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.
Dr. E just released the EDGEility plastic (delrin) Instrument Assisted Soft Tissue Mobilization (IASTM) tool. I have been using the stainless steel EDGE tool for over a year now, therefore I thought it was time for another review and to compare both versions of the EDGE side by side. This time I went with a video review. Unfortunately, the choice of this medium once again highlights one of my greatest weaknesses… The ability to speak.
Hope you find it useful regardless:
If you want to have a quick written summary of the video without the fluff, I choose the EDGE series of IASTM tools over other tools based on:
1.) No Education Requirement
2.) Total Cost
4.) Choice of stainless steel or plastic
Ground based rope climbs are great space saving full body pulling exercises. However, the top of the climb ends up being the easiest part of the exercise. Some heavy chain is a great way to maintain resistance throughout the climb. Just be sure to pad the support chain you wear well!
This is part 3, the last of a series of posts reflecting on some highlights in learning about movement that I experienced in this last year. In part 1, I addressed my experience with Applied Functional Science / Chain Reaction™ Biomechanics and presented an application of this approach using hip internal rotation. In part 2, I reflected my current thoughts on strength and conditioning. Now in part 3, I discuss my thoughts behind Fascia, Anatomy Trains, and Regional Interdependence.
Much of what we thought we knew about the biomechanical science of fascia and myofascial release is bunk. By saying this, I need to make it clear in advance that this does not change how we treat, rather it changes how we educate our patients and perhaps makes you think more critically about why you might, or might not, want to treat in a certain way. Greg Lehman provides an excellent review of fascial science on his blog.
So what about Anatomy Trains, which I have previously stated may be a beneficial overview for regional interdependence? As Dr. Lehman discussed, it is extremely unlikely that from a manual therapy standpoint we are making biomechanical changes to tissue. If anything, the biomechanical representation of Anatomy Trains better represents fascial adaptation to function and will only respond to progressive overload with daily stresses and exercise. Furthermore, if we look at function and movement, “Form Follows Function” , then the representation presented by Anatomy Trains may vary individually because tissue adapts to the stresses induced on a daily basis.
So we need to throw out the patterns presented by Thomas Meyers, correct? I personally do not think so. This is not the first time we have developed a general map which is not truly accurate of an individual representation. Our good friend the cortical homunculus also is an inaccurate representation of the somatosensory cortex.
Why? Because the brain is plastic and the somatosensory cortex adapts to how we interact with the world over time, which is most clearly demonstrated by cortical reorganization in phantom limb pain. Yet we still can use the homunculus as a general representation to give us a visual to for understanding sensation. Similarly, I still believe that seeing the patterns in Anatomy Trains can help us better see movement globally and therefore help guide treatment with complex patients representations. From a movement perspective, especially globally, we need to have some way to compartmentalize all the information and how they approximately relate to each other. Joint by joint osteokinematics and arthrokinematics help but can get complex quickly when you combine them with muscles and fascia. Patterns, such as those represented by Anatomy Trains, which encompass both bone and soft tissue, can help compartmentalize and make treatment more efficient if used appropriately. Of course, the reverse is also true, chasing patterns religiously will also take away from the most obvious, efficient, and appropriate treatment approach. Needless to say, these patterns do manifest themselves in our clients and patients from time to time, and to be ignorant of their general representations will cost you and your patient time.
As a side note, we are in a new era of our understanding of pain, with increasing emphasis on a neurophysiological role in this picture. There may be some overlap between the cortical homunculus and fascial adaptation over time. Since fascia is highly innervated with Ruffini and Pacini corpuscles, changes in fascia from physical adaptation to stress and from habituation to particular forms of movement may influence sensory perception and could theoretically be represented in the somatosensory cortex. With some recent evidence regarding the possible existence of a nocioceptive map which overlaps closely with the somatosensory cortex, there is the possibility that sensory rich fascia may be the interface that allows some of our voodoo with regional interdependence to occur, and why sometimes, specificity matters. This is purely hypothetical, but some ground work for the role of fascia and tendon pain (including pain referral) and their related cortical representation is discussed by Dr. William Gibson (His PhD thesis is available here: Pain sensitivity and referred pain in human tendon, fascia and muscle tissue.) But since we don’t have any other explanation for how manual therapy sometimes requires specificity and sometimes those points of specificity fall in the patterns represented by Anatomy Trains, this is where I am resting my patient education for the time being.
For a better summary than what I wrote above, I highly recommend a post by Alice Sanvito titled: “If we cannot Stretch Fascia, what are we doing?”.
This is part 2 of a series of posts reflecting on some highlights in learning about movement that I experienced in this last year. In part 1, I addressed my experience with Applied Functional Science / Chain Reaction™ Biomechanics and presented an application of this approach using hip internal rotation. In this post, I will discuss how my strength and conditioning beliefs have changed in 2012.
