New blog!

I haven’t written in this blog in a couple years but I recently started blogging about physical therapy again at another site. Please visit, like, follow!

https://striveforwardptblog.wordpress.com/

Instagram: @teddy1137 and @striveforwardptblog

Facebook: https://www.facebook.com/striveforwardptblog/

 

Thanks, TJ Slowik DPT USAW

 

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Rolling…yeah I roll

Rolling…rolling…really? This is something that I have done enough times that I have seen great responses with. It has a purpose and if done and followed through with can be very beneficial. Even though I have done this several times I still continue to get questions and stares in clinic from both physical therapists, students and patients.

When do you decide to roll?

In the SFMA course that I took, the instructor (Greg Rose DC) referred to it as turning the switch on. For whatever reason, your “switch” has been turned off and we need to turn it back on. This “switch” is the motor control switch. Usually, in more chronic or longer lasting issues (pain or faulty movement patterns) there is this global motor control issue.

So, when you test functional movements and then break it down into individual segments there are many deficits. Each time you test a passive vs active ROM there is this overwhelming amount of full PROM and limited AROM. Also, the AROM looks “dirty” as in they compensate greatly to achieve a desired outcome. I will test rolling when someone has asymmetrical global weakness (such as in the hips or shoulder), when they show me poor movement patterns in deep squat/backward bend/full body rotation/lumbar flexion and/or they can’t activate their glutes (with prone hip extension they say they feel it in their hamstrings and/or they have a lot of compensations to get the leg smoothly up).

Why do you roll?

It is actually quite simple. If someone can’t roll correctly then how can they possibly perform exercises in any other position such as half/tall kneeling and standing? The way we develop, we start by rolling and then crawling then standing. We can’t skip steps!

The reason why we can’t roll?

I really think, from seeing the patients who fail at it, that we develop faulty movement patterns over the course of time. This could be a result of a previous injury years ago, our very sedentary lifestyles/jobs or the result of our chosen sport. The longer we go with a poor movement pattern then the more engrained into our nervous system that pattern becomes. Rolling is just the first step.

How do you test rolling?

There are four quadrants in both supine and in prone. I usually start in supine. You want to move one body part only and attempt to roll using that one body part. If you are going to use the upper body then the lower body is paralyzed and not allowed to help at all. If there is any activation then that attempt doesn’t count and they should redo it. The patient has to be honest with you and usually after seeing a couple good movements then most times you can see the compensation. Once the upper body is tested in supine then you test the lower body when the upper body is paralyzed.

Supine right shoulder flexion -> supine right leg flexion -> supine left shoulder flexion -> supine left leg flexion

Prone right shoulder extension -> prone right hip extension -> prone left shoulder extension -> prone left hip extension.

How do you treat rolling?

Most often times you will see one area that is especially dysfunctional though there may be multiple areas that need to be worked on. Say the right hip extension is dysfunctional. In order to treat that (this way is easier so that they can replicate it at home versus using a sport cord) dysfunction you place a pillow under there right hip/torso (decreases difficulty by 25%). If they still can’t do this properly you add another pillow to make it 50% easier and so on until they can easily roll.

Once they accomplish the rolling task with, let’s say two pillows, then you want to take one pillow out and make them work for the 25%. Once they pass a step I would make them do a bunch of reps first before increasing the difficulty. Do this at each stage until they are able to roll successfully from the floor.

What can it help clear up?

Remember, whenever you want to make a quick fix always have that movement or test that they failed and retest after they perform the intervention to see if it helped clear anything up. So, if they failed prone hip extension because of both poor active ROM and excessive hamstring activation then you want to go back to that test and see if it is better. It may not be an excellent grade after but you should see a considerable change. This change should be enough to allow you the “in” to start working on those individual motor control deficits.

Sometimes over the course of the session they still aren’t able to roll without assistance. That is okay! That would be there HEP and to progress to the floor. You can give a few small, simple motor control exercises after rolling but I would make their HEP following their initial evaluation focused on the rolling. The changes should maintain and stay as long as they are consistent with working on the movement at home. Most likely these patients will have a lot of deficits to slowly work on because their entire system has been shut off for so long. Those inhibitory muscles, overtime, can become actually weak as well.

What patients will this help?

Most athletes and people who have sedentary jobs where that extension mechanism is just lost. Chronic pain patients where the general programs just haven’t work to decrease their pain or improve their function.

Runners: usually their injuries are a lack/loss of active hip extension when running. This hip extension needs to be from the glutes and not the hamstrings or lower back. Ankle injuries/shin splints fall in line with this as well. Activate the glutes and entire posterior chain extension mechanism.

Swimmers: who have been using their shoulders/neck/lower back and hamstrings for long periods in the water will sometimes just need that relearning of proper muscle activation to go with all that motion.

