Segmenting the Problem

Nowadays, everyone is preaching "holism". Whether it's rehab, weight loss, or strength training, everyone has become aware of addressing the entire body as a whole rather than segmenting it apart. After all, the body is multiple units that must work as one, not independently of each other.

This is a principle that rings very true. After all, minor changes at the top of the kinetic chain are always being found to affect the bottom and vice versa. When treating someone's ankle, I very likely am addressing their hip stability. Wrist pain? Correct the shoulder biomechanics. Back pain? Take a look at what's happening at the extremities.

However, I've been finding situations where segmentation plays a very helpful role. The time that I found where it may necessary to segment the chain is this: when the entire chain is screaming PAIN!

I have one client who has run into a bout of misfortune. Broken wrist, broken ankle, back pain, whiplash, concussion, neck pain, knee issues...and fibromyalgia. The intake form caused some nerves to bubble for me, to say the least.

How do you go about addressing this client? This client who has spent 20 years in pain and seeing minimal results or improvement at any of the joints that she is trying to treat? This client who's stress and depression can cause setbacks by triggering the additional pain of fibromyalgia?

The answer is this.

Right of the bat, I knew that the potential downfall of this client's recovery was that there would absolutely be no way to treat every problem at once, and so the pain at one joint could very easily overshadow any progress being made at another.

And so, what I told her was that we were going to pick one joint to begin treating and rehabilitating. Her instructions were to ignore everything else. We picked the most central and most problematic area - her neck - to begin with and she was to not dwell on the soreness in her hands and feet, for instance, as we went.

This method proved successful. Instead of going around in circles from joint-to-joint and running into constant steps back, we have been able to make leaps in her recovery by simply addressing one area at a time. My client still has a ways to go - her ankles, hands, and feet are still in pain - but we have branched to recovery of her mid- and lower-back, providing her the most pain relief that she has had in two decades.

This is a clear lesson that when problems are rampant, trying to address everything at once is going to get you nowhere. Once significant, sustainable progress in one realm is made, then it is possible to expand to the next without so much fear of regression.

This principle doesn't only apply to rehab and training. The leading experts in diet and nutrition have been proponents of this for years. Small changes at a time rather than trying to alter everything is the only sure-fire way to maintain long-term progress.

Summing up...

Your Tight Hip Flexors and You

I get plenty of people complaining about how tight and sore their hip flexors are. The mainstream likes to blame sedentary lifestyles and the flexed-hip position of sitting in chairs on this condition. However, if sitting were to blame, why have my new clients had no luck lengthening them, even if they stretch excessively?

Furthermore, I see clients of both the active and sedentary demographics.While those sedentary individuals certainly have plenty of physical ailments befalling them, the group that complains about their hip flexors the most are the active ones. Interestingly, in my experience, the most vigourously active of them are the ones with the most complaints.

Curious. While spending ample amounts of time sitting may contribute to shortened hip flexors, they don't seem to be the most significant factor at work. So where is the blame to be pointed?

Anatomy

The most major of the hip flexors is the psoas major, originating from the lowest of the spinal vertebrae and inserting onto the femur. The psoas minor and iliacus are present as part of the "iliopsoas" complex as well, but those two tend to be less clinically-significant.

The last hip flexor muscle is the rectus femoris, which duals as a quadricep muscle for extending the knee.

Mechanics

I'm always talking about the importance of core strength. Essentially, every muscle surrounding the spine is going to contribute to its protection.

However, let's remember that that big, strong psoas major muscle attaches to the spine! What comes of this?

Well, normally, your major core muscles such as the abdominals and obliques are the main stabilizers of the spine. The dysfunction occurs, though, when those muscles stop meeting the demand of the load being placed upon the spine. Without those main muscles being able to bear the load, any other muscle in the surrounding area, such as that psoas, are going to increase in tone and stiffness to try and compensate for that instability.

In a sedentary person who does not typically exercise, this affliction may go more unnoticed. The difference with an active individual is that, since they are experiencing more regular physical activity, the psoas has a greater amount of inherent strength and tone, causing an increased sense of tension.