I still believe in heavy sagital plane lifting. Power/explosive lifts, deadlifts, squats, various forms of pressing have important places with strength and conditioning in a number of sports. Gary Gray provides good reasoning to support the idea that athletic development does not gain a great deal from these lifts unless they are a competitive weight lifter. However, standardized tests improved by these lifts have been shown to be related to athletic success in research1,2 and professional experience does show these lifts cross over into training. It is possible these improvements may be related to changes in coaching over the career of an athlete but it doesn’t change the fact that intense overloads over time result is associated with athletes becoming stronger, more powerful, and faster. The carry over effects might not be driven purely by hypertrophy and increased neuromuscular drive, it could be endocrine related (increasing load is associated with increases in GH, testosterone, etc) and it could even be largely related by the mental discipline it takes to safely and properly lift increasingly difficult loads. The argument that he and others make is that there are other ways to accomplish this carry over and provide more specific tissue and neurological adaptation to sport. That may be the case, but it has not had the sheer volume and history of success as heavy sagital plane loading. There are certainly some sports I could see the value in dumping this type of loading today, but I think we might lose something, or cause a new problem, if we drop it all together.
So what about the multiplanar, multi-joint, functional training, corrective exercise realm? This is where I started my journey into movement through attending a seminar at Perform Better in 2003. At that time and many years looking forward, I just wanted to collect exercises and categorize them for individual purposes. I rode the anti-heavy lifting bandwagon for a good 4 years before I realized there was a value in it and put it back in my own system. I juggled the balance between the use of bigger lifts and the use of mobility/stability/sport specific power/strength development. I also began to realize how stability and mobility training was being scarred by the functional training movement. People see individuals squatting on stability balls and doing bicep curls on BOSUs under the claim of being “functional” when in fact, quite the opposite, they’re producing movements which simply do not exist in typical function unless they have some sort of odd circus specialty as a career.
In fact, for many the idea of stability training automatically seems to perceived as being on an unstable surface, which could not be further from the truth. Worse yet, when they are not on some sort of unstable surface they are frequently isolated and cued to be worked under artificial constraints of stability. Everyone is given at least 5 cues to tighten one muscle, loosen another, fire this muscle, not that one. These cues have a place when someone is painful or are early in a rehabilitation protocol, but they do not belong in an athlete’s prehab or conditioning program in the long term except if they have another exacerbation of symptoms. They do not allow the athlete the freedom of motion to develop control in multiple planes of motion. Stability is a joint by joint function specific task. Stability is not simply the ability to hollow, brace, or maintain perfect hip hinge technique (go ahead and tell any strong man competitor fully flexed over atlas stone that his spine is unstable while lifting).
Nor is stability hip abduction and external rotation strength and endurance which keeps this hip, knee, and ankle in a perfect sagital position. Stability is also nearly impossible to tease away from mobility. When mobility with load and force are only practiced in one plane of motion (IE: sagital plane heavy squatting, dead lifts, etc.), mobility will not improve in other planes of motion unless loaded in those planes of motion. Which brings me to our next topic, mobility needs training, not just stretching (dynamic or static):
I believe we can incorporate loaded and body weight exercises into general strategies for improving mobility which I think is more beneficial than a stretching regimen alone. We now know that long term static stretching flexibility improvements are primarily related to stretch tolerance, not tissue change. We are beginning to see that long-term resistance training with full ROM have similar flexibility improvements. 3,4 My belief is that incorporating more full body multiplanar movements with appropriate loading will therefore make more lasting changes in mobility in ways which are more functionally applicable than stretching because they reinforce active patterns of movement. Furthermore, performing these mobility exercises in weight bearing may theoretically promote joint stability at these newly acquire ranges of motion.
Finally, addressing the concern of timing of implementing all of these exercises into anyone’s program. Overall, I see some effectively implementing multi-planar/multi-joint mobility and stability into supplement work for their heavy sagital plane work. Some incorporate into into their metabolic days. To some extent, I will acknowledge it is possible that the advent of diverse multi-planar dynamic stretching prior to every session is already adequate to address my concerns. However, I still wonder if these are enough to make long standing changes in freeing up movement patterns, in particular in the transverse planes. Simply peppering a couple of mobility exercises from time to time may not be enough.
I began this year developing a program meant to complement existing training programs rather than replacing anything. It started first as a way to implement many of the old school strong man training and unconventional training techniques popular these days: focusing on grip strength and lifting and moving diverse objects into a dedicated session, as a way to expand motor patterns for force generation and just to mix up training. Some of this was just for entertainment and variety. Ultimately, after my exposure to the AFS approach and some of the group training at Shoreline Sport & Spine, this progressed to include a variety of multiplanar activities to promote mobility and stability. I now call these the “Mix” sessions, with the idea being utilize full body movements, lift and move diverse objects which require multiple forms of grip and body positioning, and integrate multiplanar/3D mobility and stability to complement an existing training plan.
The idea behind having these as separate sessions rather than integrated into existing sessions was that although I wanted some mild/brief fatigue from a metabolic style warm-up and a finisher at the end, I wanted to not have neuromuscular fatigue be so great prior to, or during, the session as to prevent the body from learning new movement it might not be familiar with.
