Mobility vs. Stability: A guest blog from Mitch Hauschildt

I’d like to introduce you all to Mitch Hauschildt, MA, ATC, CSC. Mitch is a great friend but also one of the best clinicians I have ever met. Hands down. Mitch is the Rehab Coordinator for Missouri State University and is the Founder of Maximum Training Solutions. You can reach him at mitch@maximumtrainingsolutions.com. Here is Mitch’s take on Mobility vs. Stability!

Mobility.

Stability.

Both are needed for proper movement and function. Without both, authentic movement will never be achieved and injury risk will rise as a result.

Let’s break it down a little bit further…

Mobility has been defined as “the ability to produce a desired motion” (via Bill Hartman). The key word in that basic definition is “ability.” If someone doesn’t have the ability to produce or reproduce a specific movement pattern (due to lack of range), then they are inherently immobile.

Stability has been defined as “the ability to resist movement.” Without the ability to resist poor movement, one will never be able to create truly authentic movement and will always have compensatory patterns.

Be careful with this, however, because it can be very easy to confuse joint stiffness with joint stability. They are 2 very different things according to the nervous system. If someone only has joint stiffness, at some point they will be stretched to the end of their limited range and they will collapse and sustain and injury because they don’t have true stability.

So, how do we train mobility and stability? Gray Cook makes it very clear that you ALWAYS train mobility before stability. That is to make sure that you avoid the joint stiffness scenario that we just discussed.

I agree with Gray on this point almost all of the time when we are talking about relatively healthy individuals with relatively “normal” mobility (whatever that is). I have found that there are some occasions where it make sense neurologically to challenge the body via stability training within an available range of motion as you continue to improve their mobility. There are also some instances where it works well to improve both mobility and stability simultaneously. As with all situations, the rules are the rules, but they can be broken from time to time.

There is one area where this rule cannot and should NEVER be broken. That is the post surgical rehab patient. Mobility and joint range of motion MUST always be the first priority immediately following a surgical intervention. Without full range of motion, performing simple ADLs becomes problematic for patients.

Neurologically, activation patterns are significantly altered with poor range of motion. Because the nervous system controls every aspect of the body, the ripple effect that poor range of motion has on the body is immeasurable.

First, joint stability will never be realized with a limited range of motion. When muscles only work in a shortened position, they lose their mechanical advantage and can’t create the appropriate torque needed to keep a joint stabile in an unstable environment.

This leads to larger issues elsewhere. When the local stabilizers can’t keep a joint centrated, prime movers take over because they are typically larger muscles that are in a position to greatly improve joint position, even though that is not their intended role. This leads to decreased performance, especially if they are an athlete, because the prime movers are tied up performing stabilizing duties instead of moving the body. For the same reasons, this will also lead to overuse injuries.

These same poor activation patterns also impact other joints in the body. For example, the rotator cuff is specifically tied to grip strength. It is a protective mechanism that is used by the brain to protect a damaged shoulder. Thus, if the rotator cuff can’t work correctly due to a limited range, that person’s grip will be compromised.

Going further, that same patient with a poor functioning shoulder will have problems in the lower extremity. It is rather obvious that the Lats play an important role with the shoulder joint. Many people forget that the Lats are directly tied to the Gluts in a crossing pattern in the low back. Thus, if one Lat isn’t working well (because of a compromised shoulder), the opposite glut won’t function properly. This can lead to knee pain because the Gluts are a powerful external rotator of the femur, keeping it in an advantageous position for the patellofemoral joint.

Continuing on down the chain, when that glut doesn’t work, it will likely be correlated with an anterior pelvic tilt. An anterior pelvic tilt is associated with a number of issues, including an ankle dorsiflexion restriction. This can lead to ankle and foot problems. And, I can keep going…

Moving away from activation patterns, we also have to keep in mind that a poor functioning joint will have other effects on the joints around them. Looking at the joint-by-joint approach (Cook and Boyle), we understand that the human body is simply a series of stacked joints which alternate between needing joint mobility and joint stability. So, if you lose joint mobility in one joint, you are going to be asking another joint to make up for it. The body will find the motion somewhere. Unfortunately, the motion will have to come from a joint that is intended to provide stability.