The Fix

It should be obvious that restrengthening the primary core stabilizers is key in allowing the hip flexors to release their protective stiffness.

This doesn't always prove to be enough, however. A number of times, those dysfunctional mechanics have been so ingrained for so many years that the psoas has a difficult time learning to make the switch back from core stabilizer to hip flexor, even when the core muscles themselves are retrained. Getting the psoas to contract into hip flexion independently of the rectus femoris, for instance, is one method I've employed, but that's another topic for later.

All in all, core stability work is the best start, whether it's for rehab or "prehab". If you don't have a problem, make sure it stays that way by keeping your spine sound and supported. (And for crying out loud, minimize your weightlifting belt use.)

Subscribe to the Weekly Updates

Do you like the content that you're reading? Sign up to receive the weekly blog update from Cain Exercise Rehab directly to your email!

Click Here!

Does Ultrasound Work?

Here's a doozy. Does ultrasound actually work?

Ultrasound is a favourite tool of both clients and clinicians. Using a machine that sends high-frequency sound waves into the body's tissue, the idea is that it increases circulation and stimulates cell metabolism in order to speed up the healing process.

However, ultrasound has been under fire in recent years. By no means is anyone suggesting that ultrasound may be harmful (unless you misuse it), but the question is this: Is there actually any healing benefit happening?

The Research

There has actually been a lot of recent research done on ultrasound's effectiveness, making my own delve into this rather quick and painless.

On one hand, when using ultrasound on human tissue in vitro (that is, samples removed from the body and placed in test tubes), the results are promising. The vibration and mild heating effect of the ultrasound on those human cells definitely shows evidence of increased proliferation. So it makes sense that ultrasound works, right?

On the other hand, let's remember that a cell in a petri dish is different than a cell that's still in the human body.

Two of the best reviews of past studies that I could find concluded that there is insufficient evidence to back up the use of ultrasound as having any beneficial effect on the healing process when it comes to actual clinical use. While some studies may show that there is something occurring underneath that ultrasound head at the cellular level, the consensus seems to be that those minor changes are not significant enough to speed tissue regeneration.

In fact, looking back on even the older research, it seems that most studies that support the use of ultrasound were heavily flawed, such as being done only on rabbits or rats.

We're people too!

Conclusion

So, does ultrasound work? As far as I can tell, probably not. Can it be ruled out? I'm gonna say no, but it's going to take something groundbreaking, at this point, to save the reputation of this particular modality.

But hey, some clients love it. Maybe there's something going on that we haven't been able to detect yet, or maybe it's just that good ol' placebo effect. At least the therapist is getting a break from using his or her hands, though.

While you ponder that, I'll go ahead and give my clients a massage instead.

Honesty and Transparency as a Clinician

Potential clients may see this as a promise. Other clinicians may use this as marketing advice. To me, it's a personal message regarding my integrity.

So far, I would say that my practice as an Athletic Therapist has been successful in the short time that I've been working so far. The client stream has become steady, my patients have seen success, and most of those who walk through my door have been very satisfied with my services.

Notice that I say, "most". Admittedly, I cannot claim to have been successful in helping every single person who has sought me out for treatment.

There are those out there who would call me crazy to make this statement. They see it as a belittlement of my abilities as a practitioner and consider it damaging to my credibility to not be able to say that I can help anyone and everyone. However, let's be honest here. Can we really act on the belief that anyone is able to treat everyone?

The way I see it, we're not in an age where the public is willing to blindly listen to anyone with a degree. In fact, we're in an era where it's encouraged to constantly question and challenge authority and expertise. If people smell dishonesty from a professional, they will certainly act on their instincts.

I see the difference between the clinicians in this field in terms of acting on this information. Absolutely, there is a certain breed of therapists who will lie through their teeth about their confidence regarding knowledge of your injury and what needs to be done to remedy it. It would be incredibly easy for me to twist my words and make a client believe that I'm the expert on what's going on, even when I'm unsure, simply to have them return again and again for treatment.