I put together a video of some the exercises used in group sessions over the last year as this thought process evolved. This video is not the best representation of everything involved in a mix session or the balance of single plane vs. multi-plane diversity. I still have a large number of sagital plane based exercises, but it still demonstrates how the movement is changed by using objects other than barbells and how freedom of motion is promoted throughout. Of additional note, these sessions were designed for group sessions, the exercises recorded below were primarily for non-competitive athletes, these are different than a competitive athlete and the sessions can be customized be more “general sport specific”, but they are inherently limited in the ability to address an individual’s functional needs.
And if I’m completely honestly, it is just fun to have an entire dedicated session to experiment with movements that are different than what are traditionally used. Sometimes a little change is all that we need to move forward.
1.) Hansen, Keir T., et al. “Do Force–Time and Power–Time Measures in a Loaded Jump Squat Differentiate between Speed Performance and Playing Level in Elite and Elite Junior Rugby Union Players?.” The Journal of Strength & Conditioning Research 25.9 (2011): 2382-2391.
2.) Gonzalez, Adam M., et al. “Performance Changes in National Collegiate Athletic Association Division I Women Basketball Players During a Competitive Season: Starters Vs. Nonstarters.” The Journal of Strength & Conditioning Research 26.12 (2012): 3197-3203.
3.) O’Sullivan, Kieran, Sean McAuliffe, and Neasa DeBurca. “The effects of eccentric training on lower limb flexibility: a systematic review.” British Journal of Sports Medicine 46.12 (2012): 838-845.
4.) Morton, Sam K., et al. “Resistance training vs. static stretching: effects on flexibility and strength.” The Journal of Strength & Conditioning Research 25.12 (2011): 3391.
Sometimes I forget how long the debate over abdominal hollowing (drawing in) vs. bracing has been going on. We’re close to 20 years on this topic. A year and half ago I started writing a clinical commentary on a herniated lumbar disc rehabilitation protocol which included addressing this very topic. A recent resurgence in interest regarding core stability (I guess it never really goes away) made me want to pull an excerpt from the article before it is published. I believe there is a time and a place for abdominal hollowing and abdominal bracing, but there is also a time for neither. The “neither part” has further been bolstered by my experience with Gary Gray’s Applied Functional Science (See Learning about Movement – Part 1). Here is the excerpt:
“Selective recruitment of the TA and multifidi utilizing “abdominal hollowing” or “drawing in” has been described in the literature and is widely practiced. (88,90) In contrast, the simple “abdominal bracing” exercise is another common exercise which not only emphasizes TA and multifidi recruitment, but has demonstrated recruitment of other musculature of the abdominal wall including the internal and external obliques.(89,91) Hodges et al.(85) have demonstrated, using an in vivo porcine model, some increased intervertebral stiffness utilizing TA activation by replicating “hollowing”, more recently, authors have demonstrated that this increased stiffness from “hollowing” is significantly less than during “abdominal bracing” due to decreased activation of the remainder of the abdominal wall musculature. (91,92) When sudden posterior trunk perturbations are introduced, abdominal bracing yielded significantly greater cocontraction of the trunk musculature, increased trunk stability, and better resistance to lumbar displacement than abdominal hollowing.(93) It also appears that the greater the conscious effort utilized to activate the muscular wall, the greater the decrease in spinal stability.(94) Abdominal hollowing has been shown to cause sufficient inhibition of the erector spinae and other musculature to decrease anterior pelvic during hip extension.(95) Inhibition of the erector spinae may have specific therapeutic and treatment benefits in addressing potential muscular imbalances, however they are valuable contributors to stable functional movement, which may result in decreased pelvic control if inhibited.
Although cocontraction of the TA and multifidi has been perceived as vital for muscular stabilization of the lumbar spine, their attempted selective activation may decrease anteroposterior trunk stability,(91-94) theoretically placing rotational trunk stability at risk through decreased activation of the external obliques in comparison to abdominal bracing.(89,91) Despite this, utilizing “hollowing activity” in the early in treatment phases of treatment can provide some symptom relief, kinesthetic awareness, motor control education, and provide some early activation of the TA and multifidi during the acute phase. However, once an individual progresses to postures that involve weight bearing, utilization of bracing may be better to enhance multiplanar stability.
Ultimately, conscious efforts towards bracing and/or hollowing do not contribute toward functional stability, rather, focus should be redirected towards addressing specific motor patterns utilizing multiple muscles in order to develop comprehensive spinal stability.(96) Moreover, from a theoretic functional perspective, consciously constraining movement in any region of the body over an extended period of time may alter the demands placed upon numerous other regions of the body. This may be best illustrated with the influence of external fixation, such as the use of a spinal orthosis for reducing pelvic mobility,(97) single segment spinal fusion influencing segmental motion around it,(98) and the increased risk of degeneration above and below the segment of lumbar fusion.(99) Although these examples entail extreme measures of stabilization beyond the level produced consciously by an individual, it serves as a reminder that a balance between mobility and stability is necessary to enable responses to the dynamic demands during movement of the human body.”
