Low Back Pain in a Collegiate Basketball Player

Howdy Readers! Today I wanted to take some time to report on a case that I was presented with during this previous basketball season. Then I will discuss how I addressed the case and what I wish that I could have changed about the case. I will also be using my findings from the patient's Selective Functional Movement Assessment (SFMA), and so here is the SFMA acronym legend:

FN: Functional & Non-painful
FP: Functional & Painful
DN: Dysfunctional & Non-painful
DP: Dysfunctional & Painful

Background:

A 21 year old NCAA division III basketball player was competing in a JV basketball game when he suffered a direct blow to the low back by an opposing player's elbow. The supervising athletic trainer (I was busy prepping the varsity team to play) determined there were no gross deformities, ruled out neurological involvement (dermatomes & myotomes WNL), and ruled out any potential fractures. Nevertheless, the player was unable to return to play and finish the game due to pain.

This player had a previous history of catastrophic injury as a high school basketball player when he was undercut by an opponent. He fell on his upper back and hit his head suffering a fractured scapula and traumatic brain injury that lead to him being placed into a medically-induced coma. Additionally, he had a history of low-back pain during high school. The year previous to the current incident this athlete suffered a season-ending concussion as well.

After the game was over this athlete returned to his hometown with his parents. The parents and the athlete planned to see a family friend that is an orthopaedic surgeon in the following days. Upon consulting with the doctor it was revealed to the athlete that he had degenerative joint disease (DJD) in his lumbar spine and he was sent back to me for rehabilitation at my discretion.

Upon hearing this I definitely began to dismiss the DJD because I knew that suffering an elbow to the low back in one game of basketball didn't give this player DJD. I began to talk with the patient about pain science, how it didn't matter if he had DJD because he had it before when he was pain-free, and how we weren't going to attempt to change it. I did discuss how we would perform an SFMA and evaluate in which patterns he was moving dysfunctionally & why they were dysfunctional.

Assessment:

SFMA Top Tier Results & Breakout Findings--
Cervical Flexion = DN: Tissue Extensibility Dysfunction
Cervical Extension = FN
Cervical Rotation = Left - FN / Right - DN: (Tissue Extensibility Dysfunction)
Upper Extremity Pattern 1 = DN (Bilaterally, Left worse than Right): (Functional Shoulder Pattern Stability/Motor Control Dysfunction)
Upper Extremity Pattern 2 = FN (Bilaterally)
Multi-Segmental Flexion = DP (Posterior Chain Tissue Extensibility Dysfunction)
Multi-Segmental Extension = DN: (Thorax Extension Stability/Motor Control Dysfunction, Hip Extension Tissue Extensibility Dysfunction)
Multi-Segmental Rotation = DN (Fundamental Rotational Pattern Stability/Motor Control Dysfunction, Hip ER Tissue Extensibility Dysfunction)
Single Leg Stance = DN (Lower Posterior Chain Tissue Extensibility Dysfunction)
Overhead Deep Squat = DN (Hip and Lower Leg Posterior Chain Tissue Extensibility Dysfunction)

Plan:

Based upon my SFMA findings I decided to attack the greatest areas of dysfunction first. I determined that the hip flexion/posterior chain TED (~40 degrees passive SLR), and cervical flexion & rotation were the patient's greatest limitations. This is what I formulated my initial treatment plan around as well. I began with an easy 5 minute warm-up on a stationary bike followed by some instrument assisted soft tissue mobilization (IASTM) to the posterior neck, proximal hamstrings attachment near the ischial tuberosity and distal attachment of the biceps femoris to prepare for some Muscle Energy Technique (MET).

Day 1: Pain (7/10)

Upper Trap MET

I performed MET techniques (redundancy?) for the upper trap, scalenes, and posterior neck extensors. I performed 3 sets of autogenic isometric inhibition on the right side and an extra set on the left side. This brought cervical flexion and rotation to FN immediately following application of the MET treatment.

I then instructed the patient to perform a couple sets of supine kettlebell carries. Each set lasted until the patient neared fatigue and was unable to retract and "pack" the shoulder/scapula. This was performed bilaterally. Reassessing the upper extremity pattern 1 revealed decreased winging compared with baseline.

