Category Archives: Clinical Topics

We could spend hours going into the diaphragm if we wanted to. For the purpose of today, I’m using the KISS principle (Keep It Simple stupid). Lets just start with the anatomy…

Diaphragm Anatomy

Think about some of the attachments for a second… Xiphoid Process, Inner Surface of Lower 6 ribs, Upper 2 or 3 Lumbar Vertebra… There are even some fibers that his Psoas Major. The point is as follows: If you are NOT looking at breathing at the very beginning of treatment, you are probably missing something huge. If you are NOT using breathing as the start of core stability- guess what… Your not doing right by your patient client. The diaphragm is an integral part of the “inner core”- Diaphragm, pelvic floor, multifidi and transverse abdominals. If any of these aren’t working- you’re dead in the water.

We must use the philosophy of regress to progress and what is the most basic of tasks that we do as human beings. Breathe. Start there, assess the persons ability to utilize their diaphragm and then move on. Some ideas- start by assessing in supine with their knees flexed and feet flat, move to legs elevated at 90/90, assess in sitting, assess in high kneeling, assess in half kneeing, assess in tandem stance, assess in single leg stance. Get the point here?

Now, let me preface this next part with the fact that I fully understand every individual has their own strategy for breathing based on the activity that they are doing, their body type, their history and how their nervous system functions… BUT- every single person should be able to lie on their back and isolate out the diaphragm and “belly breathe” without excessive use of the accessory muscle groups. This is basic core 101. If you cant isolate the diaphragm you have no business doing planks, get ups, or any other type of core work for that matter.

Most of the time all it takes is a little manual therapy to release the fascial surroundings of the lower ribs, abdomen and then some cueing for retraining to correct the neural pathways and BOOM- it will come back online and they will start to learn new strategies…

Now- take it a step further. What if you have T-Spine and/or L-Spine Mobility issues? Or Hip mobility issues? You’ve got to fix those first because as in my previous blog- mobility needs to come before stability. Once you have fixed all of the mobility (true mobility” issues (see the previous blog), get back to retraining the diaphragm, teaching proper strategies and initiating the progression of movements. One awesome way of locking in fundamental core stability is simply by using segmental rolling patterns and crawling patters… Stay tuned for the next blog which dives into ROLLING!

I hope this helps some of you and I hope this gets people thinking. And don’t forget to go visit and like the Medical Minds In Motion FB page:https://www.facebook.com/MedicalMindsInMotion?ref_type=bookmark

It’s basic, it’s simple, there are never any absolutes but when push comes to shove- just breathe.

When is a mobility issue not a mobility issue?

Say what?!?!  When is a mobility issue not a mobility issue?  You read that right.  A mobility issue is not a mobility issue when it’s a stability issue. There I said it.  Soak that statement in and think about it for a few seconds before making any judgments (in either direction).

We know the human body is a wonderful and powerful tool.  We also know that the human body is the great compensator.  When you cannot move properly, the body will get it from somewhere else.  The epitome of robbing Peter to pay Paul.  The human body will also sacrifice quality over quantity.  I bet you that right now, you have movement dysfunction that you have no clue exists and there is a good chance you don’t have any pain associated with it…  Yet…  Eventually you will.  You can take that to the bank.

When the body reacts with pain signals- basically it’s saying to you, “Hey Idiot, do something. There is a problem somewhere”.  The problem is that a lot of practitioners are tricked by the pain and they start to “chase it”, as my good friend Perry Nickelston likes to say.  Just because there is pain in one location with a potential tissue lesion, does not mean that is the root cause.  We have to look at everything in order to understand 1 think.

Janda was way ahead of his time.  He stated that you must understand the motor system as a whole in order to understand individual impairments.  Damn that dude was smart.

So back to mobility issues not being mobility issues.  Do NOT take this as an absolute.  The only absolute is that there are NO absolutes (I can thank one of my students for that line).  Mobility issues must be consistent.  We know that and we understand that.  So having a patient/client fail a toe touch and then assuming they have tight hamstrings is putting the cart before the horse.  That’s only one way to look at movement.

1- Check toe touch in standing

2- Check toe touch in long sitting

3- Check active straight leg raise (needs to be greater than 70 degrees)

4- Check passive straight leg raise (needs to be greater that 80 degrees)

If you FAIL all 4 of those, guess what, there is a good likely hood you have a mobility issue or issues limiting you.  If you pass even just one of those, it most likely cannot be a mobility issue.