85. Hodges P, Kaigle Holm A, Holm S, et al. Intervertebral stiffness of the spine is increased by evoked contraction of transversus abdominis and the diaphragm: In vivo porcine studies. Spine (Phila Pa 1976). 2003;28(23):2594-2601. doi: 10.1097/01.BRS.0000096676.14323.25.
88. Richardson CA, Jull GA. Muscle control – pain control. what exercises would you prescribe? Manual Therapy. 1995(1):2-10.
89. Richardson CA, Snijders CJ, Hides JA, Damen L, Pas MS, Storm J. The relation between the transversus abdominis muscles, sacroiliac joint mechanics, and low back pain. Spine (Phila Pa 1976). 2002;27(4):399-405.
90. Hides J, Wilson S, Stanton W, et al. An MRI investigation into the function of the transversus abdominis muscle during “drawing-in” of the abdominal wall. Spine (Phila Pa 1976). 2006;31(6):E175-8. doi: 10.1097/01.brs.0000202740.86338.df.
91. Grenier SG, McGill SM. Quantification of lumbar stability by using 2 different abdominal activation strategies. Arch Phys Med Rehabi. 2007;88:54-62.
92. Stanton T, Kawchuk G. The effect of abdominal stabilization contractions on posteroanterior spinal stiffness. Spine (Phila Pa 1976). 2008;33(6):694-701. doi: 10.1097/BRS.0b013e318166e034.
93. Vera-Garcia FJ, Elvira JL, Brown SH, McGill SM. Effects of abdominal stabilization maneuvers on the control of spine motion and stability against sudden trunk perturbations. J Electromyogr Kinesiol. 2007;17(5):556-567. doi: 10.1016/j.jelekin.2006.07.004.
94. Brown SH, Vera-Garcia FJ, McGill SM. Effects of abdominal muscle coactivation on the externally preloaded trunk: Variations in motor control and its effect on spine stability. Spine (Phila Pa 1976). 2006;31(13):E387-93. doi: 10.1097/01.brs.0000220221.57213.25.
95. Oh JS, Cynn HS, Won JH, Kwon OY, Yi CH. Effects of performing an abdominal drawing-in maneuver during prone hip extension exercises on hip and back extensor muscle activity and amount of anterior pelvic tilt. J Orthop Sports Phys Ther. 2007;37(6):320-324.
96. Kavcic N, Grenier S, McGill SM. Determining the stabilizing role of individual torso muscles during rehabilitation exercises. Spine (Phila Pa 1976). 2004;29(11):1254-1265.
97. Konz R, Fatone S, Gard S. Effect of restricted spinal motion on gait. J Rehabil Res Dev. 2006;43(2):161-170.
98. Schwab JS, DiAngelo DJ, Foley KT. Motion compensation associated with single-level cervical fusion: Where does the lost motion go? Spine. 2006;31(21).
99. Putzier M, Hoff E, Tohtz S, Gross C, Perka C, Strube P. Dynamic stabilization adjacent to single-level fusion: Part II. no clinical benefit for asymptomatic, initially degenerated adjacent segments
after 6 years follow-up. Eur Spine J. 2010;19(12):2181-2189. doi: 10.1007/s00586-010-1517-4.
This is part 1 of a series of posts reflecting on some highlights in learning about movement that I experienced in this last year. I hope to be able to do this on an annual basis as a record of self-reflection and hopefully provide some value to others out there on the same journey.
Applied Functional Science / Chain Reaction™ Biomechanics
I have previously discussed my interest in going more in depth into multiplanar movement with my posts on 3D stretching as well as regional interdependence. I have used the FMS and SFMA off and on for a few years and felt they were both efficient and useful for their respective purposes, and I love that the research community is actively exploring the validity and reliability of these tests. I will still utilize components of these tests from time to time. However, I have personally found I need to change to a more customized approach to evaluation. In the past, I have found that in the middle of testing, I would break out of the protocols established trying to “tease” out something that did not fit cleanly into any of the tests. Part of this is just my nature, I have a difficult time adhering to standardized procedures and the way I do things just kind of evolves and varies depending by how I perceive something is presented to me. As these breakout sessions grew in complexity, I knew that for me personally I needed to explore some other philosophies which probably have figured out things I have yet to even think to ask about. Gary Gray’s Applied Functional Science (AFS) was the first approach that peaked my interest after that point. Gary Gray arguably pioneered much of the functional training movement, with Gray Cook stating publicly he has been strongly influenced by Gary Gray’s thought process. However, getting to the point of wanting pursue learning about the AFS approach has been a 4 year journey. When I first watched videos of Gary demonstrating and discussing his thought process, I completely disregarded it because my bias at the time of what I was seeing was an awful amount of poor quality movement with no regard for what is currently considered stability, in particular with movement of the spine. But over time, I could not deny that this freedom of motion looked more useful than I had first thought. I finally bit my lip and jumped in, eventually realizing I need to at least give it a try. It was probably one of the best decisions I could have made and now has significantly influenced how I view movement and exercise prescription.