MET for the Scalenes

Before Treatment

Next, I performed MET for the posterior hamstrings. Specifically, I also instructed the patient on performing an autogenic isometric inhibitory technique. I performed this bilaterally and found that the patient's passive SLR increased ~20 degrees immediately by the end of treatment.

After Treatment

The patient was unable to attempt rolling exercises due to passive back pain so instead of attempting to restore rolling I had the patient perform some light stretching hip external rotation and calf stretching after having their glutes and gastroc/soleous worked out using a rolling stick by my student.

Easy Hip ER Stretch

Straight Leg Gastrocnemius Stretch - Towel prevents pronation

Bent Knee Soleus Stretch - Towel prevents pronation again

Day 2: Pain (4/10)

The patient returned the second day with increased cervical flexion and rotation patterns but they were no longer functional. I repeated the previous days IASTM and MET techniques and once again these patterns were FN after application. In attempt to prolong these gains, I applied some Rock Tape to the upper traps and scalenes. Once again I had the patient do some kettlebell carries while in a supine position. 

The passive SLR was still increased from the previous day but was still about 15 degrees short of normal. The patient was able to foam roll without increased pain and so I had him foam roll the entire posterior leg chain before IASTM to the aforementioned patterns. Again, we used the previous day's MET application to the hamstrings and this increased the passive SLR to normal.

Due to the patient's ability to have such drastic increases in mobility in such a small amount of time I suspected crucial core stability issues. In attempt to progress this patient quickly I wanted to restore rolling ASAP for the supine to prone upper extremity rolling pattern. I spent about 15 minutes working on rolling with him before calling it a day. Rolling was definitely not perfect but was much better than when we began.

Day 3: No Pain?

On the third day of treatment the athlete returned with FN cervical flexion, and rotation patterns and now Multi-Segmental Flexion was a DN. The athlete reported being sore in the shoulders and hips but no longer was experiencing any pain. We were now about 7 days out from initial injury. I continued to work on rolling patterns and was able to progress to some quadruped and tall-kneeling exercises before the day's end. I could tell that the athlete was very excited to return to basketball so I began his RTP progress with some easy free-throw shooting.

Return to Play and Further Treatment:

Unfortunately, the next day the athlete returned home for spring break and was no longer under my supervision. Despite my best efforts to provide a substantial home-exercise program for this athlete he was so enthused by his progress that he did not stick to his HEP and instead played basketball and rested his entire break.

Upon returning to school the athlete was no longer compliant with his rehab despite the presence his many dysfunctional movement patterns (MSF, MSE, UE #1, MSR, SLS, ODS) and would no longer come for rehab. Reluctantly, I continued to let him participate in practice and JV games. It wasn't because I didn't care about making him better but more because of it being an issue of me being stretched too thin between other athletes that had issues and wanted my help and patients like him that needed my help but wanted none of it because they no longer suffered. It is not an ideal situation but it is the way the world works sometimes. Ideally for me I wish I had been in a position where there was somebody(like a strength coach) that was familiar with the FMS and corrective exercises to help these athletes overcome their dysfunction.

Points of Distinction & Conclusion:

What I thought was interesting regarding this case was the patient's history of traumatic injury to the left scapula and the presence of ipsilateral hypertonic neck muscular and poor scapular stability when compared bilaterally. I do not know if this was present since his previous injury but its hard for me to ignore such a glaring "coincidence" when I see it. When I initially worked with this athlete I had a little contempt for the incomplete rehabilitation that he must have been put through following his previous injuries. 

However, I soon began to feel and conclude that much of this could have been the athlete's own doing and not that of previous clinicians. I even tried the route of touting injury prevention, performance enhancement and how he may be a ticking-time bomb for re-injury and recurrence of back pain. Some people, patients, and athletes just do not seem to want help unless they are physically writhing in pain and unable to walk. I am not sure if this is pride or pure laziness! 

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It moves, it breaths...it LIVES!

I wonder if any of my blog readers are still "sticking" around?

Howdy Readers (if I have any left)!

I just wanted to take a quick moment to let you all know that I am still alive. I have so many post ideas, videos, and things that I want to share with you all. However, I am ashamed that I have let my dedication to posting slack so much!

