be what it is. Perhaps changing it makes functional improvements and improved symptoms, perhaps not. This is key, because we really don’t understand it, and we have to know when to just ignore it and have the patient move on with life despite this perceived asymmetry, because in reality, we do not know if it might have always been present. This is important, because you have to put limits on how much you try and attempt to alter, as the concept of a “symmetrical” human is fairly illogical. Rather, the objective is to simply to provide an environment to allow movement in a way that the patient can regain trust in these areas, to become more active, which is where the healing occurs.

Your hands or tools aren’t magic. They may or may not be appropriate to providing that supportive environment for altering this pattern, but if you use them, realize their sole purpose is to get the patient moving, reducing threat and letting the tissue re-accommodate to activity.

To be continued in part 2..

1.) Schleip, R., W. Klingler, and F. Lehmann-Horn. “Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics.” Medical hypotheses 65.2 (2005): 273-277.

2.) Crosbie, Jack, Toni Green, and Kathryn Refshauge. “Effects of reduced ankle dorsiflexion following lateral ligament sprain on temporal and spatial gait parameters.” Gait & posture 9.3 (1999): 167-172.

3.) Gribble, Phillip A., et al. “The effects of fatigue and chronic ankle instability on dynamic postural control.” Journal of athletic training 39.4 (2004): 321.

What IASTM is, is not, and might be

,

The EDGE series

As indicated in my review of the EDGE series of tools and the fact that I am a re-seller of the EDGE (my disclaimer), I am a huge advocate of Instrument Assisted Soft Tissue Mobilization (IASTM) in terms of providing a different neurophysiological input in comparison to using your hands and reducing the amount of stress you place on your hands with soft tissue treatment techniques. I have found that with practice I can accomplish similar within session changes in ROM, strength, and symptoms as other manual techniques. At the same time, I question the rational of using tools to promote tissue healing and to break down scar tissue. I believe this approach has promoted far too aggressive treatment in the past, and at this time, we really do not have great evidence to support this philosophy of treatment. I hope this post provides some insight into why I have this concern.

What is the evidence for IASTM use?

While I believe IASTM to be a valuable tool in my rehabilitation arsenal with its own indications and limitations of use, there are some who have purported tools as being downright magical in their abilities to “heal” patients. Some major brands claim 80-100% success rates for nearly every musculoskeletal condition under the sun, but record and maintain these records privately, available on request only. From the published experimental study realm, far less data is available.

To date, only one randomized controlled trial in humans has shown a better outcome using a tool over hand based manual therapy intervention.  Wilson et al. (1) compared cross friction (using hands) to IASTM on individuals with patellar tendinitis. 20 subjects (12 men & 8 women) were randomly assigned to either the IASTM group (10 subjects) or the hand cross friction group (10 subjects) with both groups having the same standardized therex and modality interventions. The IASTM group had 8 treatments over 4 weeks and the cross friction group had 12 treatments over 4 weeks. Full resolution was considered having no swelling, no pain upon palpation, and minimal pain (<3/10) performing six single leg hops, squatting to thigh parallel, and performing an eccentric load step down. Clinical evaluation and self-reported questionnaires were completed at 0, 6, and 12 weeks.  Based on their full resolution criteria, at 6 weeks 10/10 subjects in the IASTM group had 100% resolved symptoms  and 6/10 in the cross friction group had full resolution. The remaining 4 from the cross friction group was crossed over to IASTM to be re-assessed at 12 weeks with 2 additional subjects accomplishing the full resolution criteria established by the researchers.

Only two other experimental studies have examined IASTM as an intervention. Burke, et al. (2) compared IASTM to soft tissue mobilization with hands on carpal tunnel syndrome and found that both were equivocal to each other. Blanchette et al. (3) compared IASTM to education, ergonomics, and stretching on lateral epicondylitis, IASTM by itself was found to have no greater or earlier improvements than the control.

Numerous level 2 evidence case reports and case series studies that examined IASTM have demonstrated favorable outcomes in isolation and after other interventions had failed.(4-9) However, as is the nature of these studies, they provide no insight on the mechanism or whether another intervention may have been just as beneficial.

From my personal perspective, I am not looking for magic and I have no concern whether outcomes using a tool may be equivocal to my hands or other interventions(2,3), because at the very least I know it does have a therapeutic effect. This now assures me that I can give my hands a break from time to time and be more willing to experiment a variety of patients using the stimulus of the tool as option, potentially identifying an individual who may be more positively responsive to the tool than you had previously assumed.

Can IASTM help with tissue healing?