I was given the opportunity to be exposed to the AFS approach through a nine week clinical rotation at Shoreline Sport & Spine in Spring Lake, MI. There are currently 6 Fellows of Applied Functional Science™(FAFS) at this location. A FAFS has completed a 40 week fellowship through Gary Gray’s Applied Functional Science (AFS) approach. The clinicians at Shoreline have integrated AFS with a wide variety of manual therapies and other interventions which was a fantastic eclectic experience that allowed me to explore a number of ways to integrate this philosophy.
Before presenting on this topic, I must first acknowledge that these are my personal reflections on the experience, and if they are in error, they should not reflect upon the excellent clinicians at Shoreline Sport & Spine. I am certain more than one FAFS will perceive I might have missed the boat on key points, and to that, I respond that I plan to formally take a Chain Reaction™ course in the future to see what else I might have missed. Furthermore, I am commenting on but a drop in the ocean of what the AFS system entails. The “Functional Nomenclature” alone requires a 44 page manual to address simply the language and fundamental principles. That being said, here are some key things I learned from this experience:
“Drivers facilitate chain reactions throughout the body”
This was the earliest, most applicable, concept I learned from my exposure to the AFS/Chain Reaction model. It may seem like a simple statement but it is incredibly profound when broken down even a small amount. Rather than simply thinking about one joint moving on another and leaving it at that, the Chain Reaction model demands that every joint be examined from a proximal on distal and distal on proximal perspective, what are the joints above and below doing, and what planes of motion (sagital, frontal, transverse) all of the joints are moving in during any musculoskeletal action. Central to this is the concept that during movement, a driver leads the movement and the joints above and below follow that same movement, but at different speeds as they progressively move in the direction dictated by the driver. This delay in speed/timing of a bone following another bone is the Chain Reaction explanation for much of what we understand about arthrokinematics. When bones move on top of each other in multiple planes of motion in the various representations of roll, glide, spin, etc., they are doing so according to the congruencies afforded to them to allow them to follow the next bone and joint as led by the driver.
In most of our manual therapy courses, we examine relative motion of one joint on another and addresses joint movement in various planes of motion based on arthrokinematics. Traditionally, looking at joints this way was left to the manual therapy realm and not the exercise prescription realm. Oddvar Holten likely made the earliest attempt to merge the manual therapy perspective with exercise prescription with his Medical Exercise Therapy (MET – Not to be confused with muscle energy technique) which focused on utilizing various apparatuses to isolate spinal segmental levels and extremities and then focusing on patient induced movement into one or more planes of motion specific to the desired outcome determined in the manual therapy diagnosis. The Chain Reaction approach more broadly addresses this by including concepts more similar to regional interdependence and primarily using the patient’s own body and extremities to control the levels of segmental or joint emphasis through prepositioning such as: Holding on to a stable or unstable support, modifying the weight bearing surface (wedges, angles, instability), conscious prepositioning, etc. It then utilizes another joint or point of the body above or below (could be FAR above or below) to facilitate movement at the joint in the plane, or planes, desired. This approach is both a diagnosis and a treatment, which is the focus of the AFS approach. It integrates extremely well with existing manual therapy interventions, or in Gary’s opinion, independent of traditional manual therapy models, resulting in him developing his own manual therapy system specific to the AFS called Functional Soft Tissue.
Getting back to the idea of a “driver”. A driver is anything which “drives” motor behavior. This could be any part of the upper extremity, lower extremity, trunk, neck, head, eyes, sense organs, and/or even fears and beliefs. The driver itself has numerous variables which can be applied to it: Is it open or closed chain based? What action is performed? What is the direction of movement? What is the speed? What are the force demands? Etc. etc.. This is just a small list amongst many other variables, not even addressing fears and beliefs. The entire process can get very complex, very quickly, when broken down in the nomenclature which requires looking at every movement from the perspective of:
- What environment is it occurring in (given available, or specified with certain controls on stability)?
- What is the beginning position (upright, seated, kneeling, prone, supine, sidelying)?
- What exactly is the driver (hand, knee, foot, pelvis, trunk, shoulder, etc)?
- What is the triangulation (direction/target)?
- What is the action (squat, lunge, reach, pull, etc)?
- What is the ending position?
I am not qualified to go into that sort of detail, so instead I will provide a broad overview with a contemporary example. Many of us are already applying general versions of this thought process, but do not realize how far we can take it. I will use the example of a kettlebell swing.
If you give a new client a kettlebell and only cue them to swing the kettlebell, they will instinctively “drive” the motion using the arms and shoulders, not their hips as you may have originally intended. They do this because you just gave them a cue which facilitates a motor pattern to accomplish the goal in the simplest way the brain understands, which is to swing their arms to swing the kettlebell, rather than to accomplish the exercise prescription goal you had intended, which was likely hip extension. If you change the cue to “Drive the hips forward”, you changed the driver of the motion to the hips, rather than the arms. Now in order to produce the force to swing the kettlebell, the individual will use a hip extension strategy. You just changed the entirety of the neuromuscular patterns utilized, even though you had the exact same exercise setup. Change the driver and the motor behavior changes. Now, if you expand this to joint by joint, things get really interesting.