Baseball players: Like swimmers, upper/lower body sports require better movement patterns

Golfers: they lose that motor control with rotations which can translate up/down the chain

Flexion based activities: just because they can’t reach down and touch their toes doesn’t mean tight hamstrings or lack of mobility. Often times they have impaired whole body movement patterns.

Questions…?

TJ Slowik PT DPT

Changing Conventional Thought

Changing conventional thought

My first real post on here was originally going to be reserved for pain or maybe motor control and inhibition/compensation seen in runners/athletes of all types since I have seen a few more of those patients recently. But, now I just want to talk about being a physical therapist for a moment.

Over the previous 6 months my treatment principles have undergone a major transformation. You tend to realize the things that you don’t know or don’t have a good answer for when you have a student. Wanting to educate the student and really increase their level of understanding comes first from your understanding what is going on. This extends to the treatment of the patient. The why questions pop up a lot and I hate not having a good answer for them or at least a possible reason. I always had a lot of questions and attempted to answer them for myself but something about being partially responsible for a future physical therapist really motivates me.

This week a new student started with me. Today we talked a lot about pain and the the difference between motor control and strength/core stability. Going through the explanations of everything made me really think back to this whole changing a young therapists mindset and how much different it is to think along these lines vs what you are taught in school. I just graduated about a year and a half ago and for the most part the information being taught hasn’t changed much. ROM/MMT/flexibility and biomechanical changes in joint positioning. These were the things that were heavily stressed to be important. What wasn’t stressed was how meaningless all these are. Humor me for a second.

ROM: Yes, A/PROM is very important but it is amazing at how little so many therapists take into account active vs passive ROM in the spine. Just because lumbar flexion is limited in standing doesn’t mean that the hamstrings are tight or there is a joint that is out of place. You have to check passive as well in an unloaded position. What is worse is the cervical region. Limitation in ROM sitting does NOT mean that there is a closing/opening restriction. You have to check PROM in NWB. Most times this motion is actually perfectly fine and it is not something you need to start closing down or manipulating telling the patient that they have something out of place. All this does is raise their pain avoidance levels.

MMT: Please don’t rate someone a 4/5 via MMT of hip extension if they can’t complete AROM of hip extension without hamstring compensation. That 4/5 in glutes quickly turns into a 4/5 in hamstring strength and less than a 3/5 in glutes. Also, strength, most times means nothing if they can’t use it properly.

Flexibility: Tight hamstrings? The cause of Pain? Really? Come on. Just ask yourself this question. Why does something get tight? It a protective reflex from the CNS. You have the find the cause/movement dysfunction that is causing this massive compensation.

Manipulation changes joint mechanics: Where have you ever read that palpation skills are good? Have you ever seen a cadaver? If you manipulate something that isn’t out of place do you make it out of place? So how is it that manipulating something returns it back into place? Most research shows that it is impossible to target a specific joint without getting residual movement in surrounding areas so how can you really say that you are only manipulating the SI/C6/L4 etc.? Yes, manipulate and mobe but know why you are doing it so that you don’t scare the patient into believing that they will fall apart if they rotate slightly.

I know that I took the above to the extremes and there are always exceptions but for the majority the above is very much true.

This got completely off track quickly.

I faced the above reality when I stopped thinking about conventional PT treatments (cough, any doctor TV show, cough) and began to look at the body like we should. This includes less about strength/ROM and more about movement patterns and inhibition. Less about core stability and more about what pain is and what it isn’t. It is difficult to reboot much of what you have learned and takes time to really get back into a comfortable treatment approach incorporating all the new information you learned especially with major changes being made.

With a new student, I realized that I am still learning how to incorporate these new philosophies into my evaluation and treatment processes. It isn’t engrained into my thinking patterns yet but, like motor control/inhibition, practice will help write that new book.

Signed…the always honest TJ

Introduction…about the author

Hi, I am a currently a Physical Therapist in Pittsburgh and I created this blog to share some of my experiences in our profession with others. I graduated from University of Pittsburgh in 2013 and have spent considerable time improving my skills by learning some of the more  popular concepts of treatment. I am not a singular therapist…meaning one that is solely invested in only one type of treatment such as Mackenzie/Mulligan/biomechanical/Pain/movement impairment syndrome based…but rather a young therapist attempting to take all those skills/concepts and combine them into a singular treatment plan. If I had to specify my approach to treating my patients it would include something like:

Pain education/science -> Mackenzie -> Manual therapy -> movement based/motor control/SFMA exercise regimen

I question many of our basic concepts and am always eager to learn. I am not perfect and I do not have all the answers! I will rant and rave occasionally about random topics (I get emotional in regards to our profession and some terrible treatment plans that I have seen out there). I will consistently bring most of my posts back around to the concepts of pain and the central nervous system as well as motor control vs strength.

I want to learn a lot from myself with this blog and I hope that I am able to help others along the way. Let this journey begin!

TJ Slowik PT DPT