"I prescribe you to foam roll. Every week. Under my supervision. Forever."

But, let's put it this way. Being a therapist and trying to establish a reputation nowadays is a lot like dating. You can be dishonest and massage your ego to get that one-night stand, or you be upfront and give it to someone straight in order to have a long-lasting relationship.

I can't see dishonesty with clients as anything short of unethical, and if I were to lie just to try to keep business, I could expect to see people catching on quite quickly and never coming back. In my experience, people have been extremely grateful when I'm honest and transparent with how I do business and my thoughts regarding their conditions:

"I've assessed your injury, and I think it's something out of my expertise. I'm going to refer you on to someone more suitable."

"I'm really not putting the pieces together here. Give me five minutes to check some references and do some research to see if we can figure out what's going on."

"I can't pretend to be 100% confident on what to do here, but let's try two treatments and see if we're finding benefit. If you're not feeling progress, I won't be insulted if you decide not to come back."

So far, those honest statements go a long way. Telling a client that I'm unsure about what ails them actually makes them more willing to come back due to the trust that I will continue to puzzle it out. Referring them on makes them confident that I'm looking out for their own wellbeing over my own and has resulted in them returning for different injuries later or even referring more business to me. Being honest about needing to check a source instills that you're being mindful and trying your gosh-darn hardest to help them.

With that said, I encourage all clinicians to be as forthcoming as possible with patients. Clients want honesty and results, and it is our job to provide. And to those clients, I advise you to find a practitioner who will deliver those qualities. The best-possible therapist for you is out there, and you absolutely deserve them.

Building Confidence in Ability

Back when I was in high-school, I took a class that involved a weekend practicum in the role of an outdoor camp counselor. There were a few typical rules asked of us in this position: Don't flash your cellphone or other technology around, don't swear in front of the kids, etc. One rule resonated as being particularly important to me, though.

"Girls, please no Lulu's or yoga pants. Boys, don't wear beaters. We want the kids attending camp to be motivated to do the things you're teaching them, not to aspire to look like you."

 

"You kids go canoeing while I stand here looking fabuloussssss!"

This was one of my earliest impressions that paved my philosophy as I became a professional with health and fitness. I heavily emphasize ability and performance over aesthetic regardless if I'm teaching a fitness class or rehabing a client. I find a much greater sense of achievement when my clients tell me they were able to run without pain that week than I do when they tell me they dropped a waist size.

Don't get me wrong. I'm not knocking the importance of developing healthy body image and allowing people to feel beautiful. I'm just not the best person for that job. As the "tiny" kid while I grew up, I quickly came to the terms with the fact that I'd never be the large, flashy muscle-dude in the magazines, but would always find solace in my ability to outrun my peers. For this reason, I find a particular speciality when it comes to training and coaching young people in their confidence in physical capability. Even more fulfillment comes when I'm able to guide someone to a physical achievement that they always assumed was out of their reach, such as introducing a previous non-athlete to success as a runner.

Pictured: A lot of runners who had never done a sport one year ago.

Training ability and function, I find, will leave an individual with a much more sustainable confidence and sense of identity than simply training towards a certain aesthetic. Especially when considering the toxic ideals instilled by modern media, training for an appearance involves a very different type of anxiety and mental coaching that I can't call myself experienced with. In fact, when asked on whether I still do personal training on the side with my rehab business, my answer is usually "no". With the exception of youth and sports-specific training (mostly speed and sprinting), I don't have a particular love for that kind of work these days. There are plenty enough workers who can focus on the aesthetic or coach someone in believing in their body image, but I'll use my time the way that I use it best.

Focus on what you can do rather than how you look while doing it.

Do More Techniques Make A Good Therapist?

"Do you do dry needling? Acupuncture? Active release? Graston?"

These are questions that I, as an Athletic Therapist, get quite often from potential clients. People are looking for the best-qualified clinicians to trust with their health. It seems like a given that the therapist with the most skills will be the best at treating their clients, and so advertising those additional certifications and continued-education courses are a sure-fire way to pick up on that.