Take for example working mobility and stability of hip internal rotation. There are a handful of non-weight bearing activities which involve the femur actively or passively internally rotating on the pelvis.
We may begin with a manual therapy intervention to address mobility, then provide a mobility exercise, then a stretch, then we prescribe an exercise for stability, then we address another joint which may be associated, and we give it a mobility exercise, and a stretch, and a stabilization exercise, on and on we go. We may end up providing a large amount of exercises, all of which take time, with very specific cues and details to remember. Now with AFS, if we apply the concept of a driver along with any number of subtle changes, or “tweaks” as Gary likes to call them (the process is called “tweakology”), we can tailor a custom exercise specific to our patient needs across multiple joints with reduced need for extensive cuing and details. This can be done with fewer exercises overall because we can integrate mobility, stability, and movement across multiple joints, in multiple planes of motion, into simple exercises which require less time for the patient perform. Progression and regression are simple to teach because you are using movement patterns the client/patient already knows, you simply tweak one or two components to make changes towards the movement you want to improve.
As I am already far over my target word count for this post, I will finish with a video in which I discuss some basic strategies to emphasize hip internal rotation in weight bearing and function:
Movement “flows” are a popular trend in the personal/fitness/strength and conditioning realm these days. “Flows” are a sequence of movements or exercises put end to end and performed in a continuous fashion. These movements are performed continuously for the desired amount of time or repetitions. To some extent, they have existed for 1,000 of years in martial arts in patterns of movements called “forms” which paired together martial arts techniques in both short and extremely long sequences (I have learned forms over 10 minutes in length in various styles over the years, and some forms of Tai Chi can be even longer). These grew and evolved to include many acrobatic techniques as well. The value of any these forms are debatable, but for those who enjoy them, they are worthwhile. Similarly, for those who are looking for something different, the current trend of movement flows are worthwhile. After all, movement in life is varied and diverse, not confined to singular patterns. Not to mention that flows can be quickly fatiguing through a variety of changing movements rather than the need to do a high volume of the same exercise.
Over the last few months, I have been toying with the idea of incorporating movement patterns and exercises that I think are generally beneficial to overall movement into standardized flow. As it stands, I have developed two sequences which I have been putting through trials with a variety of victims (read: clients and friends) with positive response. Therefore, I have decided to throw these out to the public for others to try. These flows are great for a warm-up or a stand alone exercise and can be blended together for a physically, and sometimes cognitively, challenging exercise.
Dynamic Principles Basic Flow #1 emphasizes mobility and stability for the hips and shoulders, trunk control, and multiplanar movement driven by both the upper and lower extremities.
Dynamic Principles Basic Flow #2 emphasizes dynamically lengthening the frontal and lateral anatomy lines, multiplanar spinal mobility, and multi-angle hip extension
As always, thoughts and opinions are welcome!
Back in August, a group of authors, van den Bekerom, et al. published an article in the Journal of Athletic Training which reviewed the evidence for the use of RICE in acute ankle sprains1. The authors concluded that, other than some extremely limited and low quality evidence for ice, there is very little evidence for rest, compression and elevation. The most interesting to me, and purpose of this post, was the discussion of rest, which I felt the was best summarized from the article itself: “All included studies had a similar conclusion: some type of immediate posttraumatic mobilization is beneficial in the treatment of acute ankles sprains“. And curiously, although this was a team of medical doctors writing this article, it appeared that form of mobilization was preferentially (not directly stated) manual therapy.
Although I have not had a chance to do a thorough follow-up lit review myself (always a good practice in reviewing systematic reviews), based on references selected by these authors, it appears there is more published evidence (regardless of quality) towards the use of manual mobilization/manipulation2-6 than activity/exercise7-9. Of particular interest was an examination by Eisenhart, Gaeta, and Yens6, which examined the use of manipulation (fibula, talocrural, cuboid, and anything else clinically determined), soft tissue techniques (fibularis/peroneals, etc.), and lymphatic techniques combined with RICE (with or without pain meds) in comparison to RICE alone (with or without pain meds) in an emergency department. The group which received manual therapy demonstrated decreased pain, decreased edema, and improved dorsiflexion/plantar ROM (ROM was not statistically significant though) compared to group that received RICE alone. Since it typically does not get more acute than patients showing up at the emergency department, I felt this was a great study to demonstrate the value of manual therapy for acute ankle sprains. Combined with evidence that long term restrictions in posterior talar glide post ankle sprains4, there is clearly evidence for some form of early manual therapy in most inversion ankle sprains.
Despite recognizing the increased risk of compensation injury and general increased risk of injury from deconditioning, RICE, in particular rest and relative immobilization, remains the mainstay for the acute inversion ankle sprain. It is my belief (and I am sure many others) that this treatment philosophy needs to change at every level of patient care, and I believe athletic trainers and physical therapists need to lead the way. Although consideration for the individual patient should be made, as a general guideline, if we are presented with a patient with an acute inversion ankle sprain, our thought process needs to move away from the “rest/immobilization” component unless there is a clear need. Obviously “RELATIVE REST”, ie: not return to full sport participation may be a short term need, but full immobilization and crutches for the purpose of non-weight-bearing is likely unnecessary and potentially harmful. Instead, once a fracture or significant traumatic instability is ruled out, make the foot and ankle move, both actively and passively, and ideally with full weight bearing. Clearly if an excessively antalgic gait is present and cannot be resolved with manual therapy, tape, or other modalities, an assistive device may be necessary to improve the quality of gait, but ambulation with gait training to avoid compensation should occur early.