As an example, if an ankle patient doesn’t regain full range of motion, they will develop knee or back pain. This is because the knee and low back are intended to be stable joints, but when presented with a lack of mobility below them, these joints become unstable and painful. It is consistent and predictable.

Honestly, these examples are just the tip of the iceberg. As you read this, you may be thinking to yourself, “I know Mitch, this is common sense.” And you are right. Unfortunately, I can’t tell you how many young athletes come into my practice from other therapists who are cleared to return to play missing 10, 20, sometimes 30 degrees of motion. Then, I get to tell the kid and their parents that they can’t play because they aren’t ready and then I get to spend the next few months fixing what should have been done early in the rehab process.

It’s honestly not about me though. None of us got into this profession for us. We love our patients and want the best for them. So, lets start doing just that. Give them the best treatment available. Today. Tomorrow. Next week. Next year.

Mobility precedes stability in the post surgical patient. ALWAYS!!

A Challenge…

I’ve been doing a lot of thinking lately…  Most of this thinking has resolved around what can I do to make myself a better PT, a better educator and actually a better person.  I’ll be honest, it’s  been a struggle to stay motivated and to stay upbeat sometimes.  I think that’s a natural phenomenon sometimes that we ALL go through.  It’s how we learn from those phases that will make us better at our craft and better people.

What am I doing to make myself better?

* Reading more… Not just rehab stuff, but other works as well. “Expanding my horizons”

* Reflecting on my career.  What have I do right, what have I done wrong and what needs improvement.

* Eating healthier.  This has always been my crutch… Good food and good wine.  I’m learning how to moderate and how to experience what I WANT without over doing it.  🙂  A BIG challenge.

* Reviewing ALL of my previous teaching evaluations.  What have my students and course attendees said?  Yes, I’ve already read them before and made significant changes, but it never hurts to go back.

* Planning my next educational route-  Looking like a PhD in Higher Education and Leadership.  Going to be a long road, but a good one.

* Started the EARLY phases of writing a book- stay tuned on this one.

* Clinical Education Pathway-  I want to finish 2 things over the next 2+ years:  My COMT and go through the DNS Progression.  I want to become a better Manual Therapist and I want to become better at Neurodevelopment.  I’ll also be doing more strength/conditioning education to get “outside my comfort zone” 

That’s just scratching the surface… There is more, but I won’t bore you with the rest.  The point of this blog is to help people realize, it’s OK to loose focus sometimes but it’s how you come out of those funks that really defines you as a person.  Make a list of what you need to do to make yourself better and I CHALLENGE you to stick to it, own it and become better at your craft and at life in general.

I hope this excites at least one of you to reflect and make some changes.  If this reaches one person, I consider it a success.

Happy Sunday Everyone!

-Rick

 

The Top 10 Blogs on the face of this planet according to Rick…

Instead of writing about something specific today, it’s time to provide my TOP 10 List of the best blogs out there… (Actually it’s 11 because there is a tie for #1). Simply, these are the 11 that I utilize the most and read religiously.

You can agree with me or disagree with me. These are my opinions and my opinions are just that… My opinions. I apologize to any of you that I left off this list. Wait a second- scratch that… I don’t apologize because you should NEVER apologize for your opinions. Ok, so here we go from 10 down to 1.

***I took a very scientific approach to deciding on 1-10. It was all subjective and again, my opinion. 🙂

I hope you all enjoy these resources as much as I do. Have at it!

#10- PT Think Tankhttp://ptthinktank.com/about/
* Great blog with advice from clinical to business to interpersonal skills. They have been around for a long time and always have good shiz.

#9- PranaPThttp://prana-pt.com/blog/
* Outside the box thinking and an very down to earth solid information. Good job keeping us all updated.

#8- The Student Physical Therapisthttp://www.thestudentphysicaltherapist.com/
* Because new grads are just that… New grads. Awesome resource to help new grads enter the PT world

#7- In Touch Physical Therapyhttp://intouchpt.wordpress.com/
* This guys is a MANual therapist among boys.