Two of the largest names in IASTM make numerous claims regarding the tissue healing and “regenerating” ability of their IASTM tools and techniques. They both have webpages which claim amazing research evidence for their philosophy of treatment. Sadly, little of this “evidence” is available for public consumption. A quick glance at this list shows that only 3 studies on rats provide any insight on the role of IASTM in tissue healing. I will separate many of the popular claims of tissue healing into 3 categories to review the literature: Activate the histamine response and increase local inflammatory response, break down scar tissue and/or re-arrange some nondescript “fibers”, and increasing fibroblasts to the region.

Activate the histamine response and increase local inflammation

Oddly, although erythema is the most obvious effect noted clinically with IASTM, this is not something that is well studied. I have only been able to find one study which utilized Gua Sha to examine micro circulation. (10) The comparison of Gua Sha to IASTM is difficult to make because Gua Sha is significantly more aggressive than most forms of contemporary IASTM.  Gua literally translates “to scrape or scratch” and Sha can best be described as “red, raised,millet-size rash”. As shown below, it is extremely traumatic looking:

Gua Sha Treatment - NOT A GOAL OF IASTM!

I personally would never want to do anything like this one of my patients. With that in mind, the results of the study demonstrate that, shockingly, yes local superficial circulation is increased when you scrape the tissue.  However, this was after 7.5 minutes of aggressive treatment, which is far more than the average IASTM protocol. Furthermore, the circulation increases were noted as superficial, which questions the ability to infer increased nutrient delivery to, or removal of waste from, deeper muscle, tendon, or other soft tissue.

On a side note to those of us that are neurophysiologically minded, this study also examined Gua Sha’s effect on decreasing pain. After treatment, decreased pain was not only noted locally and regionally but also in  areas far distal from the treatment region. This finding made the authors themselves question the relevance of increasing local circulation for the purpose of pain relief. But I digress…

Scar Tissue (Type III collagen) break down and “realigning fibers”

So what about the idea of breaking down scar tissue or realigning fibers? Loghman and Warden examined IASTM on experimentally induced MCL injuries in rats. (11) They did not specifically address the soft tissue breakdown or “fiber realignment” but did note that “There were no grossly observable differences between ‘IASTM’ treated and non-treated ligaments at either 4 or 12 weeks post-injury; however, non-treated ligaments often had more adhesions and granular tissue, and were more difficult to harvest than IASTM-treated ligaments.” which to date is the only experimental discussion of tissue adhesions related to IASTM.

I will note that Dr. E has reported that a colleague of his is completing a ultrasound imaging study which notes changes in the fiber quality after 2-3 minutes of IASTM treatment. Since this study is still being prepared for publication, at this time I have not been able to review the results.

This is one area I would love to see evidence for tissue change, and I believe there is a “slim chance” for us to scrape “adhesions” surrounding superficial paratendons and tendon insertions around our distal extremities (ie: achilles tendon and insertion).  However, it is important to keep in mind that when we feel the “grittiness” or “adhesions” under our tools, we really don’t know what we are feeling. We cannot say with certainty that it is scar tissue we are feeling. We forget that way back in the day during cadaver dissection we used to see a lot of fatty tissue and non-deformable soft tissue adhesions subcutaneously which could easily explain what we are feeling. Further more, often times after several sessions of treatment, these “adhesions” rarely change, only the tissue tension and tonicity we originally aimed for changes. BUT, there are times that these “adhesions” do disappear after treatment, and I would like to know more about that.

Despite all this, I will not deny that secretly in the back of my head I would love to believe that me scraping paratendon sheaths is breaking up longitudinal “scar tissue” (type III collagen) and promoting movement of the sheath and therefore the tendon, but I recognize simple muscle activation and movement probably breaks up as much “scar tissue” as anything I am trying to do to the tendon with the IASTM tool.

Promoting Collagen Synthesis by increasing fibroblasts proliferation

rat

Increased fibroblast proliferation has been the only consistently demonstrated histological property of IASTM. (11,12,13) Although this has only been noted in rats.  Furthermore, Gehlsen et al. demonstrated that increased pressure from the tool resulted in greater fibroblast proliferation. (13) However, what the value of increased fibroblast proliferation is in the long term has not been demonstrated. Loghman and Warden’s rat MCL study showed that although the IASTM group had greater improvements in healing early on, by the 12th week, there were no histological differences in healing between treated and untreated rat MCLs.

And that’s it, that is all we know regarding tissue healing and regeneration related to IASTM. From evidence in rats only, we can promote fibroblast proliferation, but even in the rat studies, when compared to tissue healing without IASTM, no difference is noted after 12 weeks of healing.

Conclusion

Personally, I do not think the tissue healing concepts will pan out any better in future research, nor do I care if it does or not. It is too easy to fall into the “tissue quality” trap, where we chase the make-believe picture of “good quality tissue”, rather than looking at objective measures which are rapidly changeable to meet the patient’s functional goals. As with any manual therapy intervention, I am primarily interested in within and between session improvements which allow me to promote movement to get the patient moving which is ultimately the only thing that will change tissue. If IASTM helps tissue healing, it’s a bonus, but I do not want it to be focus of my treatment or my education.