Being an Athletic Therapist who is still relatively entry-level, though, these questions often frustrate me. To anyone in the public, or even to we therapists while we're still in school, yes, it seems like it'd be obvious that the more techniques, the better when it comes to treating. After beginning my career, though, I saw through the ploy.

Think of it like this. If a therapist was "better" at treating clients just based on knowing how to do the newest technique, then that would be like saying that the best personal trainers are automatically the ones with the most state-of-the-art equipment. Sure, those tools help, but the skills that set you apart from other professionals are knowing when, how, and why to use them.

I don't like to blow up my own ego or discredit anyone else, but this won't be an uncommon story across the board. I have a small set of entry-level treatment techniques: massage, joint glides, electrical stimulation, and a few more. However, I often get clients coming to see me after weeks - sometimes, months - of seeing another practitioner (whether it's another AT, physio, or chiropractor) who spent every treatment throwing fancy techniques at their client. Sometimes the treatments didn't work. Often, they did, but temporarily. After feeling like nothing was working in the long term, these clients will tend to try another clinician, and when I see them, sure, I don't have all those fancy skills, but I have my problem-solving skills.

After receiving a month of shockwave therapy on the shoulder, maybe the client really just needed more strengthening at the neck to reduce pain. Instead of endless active release on the low back, maybe conservative massage and core strengthening is going to be most-effective. Acupuncture to fix those nagging post-ankle sprain aches? Maybe start focusing on the mechanics at the hip instead.

I'm not trying to disprove the use of these higher certifications and treatment methods. By all means, they are meant to make a therapist's lives easier and be a part of an all-encompassing rehab plan. The thing to take away is that virtually any treatment method - whether it's the basic massage we learn in school or the dry needling we learn to do years later - all have the potential to accomplish the same goals. The trick is knowing where to use those techniques, why, and what to do afterward, and that comes down to the individual practitioner, regardless of what kind of continued-ed they've done.

Fancy tools are all and good, but by all means, they're far from the only thing to factor in when choosing a therapist.

Does Symmetry Matter?

I've had a few clients who see me regarding an injury or condition who have expressed a lot of worry over their muscular asymmetry.

Symmetry is a big concern in the fitness world; particularly in the circles of physique, fitness, and bodybuilding competitors who rely on the aesthetic of it for their performance.

However, when it comes to our health, fitness, and function, does symmetry really matter that much?

The answer is, frankly, nope.

You see, outside of the gym, our lifestyles don't really allow for the perfectly equal use of our limbs between left and right and the promotion of a symmetrical body-type. You have a dominant hand, a dominant leg, a preferred sleeping position. Without the focus of isolated exercise to specifically target the growth of individual muscles, it's unlikely you'll attain that perfect mirrored figure.

Does that translate to pathology, however? Probably not. Obviously, if there's a severe discrepancy such as a smaller quad due to a 6-month limp or one arm that's smaller after recovering from a fracture, those are more clinically significant. When it comes to a typical population group, though, smaller differences between left and right will usually be negligible.

Take the shoulders, for instance. I've heard many individuals remark on the fact that one of their shoulders - and thus, the entire arm - hangs quite a bit lower than the other other and worry about the implications of the "muscle imbalance" behind it. This is a perfectly normal occurrence though, with the dominant arm often - maybe even nearly always - hanging lower due to the more-constant reaching and lengthening of the musculature on that side.

And this isn't an isolated circumstance. Development of traps on one side, tone of spinal erectors, asymmetry of the abdominal muscles, and more. These discrepancies do not signal poor health; only habitual differences between sides. When flexing in the mirror, do not be alarmed by those subtle differences. You don't not need to be equally sized, toned, or flexible on both sides.

Don't get me wrong; I still will always note these asymmetries when examining a client who sees me in my clinic, as perhaps they are part of a larger problem that I haven't quite picked up on yet. However, it's important to keep those notes in the back pocket until needed, as it'd be useless to get hung up on every small change right off the bat. It's good to remember to not get hung up on how alike left and right look and to just focus more on each joint's ability to perform it's required functions overall.

In the words of Eric Cressey: