I’ve been thinking for a long time now how I should write this post. This is kind of a play on one of Gray Cooks audio lectures on having a movement philosophy (www.movementlectures.com) I’ve thought about tailoring into specific categories… I’ve thought about taking it the direction of comparing philosophies… I’ve thought about how can I make this post different than other that have posted similar related blogs…
After thinking about all of that I decided to do what I do best… WING IT and just type away with what goes through my head when I am either looking at a patient move or I am teaching movement strategies to a class of clinicians. I get asked all the time to describe what’s going on in my head when I look at patients, so here it is. A glimpse into the mind of Rick Daigle- and fair warning that there is a lot of madness going on! I’m going to do my best to organize what goes on in my head, but those of you who know me, realize that this will be a TALL task. Can you say ADD? Oh my god, look there’s a squirrel!
For starters- there is no cookbook here and what I am going to tell you is how I do things. It does not mean it’s the best way or the only but rather it’s my way! How I treat patients is from a combination of all the people I have learned from. Here are a few (but not all)- Gray Cook, Tim Heckmann, Kai Aboulian, Gary Gray, Perry Nickelston, Mike Voight, Tom Myers and my mom. (Mom taught me how to listen- we’ll talk a lot about that in this blog).
When I first meet a patient I place them into one of three categories:
2- Traumatic Injury
3- Overuse/Repetitive Stress Injury
For the purpose of this blog; we are going to focus on the third category. With regards to the first two; I won’t look at their movement until all restrictive phases are gone and I know I am clear. THOUGH- I will without a doubt be looking at and treating other parts of their body (IE working on hip mobility when I patient is still in the shoulder sling post-op). By focusing on the third category, my hope is that you can see where my head is going with treating patients.
Day 1- Initial Evaluation
This is where I do my standard evaluation and figure out why they think they are in PT. I’ll use methods to diagnose their pain and work at trying to calm their pain down with a multitude of strategies. If they are VERY acute, I won’t go further on day 1. If I think they can tolerate, I might go into looking at a few key movements. But to me, the most important part of Day 1 with a patient is the HISTORY! Listen (thanks Mom) to the patient and let them tell you their story as you would be surprised how much info you can get. I think most of us reading this know who James Cyriax, MD is and probably know that he formed one of my favorite quotes- “If you listen to a patient they will tell you what’s wrong with them. If you listen to a patient long enough they will tell you how to fix them.” Pretty strong and accurate words. I cannot tell you how many times a patient has told me something that I thought was irrelevant and then BOOM it showed in their movement.
Day 2- This is where the magic starts… Movement baby! When they first walk in on day 2, it’s right to my movement screens. The SFMA, Y-Balance Test, FMS (yes I know this is meant for people without pain, but I still like to look at it for information), gait analysis and of course (drum roll please) rolling and crawling assessments.
Now before I go any further, I’m going to focus on the SFMA (Selective Functional Movement Assessment) and Rolling patterns for this post. I’m going to talk about how I use it, which might be different than some people, but again, this is my opinion and what works best for me. The best part of the SFMA is that it give you a systematic approach to looking at movement and while it is not the end all be all, it sure is damn close and pretty spot on for finding dysfunction that’s hiding from you.
For those of you who have never used the SFMA, well, you need to. Take a look at http://www.sfma.com or http://www.rehabeducation.com to find out about courses coming to a city near you! By far the biggest game changer in my career yet. BOOM!
Ok- the basis of the SFMA is to find where stuff is not working properly and use it to help optimize their function and help create a better system of movement and fix compensation. We place each movement into 1 of 4 categories:
1- Functional and Non-Painful (FN)
2- Functional and Painful (FP)
3- Dysfunctional and Painful (DP)
4- Dysfunctional and Non-Painful (DN)
Where do you think we are going to target? If you said DN, winner winner chicken dinner! That is the movement the person has NO pain with but can’t do it properly. Also, don’t forget- Not bad is not good! Be picky. Just because EVERY movement might be dysfunctional, does not mean the person is a train wreck. They might have 1 or 2 BIG dysfunctions that when fixed will allow the little dysfunctions to go away. In other words a horrible looking multi-segmental rotation might be graded as more important in my head when compared to a mildly dysfunctional cervical extension… Just a little side note- EVERY patient is different and I might think dysfunction A is more important for one patient but dysfunction B is more important for another patient.
So where do we go from here??? We know patient A has 4 DN’s but do we know why yet? Nope… We have to look at specifics and determine if the problem is related to mobility, stability or motor control. That’s where we will get into figuring out what needs to get fixed. Ok, in my OPINION- Mobility has to get fixed first. If you put load on to a mobility issue, well, you’re screwed. If you put load onto someone who has a motor control issue, well, you’re still screwed. Mobility first then motor control and then load it and gain stability.
Remember not to get punked and automatically think it’s a mobility problem until your full assessment is done. Why? Well if there is an inconsistency, it cannot be mobility. Mobility issues (think of a bony block in the hip) is and always will be consistent until you fix it. A lot of times it’s a persons inability to fire the deep stabilizers and sequence that makes them look like they have a mobility issue. Loaded vs unloaded, active vs passive and unilateral vs bilateral need to be assessed before you can determine the true cause. Take that to the bank.
Now- You clear out mobility through each joint (we’ll talk joints shortly) and the soft tissue is clear but the person still cannot move. Get them on the ground and start rolling. To segmentally roll from supine to prone (or vice versa) the inner core (diaphragm, pelvic floor, multifidus and transverse abdominals) need to fire and stabilize. Rolling is my way to assess and then train the brain to fire the inner core. Oh yeah, don’t forget breathing… That’s kind of important don’t you think? Not on the docket for today, but just take a moment and review all of the attachments of the diaphragm- important maybe? Yeah, I think so.
Ok, so what did I just say? The basic jist is find the issue causing the body to compensate. The human body will always sacrifice quality over quantity so you have to fix what it is compensating for. Treat the patients pain with your methods, absolutely, but if you do not find the root cause I promise you the patient will be back to see you again in the very near future. Remember this simple fact and you’ll be fine- Everything is attached to everything and anything can cause anything. Again, take that to the bank. Something else you can take to the bank is the Joint By Joint approach from Gray and Mike Boyle. The body has to alternate joints mobility vs stability. You cannot have 2 stable or 2 mobile joints stacked on top of each other… Unless you are looking for that person to fail miserably at their task.
Have a system… Have an open mind… Have a global view…
Don’t just focus on pain… Don’t cut the patient off… Don’t overthink it…
Do look at patterns… Do listen to everything… Do right by your patient and promote proper movement…
So that’s a brief glimpse into my mind… That only scratches the surface of what goes on in my head when treating patients. One thing I can promise you is that I function different from patient to patient and day to day. There is no cookbook and there is no standard way of doing anything in my opinion. I do what works for me and I get results- that’s what matters. Keep putting more tools in your tool box and be the best clinician you can be by pulling the right tools out at the right time.
Oh yeah, DON’T OVERTHINK IT! If you aren’t sure- it’s dysfunctional.
And a little side note- If there is a T-Spine mobility issue, I’ll usually start there. The t-spine is somewhat important to human movement.
I hope you all enjoyed this little tidbit of info and trip through my crazy head. Remember that these are my opinions and they might not work for you. Find your own Movement Philosophy and stick to it, keep learning and have some fun!