Tag Archives: rehabilitation

6 Principles To Prevent Injury

This is going to be an opinion post… That being said, I fully expect some people to not agree with what I am saying here. Keep an open mind when reading this and remember- this is not for everyone.

I have been seeing a lot of blogs lately with specific do’s and do not’s, which has got me frustrated. It is haphazard to generalize and put a large group into the same exact category. What I am doing here is a combination of global principles and utilization of the KISS Principle. (Keep It Simple Stupid) and hopefully this will resonate with some individuals.

1- Mobility before Stability: If you can’t move, figure out why you can’t move and then fix it. The caveat here is when is a mobility issue really a stability issue? When do you mobilize a joint? When do you stretch some soft tissue? When do you perform other manual therapy techniques? The big point here is that a lot of people try to put load on top of a mobility issue that is present. Great way to ask for an injury.

2- Proper Assessment and Creation of Goals: Each patient/client/individual is an individual and their prevention programs must be specific for that person and their goals. Don’t just throw crap up against the wall and hope something sticks. Have a reason for everything that you do and use the specificity principle.

3- Corrective Exercise Is Great- But Should only be used as a corrective: I see a lot of individuals only work on correctives. While this is not bad, it’s not good. Once the correctives have “corrected”, move on to the next step of adding some load and locking in this new found stability.

4- Teach a Proper Hip Hinge: I personally think the Hip hinge is one of the most important movements in the human body, but unfortunately it’s taught wrong or not focused on. Getting the person to disassociate hip from lumbar mobility is huge with creating great lumbo-pelvic movement and stability.

5- Technique, Technique, Technique: No slop. Do the exercise right, or figure out why the person can’t do it right. Regress to Progress. Simple principle, yet a game changer.

6- The only absolute is that there are no absolutes: Stick to principles and vary your techniques based on individuality and the needs of the person sitting in front of you. Understand that you need to think outside of the box and be creative to not only keep people interested but also to train the neurological system with some variability.

Those are my 6 Keys to Injury Prevention. Is this the best list ever? No. Is it the worst list ever? No.

-Rick

“Rick Daigle, PT, DPT is the Founder and President of Medical Minds In Motion, LLC and has been educating health and wellness professionals all over the US on Injury Prevention, Rehabilitation Techniques and Movement Dysfunction.”

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.

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

The Top 11 Mistakes Physical Therapists Make

So this is a blog I wrote last year that got a lot of play- I’ve updated it a little and wanted to re-post it. Enjoy and please let me know if you do not agree!!!

I will probably ruffle some feathers with this blog- but that is my exact intent… You may agree with some and you may disagree with some. Please feel free to open up a discussion with me, that’s the point.

I have been cruising around the web reading blogs, articles, websites, face book pages and everything else possible and I have noticed one common trend. I am seeing the Fitness world really pushing hard to “better themselves” and learn from each other. By learning from each others mistakes (and our own) we will only become better at what we do. I came up with the idea to list what I think the 11 most common mistakes Physical Therapist’s make on a daily basis and how to resolve them. Here we go from 11 to 1!

But FIRST- Let me say that I have made EVERY one of these mistakes, but it’s learning from them that makes us better.

11. Inconsistent Re-Evaluations…Re-evaluations every 30 days or 10-12 visits is essential to developing proper Physical Therapy routines for patients. If we are doing a good job, the patient should be progressing consistently and we need to see where their “new baselines are. In all actuality, we should be reassessing every visit the person comes in for. Everything manual technique, every movement should be used as a way to evaluate and determine progress.

10. No reasoning for developing certain exercises in a patients program…When I have students I tell them one simple thing: I do not care what exactly you do with your patient (to a certain extent) but have a REASON for what you are doing. Physical Therapy is NOT cookbook so create a program for the patient sitting in front of you! There is no such thing as a bad exercise but there DEFINTELY is a wrong exercise for the wrong person! Regress to Progress…

9. Have the blinders on to other professions…I believe in chiropractic care, I believe in acupuncture, I believe in strength and conditioning, I believe in anything that works. PT’s have a tendency sometimes to only believe in what they do. If you do not have a Strength and Conditioning background, don’t pretend to be a strength coach. Working together with other professions will only make you better as a practitioner and it will only help your patients get better faster and more effectively!

8. PT’s tend to call themselves “Mulligan” Therapists, “Mckenzie” Therapists, “Maitland”, etc… Using tools and not the Tool box…This bothers me a a lot. Be your OWN therapist. Yes we must learn from others but there are pros and cons to each tool we use. A GREAT therapist knows how to use the tools to work with each specific patient. A GREAT therapist also never stops learning and never stops putting another tool into their box.

7. Utilization of Modalities for time killers or because it can be billed for…Do I even need to explain this one. If you know me; you know I hate utilizing modalities such as E-Stim and Ultrasound. If I need to explain this one to you then you probably fall into a lot of these categories I’m discussing. There is a time and place for Electrical Stim but US; I’ll battle anyone on this. Steel cage death match anyone?

6. A lack of understanding on how to market and build relationships…
This baffles me? PT’s build relationships with patients everyday but for some reason have a hard time talking to physicians or other health care providers. Have confidence in your knowledge and your skills. Chances are they will respect you more if you have confidence and can be clear and concise.

5. Not having the “cojones” to either question a possible improper diagnosis or make their own diagnosis…If you think something wasn’t diagnosed wrong- make sure you approach the appropriate person. Be ready to back your belief with solid data, but if you feel strongly, do not hold back. But make sure you are respectful. PT’s (in most states) are allowed direct access and that means we are an entry point into the healthcare system. Making a proper diagnosis from the start, needless to say, is fairly important. Now the fun part begins- you have made the diagnosis, but now you get to figure out WHY!

4. Are just content with being “good” and not “great”… Do something great, be something great and don’t settle for just good. Constantly learn, absorb, be mentored, mentor and teach others. This will set you apart from the pack. If you want to “just be good”, you will never get ahead and you are not doing right by your patients. Strive to be the best and nothing less.

3. Not listening to the Patient sitting right in front of you…The history is the single most important part of patient care. Take a proper history, listen to patient and you will gather more information than you could ever imagine. The history will lead your evaluation and will set you up for success. Patients also crave this. So give them what they want!

2. Not educating patients on the “why”…This really can be 1B. Just giving someone an exercise is not good enough… Just doing a mobilization is not good enough… Just doing post-op rehab is not good enough… You need to give the why component to the patient. Explaining why someone is not allowed to do X after a Cuff Repair or why open chain knee extension is the Single. Worst. Exercise. Ever. Just telling someone is not enough; you must educate them on the why. If you do this simple task, they will trust you more, listen to you more and get better faster. Isn’t that what we want?

And #1…. Drum Roll please……….

1. Go straight to the site of pain…
To take a phrase from a friend and colleague, Perry Nickelston: “Stop Chasing Pain”!…
Man has he this nailed on the head. Simply speaking just because someone has knee pain, doesn’t mean the problem is coming from the knee. By understanding human movement and how the body functions you can pick out and find the Non-Painful Movement Dysfunction that’s causing the Painful Dysfunction. It’s as simple as that. Systematically assess human movement and assess the patient- I promise you will find things that will blow you away and will blow your patient away. In other words: Treat the Problem and not the symptoms. You also must be able to explain to the patient why a sprained ankle 3 months ago is the reason for their neck pain. You have to get it first before the patient gets it. If you can answer this question, then you are on the right path. ”Why would a rigid great toe with decreased extension on the lead leg of a pitcher lead to medial elbow pain in the throwing arm?”