For those who prefer guidelines towards directing treatment, Whitman, et al. 10 developed a CPR for predicting whether thrust, non-thrust manipulation, and exercise in acute inversion ankle sprains could improve outcomes. They were able to determine that the presence of 3 out of 4 variables: Symptoms worse when standing, symptoms worse in the evening, navicular drop greater than or equal to 5.0 mm, and distal tibiofibular joint hypomobility were present; are predictive of dramatic improvements with a 95% success rate in treatment outcomes if manual therapy and exercise interventions are utilized.
To drive home these points I have 2 recent cases I want to share to demonstrate the clinical value of manual therapy in the management of an ankle sprain. Case 1 involves a 55 year old female who recently experienced an acute ankle sprain after waking up in a recliner and getting up rapidly, not realizing her left lower extremity had “fallen asleep”, resulting in a significant inversion of the left ankle and a “not so graceful” landing onto the floor. Initial evaluation revealed she was positive for 3 of 3 of the Ottawa ankle rules, so she was referred for X-ray. X-ray was cleared, she was provided crutches, and she presented to me 16 hours post injury with significant swelling and difficulty weight bearing. I performed distal fibular head mobilizations and talocrural mobilizations which result in immediate visible decreases with swelling without the involvement of any lymphatic techniques. Furthermore, it allowed the patient to weight bearing with 80% decrease discomfort. Additional soft tissue treatments of the peroneals and lateral aspect of her gastroc allowed her to ambulate without an antalgic gait, and without the crutches she arrived with. Although she still reported some mild discomfort, she was able to be off her crutches from that point on. I was able to see her for 2 sessions before she was sent on her own with 90% improvement within a week after her initial sprain. I would have liked to continue to work on the foot ankle, but she was private pay and she was satisfied with the improvements she already had, I discharged her to HEP with self mobs and progressive strengthening and instructions to keep moving. Clearly I can’t say if these outcomes would have been any different had she been partial-weight bearing for a week or more, but I can say that I was able to produce immediate functional improvements which improved the quality of her life sooner rather than later.
Case 2 is a story of me, jumping for a Chinese flying lantern stuck in a tree, not realizing on return to the earth my ankles would need to accommodate to a muddy ditch with a 75 degree decline in a very short amount of time. Unfortunately, they did not accomplish this goal and I crumpled like a sack of potatoes with the right ankle significantly inverted under my collapsing body. Of course I had just read this article from van den Bekerom, so I got right up and tried to avoid limping for the rest of the evening. Keep moving and it will just resolve itself right? Well nearly 2 months later of working through it, doing occasional self mobs or having someone do a talocrural manips, I still had episodes after training or moving where there were a few minutes that I could not weight bear pain free without significant pain on the lateral plantar surface and partially through the mid-foot In the back of my mind I kind of thought this may be something cuboid related because this was a typical presentation for it, and I somewhat proved it to myself that I got the most relief when I attempted a self mobs of the cuboid using a small kobble tool, but it never lasted. It was not until I had learned that one of my fellow PT students, Nan Hannum had recently been trained in the Dr. Allyn Peelen (a local podiatrist) method of cuboid mobilization that I finally had it formally treated. Although I always have a hard time believing in a “systematic” or sequential approach to mobilization, I have seen and experienced great results with Dr. Peelen’s method of treating cuboid and all sorts of vague ankle/foot issues that did not resolve with other manual interventions. So I thought, why not have her try it on me, especially since it had been consistently problematic and interfering with my activity levels. With one treatment, followed by a foam bolster taped under the cuboid to “hold the treatment”, I was 80% percent improved. We repeated that treatment 2 days later, second bout of tape, this time 90% improvement. I took the tape off 3 days later, and was able to run 2 days later for the first time in 2 months (Thanks Nan!). Furthermore, that specific pain has not been back since (although I did tweak my talocrural recently of course). Needless to say, the purpose of this case study was that I personally believe that if I had the talocrural and the cuboid (along with anything else clinically relevant) mobilization the first week, I would probably never have to wait 2 months to get full relief and I probably would not have developed subtle hip pain secondary the subtle antalgic gait. Yes, from an evidence based perspective that is a stretch, but when you see the acute benefits (regardless of the mechanism) of manual therapy with numerous patients, it is hard not to make the judgment that earlier treatment may have prevent later complication.
So with my rambling out of the way. I leave you with a slew of videos of my favorite ankle mobs. First off, you can’t go wrong with Dr. E’s collection of eclectic strategies to improve ankle mobility:
Second, don’t forget the cuboid whip, personally I have had good experience with this with patients, but as demonstrated with the Peelen cuboid sequence, we probably don’t need to be this aggressive because this can be painful!