So what could it be?  It could be a lot of things but lets use this example.  A patient presents with a limited toe touch in standing and then a perfect toe touch in sitting.  One of the likely scenarios here is that this person has some fundamental core stability issues such as a lack of pelvic stability or diaphragmatic issues which is causing their hamstrings to contract in standing and stabilize the pelvis, thus causing a compensation.  You then have the person long sit- and BOOM they touch their toes.  What’s stabilizing the pelvis in this position- the FLOOR.  Hamstrings shut down, stop overworking and bingo, the person touches their toes.

Now- how do we go about fixing their toe touch in standing?  Stretch their hamstrings?  Mobilize their l-spine?  Nope. Not going to work.  Go to your days of Pediatric development and focus on rolling, crawling, half kneeling balance.  Maybe even before that you need to assess their breathing and teach proper diaphragmatic strategies.

One of the most powerful options to fix this issue is segmental rolling.  The next blog coming out soon is titled “This is How I roll” and will go in depth into segmental rolling.  Think about how we develop and think about what needs to stabilize properly in order to roll from your back to your stomach.  I have a few good videos that will accompany that blog which will demonstrate this.

The point is- develop proper fundamental core stability and you will clear up a lot of “mobility” issues.  Just remember this:  Mobility issues will be consistent.  If it’s inconsistent, you need to look at what stability problems are present.

 

My Movement Philosophy…

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:
1- Post-op
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!

– Rick

To Move or Not to Move- That is the question!

I routinely get asked by clinicians and other professionals alike the following question- “Why do you say that you hate to restrict movement unless you have to?”  This question is usually followed up with something along the lines of, “What if the person is in pain, won’t increased movement irritate the issue?”

To me these are both great questions and questions that really should not need to be asked, but yes of course, they get asked.  Let’s take a few moments to break down these two questions:

“Why do you say that you hate to restrict movement unless you have to?”

My initial response to this question is pretty simple.  We were meant to move- If I restrict movement in one place, the body is going to compensate elsewhere and we will get the chain reaction we do NOT want.  Take the philosophy of Regional Interdependence for example, which means, impairments in seemingly unrelated parts of the body in fact have direct relationships to the dysfunctional movement.  Example-  A restricted distal tib-fib joint at the ankle leading to decreased dorsiflexion can and will ultimately cause gait abnormalities which will lead to LBP or some other issue.

Let’s break down Regional Interdependence into two categories-  Joint and Fascia.  Take the Joint-by-Joint approach which states that each joint in the body is either more mobile or more stable and that each joint must be surrounded by the opposite type of joint.  Mobile-Stable-Mobile-Stable, etc.  Now let’s look at fascia-  Specifically, the Anatomy Trains.  Take the Superficial Front Line as an example-  there is a continuous line of tissue going from the foot and travels all the way to the forehead.  Everything is connected to everything and anything can cause anything.

The basic jist here is that if I limit someone from moving their shoulder I will in fact create dysfunction in the t-spine, or the elbow or the c-spine or even the hips.  The body is mean to move globally and if we limit locally, we’ll start to develop poor movement patterns.  In a lot of cases we’ll actually put poor movement patterns on top of other poor movement patterns.

Now, here is an example of when I WILL limit movement.  Take the patient that comes into therapy and is 2 weeks post-op Bankhart Repair.  Am I going to crank their arm into 90/90?  Absolutely not!  For those of you who don’t know what a Bankhart repair is, just go take a look at http://en.wikipedia.org/wiki/Bankart_repair.  The key here is that when you Externally Rotate and Abduct the shoulder, the humeral head will stress out the anterior capsule and anterior labrum.  That would not be good in this case.  Thus I will limit motion (for as little time as possible).  One this person is past their restrictive phases, I am going to regain their motion as fast and as safe as possible.  Some of you are probably asking yourself, “What are some strategies that I can use to help me in the long term, while protecting the repair?”  This is a GREAT question with a simple answer-  while they are in their sling, work on their hip mobility, work on their t-spine mobility and work on everything you possibly can, without affecting their glenohumeral joint.

In other words, get CREATIVE and have FUN!

“What if the person is in pain, won’t increased movement irritate the issue?”

Chances are this person is in pain because their movement, well, sucks.  If you don’t fix their movement dysfunction the chances are pretty good that they will not get better.  This is where your ASSESSMENTS come into play and will drive your treatment direction.  Personally I extensively use the Selective Functional Movement Assessment (SFMA) to show me exactly where and why there is dysfunction.  Is it mobility?  Is it stability?  Is it motor control?

We were created to move and we need to tailor our rehab philosophies and our training philosophies to fit this model.  The body knows movements and the brain knows movement patterns.  Develop proper movement patterns by allowing the body to move and you will begin to unleash potential you thought would never be impossible.  Remember this-  everything is attached to everything and anything can cause anything and you’ll do just fine.  That and you’ll have happy patients and clients!

-Rick Daigle, PT, DPT- Founder and President of MMIM