I thought that this short post could be used to sum up some of the changes that are about to occur in my life and to state what I have been up to. First of all, I have now successfully defended my thesis and only have a few tiny edits and format changes to make before finally submitting it. Secondly, this means that I am only a couple of weeks from completing my Master's degree at Illinois State University. I had a lot of great classmates, and instructors with a variety of backgrounds and personalities that have helped me diversify how I think about, look at and treat my patients. I owe a huge thank you to all of them.

This also means that soon I will be finishing my tenure at Illinois Wesleyan University as a graduate assistant athletic trainer.  This is a bitter sweet feeling for me. I have made a lot of good memories, learned a lot, and met some great people over the last two years. I will miss working with the Men's Basketball team at Illinois Wesleyan. I had a great time working with them and it was a blast when they went to the NCAA Div. III Sweet Sixteen last year and the Final Four this year. They were the first team that I was solely responsible for after becoming certified as an athletic trainer. My interactions with the players, the injuries, coaches, fans and parents have been integral in influencing my clinical practice. Over the past few weeks I have received a lot of praise from them, their parents, and the coaches but the truth is I owe them just as much thanks.

What makes this even more bittersweet is the fact that they will be the first and last team that I solely work with for quite a while. This is because I have decided to accept a doctoral student position at the University of Miami (Florida) to get my PhD in exercise physiology. There, I will work as a research assistant instead of being a clinician like I did with my master's.

This is going to be a huge change of pace, culture, and life for me. I have lived in the midwest all my life, loved cold weather, and never attended a private college before. I am definitely in for some culture and climate shock when I get there. However, I do look forward to trying my hand at continuing my clinical skills in a non-traditional fashion for an athletic trainer. I don't have anything set in stone and who knows how busy I will be but I may attempt to do some small-scale concierge or private 1on1 work clients that will focus on injury prevention and performance enhancement. Coincidentally, there was a very fitting article related to this type of service over at The Manual Therapist today.

I am getting to the point of this post where I need to wrap it up, say good bye and get back to work. There is much to be done with moving, preparing my thesis for publication, scholarships, and getting back in shape myself. It is a very exciting time for me and I hope that from this point on I will be able to contribute to my blog more frequently than I ever have before since it's inception. In fact, this blog is now over a year old! I know this because I just received a domain renewal notice ;) I have received about 100,000 page views in the past year. I hope that I can increase that exponentially over the next 365 days! I wish you all the best.

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Guest Post: Acute idiopathic torticollis in a male high school basketball player.

Hey everybody! Today's post was written by my good friend Yuya Mukaihara. He was telling me about some success he was having using some Rocktape samples that I had given him so I asked him to write up one of the cases for my blog. So without further adou here it is:

I am one of Adam's classmates at Illinois State University and I work at a local HS. I am a Certified Athletic Trainer with CSCS, and NSCA-CT credentials. I have Graston Technique and Technica Gavilan IASTM certifications. I have also taken some PRI courses--Myokinematic Restoration, Postural Respiration, CCM, and I just finished Impingement & Instability this weekend. I use manual therapy, PRI, and corrective exercises in my practice but this case was an acute episode of left torticollis. So, I mostly used manual therapy to manage this case.

The athlete kind of looked like this...

Background

Torticollis, also called as cervical dystonia or spasmodic torticollis, is a condition of the neck that results in sustained involuntary muscle contractions that may cause pain and neck rigidity.^1,2 66% - 75% of the patients experience pain, which is the main cause of disability in those patients.¹ It is more common in women than men and occurs in 5 to 20 out of 100,000 individuals.² Idiopathic torticollis is considered as primary cervical dystonia due to no history of physical examination or laboratory tests whereas the secondary cervical dystonia is due to an abnormal developmental history.¹

Currently, the pathogenesis of torticollis and the anatomical origin of its symptoms are unclear; however, an onset of idiopathic torticollis is often gradual and it displays sustained co-contraction of agonists and antagonists of cervical muscules.^1,3 Commonly, it is treated with a series of Botulinum toxin A injections into overactive musculature.¹ However, torticollis can conservatively be managed by reducing pain and involuntary muscle contractions with Kinsiotaping ⁴, manual therapy ^5,6, and therapeutic exercises.³

In this case report, I used Muscle Energy Technique (MET) and Strain-Counterstrain (SCS) technique with an application of Rocktape to manage acute idiopathic torticollis in a male high school basketball player while he played playoff games.