I want to end this post with reference to a recent study by Alfredson, et al. which examined the most extreme version of tissue scraping, surgical scraping under anesthetic, in the treatment of chronic achilles tendinopathy. (14) In their study, they recruited only individuals with bilateral chronic achilles tendinopathy, and surgical scraping was only performed on one side (the most painful side). Despite having expected to need a second surgery for the opposite side, 11 of the 13 patients had full resolution of symptoms bilaterally after unilateral scraping. Many already had full satisfaction bilaterally within the first 6 weeks. The authors make a good discussion why they believe these improvements were centrally mediated, not mechanically oriented. It is an excellent read and well worth the time locating.

The Sales Pitch

With the understanding that many of the systems out there have little published evidence for the unique benefits of their expensive educational programs that they require you to complete in order for you to be able to purchase their IASTM tools. Why not consider one of the lowest cost options on the market with the best ergonomics, inclusion of all the most popular concavities and convexities (multiple tools in one), and no entry level requirements available in both stainless steel and plastic? Check out the EDGE and EDGEility series of tools!

1.) Wilson JK, Sevier TL, Helfst RH, Honing EW, Thomann AL. 2000. Comparison of rehabilitation methods in the treatment of patellar tendinitis. Journal of Sports Rehabilitation. 2000;9(4): 304-314.

2.) Burke, et al. 2007. A pilot study comparing two manual therapy interventions for carpal tunnel syndrome. Journal of manipulative and physiological therapeutics 30(1):50-61.

3.)Blanchette, Marc-André, and Martin C. Normand. 2011. Augmented soft tissue mobilization vs natural history in the treatment of lateral epicondylitis: a pilot study. Journal of Manipulative and Physiological Therapeutics 34(2):123-130.

4.) Slaven EJ, Mathers J. Management of chronic ankle pain using joint mobilization and ASTYM® treatment: a case report. Journal of Manual and Manipulative Therapy. 2011;19(2):108-112.

5.) Davies CC, Brockopp DY. 2010. Use of ASTYM® Treatment on Scar Tissue Following Surgical Treatment for Breast Cancer: A Pilot Study. Rehabilitation Oncology. 28(3):3-12.

6.) McCrea EC, George SZ. 2010. Outcomes following augmented soft tissue mobilization for patients with knee pain: A case series. Orthopaedic Physical Therapy Practice. 22(2):69-74.

7.) Hammer, W.I., Pfefer, M.T. 2005. Treatment of a case of subacute lumbar compartment syndrome using the Graston technique. J Manipulative and Physiol Ther. 28:199-204.

8.) Hunter, G. 1998. Specific soft tissue mobilization in the management of soft tissue dysfunction. Man Ther. 3: 2-11.

9.) Melham TJ, Sevier TL, Malnofski MJ, Wilson JK, Helfst RH. 1998. Chronic ankle pain and fibrosis successfully treated with a new non-invasive augmented soft tissue mobilization technique (ASTM): A case report. Medicine & Science in Sports & Exercise. 30(6):801- 804.

10.) Nielsen, Arya, et al. 2007. The Effect of Gua Sha Treatment on the Microcirculation of Surface Tissue: A Pilot Study in Healthy Subjects. EXPLORE: The Journal of Science and Healing. 3(5):456-466.

11.) Loghman, M.T., Warden, S.J. 2009. Instrument-Assisted Cross-Fiber Massage Accelerates Knee Ligament Healing. JOSPT. 39(7):506- 514

12.) Davidson, C.J. Ganion, L.R. Gehlsen, G.M., Verhoestra, B. Roepke, J.E., Sevier, T.L. 1997. Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Med Sci Sports Exerc. 29: 313-319.

13.) Gehlsen, G.M., Ganion, L.R., Helfts, R. 1999. Fibroblast responses to variation in soft tissue mobilization pressure. Med Sci Sports Exerc. 31: 531-535.

14.) Alfredson, H., Spang, C., & Forsgren, S. (2012). Unilateral surgical treatment for patients with midportion Achilles tendinopathy may result in bilateral recovery. British Journal of Sports Medicine. Epub Ahead of Print. Nov 28.

Quick Video Link: Furniture Slider Exercises – Multi-Planar Single Leg Squat

, , , , ,

Furniture sliders are extremely inexpensive (less than $10 at Lowes) and extremely versatile. I was inspired by Ross from Ross Training to experiment with these tools. One of my favorite exercise progressions is a multi-planar single leg squat. The slider is a great cue to promote mobility and stability as well as adding flow to a sequence of movements. It easily allows progressions and regressions based on the needs of the individual.