#6- Craig Liebensonhttp://www.craigliebenson.com/articles/
* Not really an official blog, but this guy is a rock star and could be considered “Dr. Functional”

#5- Evidence In Motionhttp://www.evidenceinmotion.com/about/blog/
* These guys are some heavy hitters with outside the box thinking backed up by, well, evidence…

#4- Girls Gone Stronghttp://www.girlsgonestrong.com/blog/
* Simply because nutrition, wellness, strength and everything IS part of the rehabilitation process. Just a rocking awesome blog with tons of info that I think EVERY clinician should know. Ok PTs- Get out of your comfort zone a little and expand your knowledge!

#3- Perry Nickelstonhttp://www.stopchasingpain.com/
* Ok, again not a blog (remember this list is my opinion). He is a MUST follow. Website, Facebook, Twitter, etc. Just don’t follow him home- he could kick your ass. I am very luck to call Perry a friend and I have learned more stuff from him in the past 5 years than I can even wrap my mind around.

#2- Charlie Weingroffhttp://charlieweingroff.com/
* Where do I start. One of the best in the biz. His stuff is solid and is not afraid to call you out. One of my favorites of all time.

TIE #1– The Manual Therapisthttp://www.themanualtherapist.com/
* The most consistent source of information. Period. Interactive, informative, fun and guess what, practical!

TIE #1- Mike Reinoldhttp://www.mikereinold.com/
* Mike is a superstar of sports medicine. His experiences alone should drive you to his site/blog. Again, solid, consistent, relevant, outside the box and always on top of new stuff

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.

 

What’s Lacking in Rehabilitation Education?

I’m only going to speak on Physical Therapy with this topic even though the field or rehabilitation is far wider than that…  Please remember that as you all read this.

I’m probably only going to scratch the surface on this topic and this discussion will continue to evolve.  The medical world, more specifically the rehabilitation world has gotten (in my opinion) too hung up on degrees,  pieces of paper, what others are doing, other professions “infringing” on their own and doing “what the book says”… Here is a little about what I see and have seen…

I was interviewing a PT a while back for a staff clinician position. (Note: this person was a new grad).  The interview went well and this person seemed to be potentially a team player and had some good knowledge.  After the interview, we got to the always uncomfortable money discussion.  I asked this person what they were looking for and I do not think I was prepared for the answer as I spit out my coffee.  “It has to be over $100,000”.  I was flabbergasted…  My response was- “I direct the place and I don’t make than and how am I supposed to pay you way over my senior clinicians who have FAR more experience.  This potential clinician responded with- “we’ll I have my Doctorate”.  I looked back, said that was nice and ended the interview.

OK- Let me say that I fully agree with the DPT (hell, I have one) but it needs to be taken in perspective.  I’m all for gaining more respect in the medical community and I am all for progressing even further into required Residencies and Fellowships but we also need to take a step back and look at the basics!

What about work ethic?

What about a desire to work with other professionals?

What about a desire to educate other professionals on what you do?

What about taking clinical experience and combining it with research to make TRUE evidence base practice?

 

I think some of these issues are generational, I think some are learned and I think some has to do with our education system.  We teach students to read books and find answers in lab manuals. We teach students so that they can pass their board exam…  Obviously passing your board exam is kinda key-  You think???  BUT- Why not teach students how to take the board exam but also how to think outside the box. 

We need to teach PRACTICALITY.  How is XYZ you learn in school going to translate into a real patient?  How is a real patient going to translate into XYZ.

If we want to take the next step in gaining respect in the medical community we need to do the following tasks…

1- Teach practicality

2- Teach how to collaborate with other professionals

3- Teach how to combine research with clinical experiences

4- Teach how to take the blinders off

5- Teach where to find techniques/etc that you won’t learn in school

 

I am sure some of you will agree with what I am saying and some of you will disagree.  Not every school is like this, not every graduate DPT program is like this and not every PTA Program is like this.  Take Rob Butler at Duke and Mike Voight at Belmont-  those guys are doing things the way they should be done.  They are preparing students for the real world and they are the ones helping shape the new generation of rehab professionals.

As I embark next week on educating my first Cohort of PTA Students, I can only hope that my students come out with a thought process that sets them apart.  That they come out prepared for their board exam but they also know PRACTICALITY and can think outside the box.  That’s my goal…  This is going to be fun!

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