Finally, I was able to track down two videos of Dr. Allyn Peel himself both performing and using a plastic model to explain his approach to cuboid/foot ankle mobilization.
Oh, and one last thing, don’t forget about the other 6-8 hours of an acute ankle sprain..
1.) van den Bekerom, Michel PJ, et al. What Is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the Treatment of Ankle Sprains in Adults?. J Athl Train 2012;47(4):435-443.
(2.) Bleakley CM, McDonough SM, MacAuley DC. Some conservative strategies are effective when added to controlled mobilisation with external support after acute ankle sprain: a systematic review. Aust J Physiother. 2008;54(1):7-20.
(3.) Green T, Refshauge K, Crosbie J, Adams R. A randomized controlled trial of a passive accessory joint mobilization on acute ankle inversion sprains. Phys Ther. 2001;81(4):984-994.
(4.) Denegar CR, Hertel J, Fonseca J. The effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. J Orthop Sports Phys Ther. 2002;32(4):166-173.
(5.) van der Wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, de Bie RA. Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: a systematic review. Aust J Physiother. 2006;52(1):27-37.
(6.) Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc. 2003;103(9):417-421.
(7.) Karlsson J, Eriksson BI, Sward L. Early functional treatment for acute ligament injuries of the ankle joint. Scand J Med Sci Sports. 1996;6(6):341-345.
(8.) Brooks SC, Potter BT, Rainey JB. Treatment for partial tears of the lateral ligament of the ankle: a prospective trial. Br Med J (Clin Res Ed). 1981;21;282(6264):606-607.
(9.) Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ. 2010;340:c1964. doi: 10.1136/bmj.cl964.
10.)Whitman, Julie M., et al. Predicting short-term response to thrust and nonthrust manipulation and exercise in patients post inversion ankle sprain. J Orthop Sports Phys Ther 2009,39(3): 188-200.
Most of the time when we deal with an acute inversion ankle sprain, we look at how to manage it for 16-18 hours out of the day and maybe add in some elevation at night if there is significant swelling. But could we do a little more to speed the recovery time or at least decrease the discomfort during the night? If the individual with an ankle sprain sleeps on their back or on their side (if they lay on their stomach, this solution will not work), here is something to try to help mediate some of the acute pain with laying on their back/side with an acute inversion ankle sprain. This mechanism/solution may seem negligible, but I can assure you that your patient will thank you for at least suggesting this as an option.
Although anatomic variations and pre-existing lack of mobility may prevent this from occurring, but for many, when the leg is rested on a surface, such as in supine with the posterior aspect of the calcaneous in contact with the surface, the effect of gravity naturally places the ankle into a bit of plantarflexion. With plantarflexion, a concurrent anterior glide of the talus occurs which is slightly accentuated by gravity both on the foot and through the talocalcaneal bridge with the tibula/fibula. This is because the calcaneous acts sort of like a fulcrum in which the talus has a relative anterior glide due to the effect of gravity driving the tibia and fibula gently posteriorly on the talus towards the resting surface due to size and weight differences. As a result, additional stretching/irritation of the anterior talofibular (ATF) ligament may occur. If the patient rolled on the side which places the injured ankle’s lateral aspect to be faced towards gravity, gravity would then contribute to the foot/ankle invert/adducting and minor stretching/irritation of the calcaneofibular (CF) and ATF ligament. Similarly, having the ankles lateral aspect on the support surface, through bodyweight and lack of conformity of the surface, minor stretching/irritation of the CF/ATF ligament may occur.
One way to counteract this kind of stretching/irritation is with a conforming pillow, which can assist with preventing the amount of plantarflexion in supine, and inversion, in side lying which may occur while laying in bed/couch, etc. But a pillow can be more cumbersome and require a fair amount of adjusting throughout the night to accommodate. Another way is through a small homemade/athletic training room/clinic made supportive device:
Take a simple piece of foam tubing (IE: pipe insulation tubing or thin floatation device) cut it to a length that can cover the back of the ankle and both malleoli. Thread a piece of string through it to allow it to be fastened around the ankle. Tie the string tight enough to allow it to stay on the ankle above the calcaneous at the talotibiofibular joint, but loose enough to easily remove.
This foam supportive device provides support at the talotibiofibular joint which, in supine, reduces the influence of the posterior glide of the tibia/fibula on the calcaneous (reduced relative anterior glide of talus) and also mildly dorsiflexes the ankle. In side lying, it can be positioned more inferiorly to prevents inversion/adduction with the lateral aspect facing to the sky, and left at the talotibiofibular joint line when the lateral aspect of the ankle is facing the resting surface. Basically, we are trying to prevent additional stretching of the soft tissues associated with anterior glide of talus.
In theory, this may secondarily assist with healing, as it helps keep the ATF,CTF, the capsule, and other tissues in an approximated position. This may be beneficial after aggressive posterior talus mobilization/manipulation as well.
…Ofcourse, everything I just described above could be complete hocum and simply the additional sensory contact around the ankle could act like a counter-irritant. Regardless, speaking from experience, it just feels better.