Case Report

A 16 year-old basketball player came into the ATR 10 minutes before his practice started, c/o of left neck pain and tightness that resulted in his inability to look left. He stated that he started noticing tightness and pain that gradually becoming worse in the afternoon. Any other symptom was stated. It was in-season and was a day before his playoff game and he was needed in practice because he was one of better players on the team.

- At resting with seated, his neck was rotated and side bended to right a little bit.

- Active left cervical rotation was limited and was about 15deg with pain in the left side. Full right rotation.

- Active left side bending was also limited and was about 10 deg with pain in the left side. Full side bending.

- Palpable tightness over left cervical extensors, upper trap and levetor scapula compared to right. He c/o pain with palpation of these muscles.

- MMT to cervical flexion, extension, right rotation and right side bending were 5/5 without pain. Left cervical rotation and left side bending were 3/5 due to pain.

- No history of a car accident, head or neck injury, or shoulder pathology. No history of medical conditions or surgery that should be noted. No signs and symptoms other than tightness, pain, and limited ROM of the c-spine.

Course of Treatment

Day 1, after a quick evaluation, he had to go to the practice so I only had 10 minutes to treat him. I began with MET isometric reciprocal inhibition on left rotation and side bending. I didn't target specific muscle but general motions. I had him to rotate and side bend to the right from neutral to gain motions on the left side by inhibiting these tight musculature. There was not much improvement but he had to go to the practice.

15mins later, the player came back to me because he could not play due to pain. So, now I had a little bit more time to treat the athlete. I had him lay supine and checked his passive ROM. Passive left cervical rotation and side bending caused pain as did active, displaying limited ROM.

I used SCS on his left upper trap and levator scapulae because I suspected muscle spindle hyperactivity.  After resetting the mechanoreceptors, he had increased left cervical rotation and side bending.

After finding the most tender spot, I kept a pressure and started counting time. Then I slowly increased left rotation. Once he feels no tenderness under my finger, I stayed there for about 20-30sec and then increased a little further and repeated. At the same time, I added some side bending a little by little to gain the ROM.

After one session of this technique, his active left rotation was about 80% of his right rotation and side bending was about 30% of his right side bending. (active left cervical rotation about 75deg and side bend about 25deg).

Then, I performed a 1st rib MET on the left for one set of five isometric contractions to inhibit his left scalenes and to regain the function of left side bending.

Fortunately, I had a sample of Rocktape from Adam, so I put the player’s neck into flexion, right rotation and right side bending to place his left neck muscles on stretch then applied two strips of Rocktape.

One strip was applied from the occiput to about T3 level and the other strip was applied from the mastoid process to scapular spine. My intension to use Rocktape was to inhibit the hyperactive or hypertonic muscles. I had some personal experience of inhibiting hypertonic muscle with Rocktape previously.

After those interventions during 15 mins of treatment, he was still limited to left sidebending with pain, but was able to complete the practice with the team. He ended up keeping the Rocktape on for the next four days.

Day 2, the day of the playoff game, he returned with full left cervical rotation without pain and improvement on left side bending, which was 80% of right side with minor pain. On that day, I used MET for left 1st rib, upper trap, and levator scapulae with isometric autogenic inhibition. He played the game without any complaint, and we won the game.

Day 3 and 4, he had no limitation on both left rotation and side bending and no pain. On that day, I used MET for 1st rib only. No deficit with RROM for flexion, extension, both rotation, and both sidebending. He completed a practice without any complaint.

Day 5, he had returned to play without treatment. He completed a practice without any complaint.

Day 6, he had no complaint from day 5.  He played the playoff game without limitation or complaint. We won the game.

Conclusion and Discussion

In conclusion, Rocktape and manual therapy were a lifesaver for this athlete, his team, and me. Without them, I think he would continue to suffer from his tight and painful neck muscles, which could have affected the dynamics of our entire team and lost their first playoff game. Also, I was satisfied with the immediate improvement of cervical motions, especially rotation, with SCS technique. I wonder how an outcome would have been if I did not know SCS technique and just provided a very traditional intervention, such as heat modality and stretch. I need to thank my undergraduate program and faculty, which brought a SCS technique expert from University of Oregon for us to learn.

Further, I think the tape maintained immediate effects of the SCS and MET techniques and even more so enhanced inhibition of those hypertonic muscles that caused pain. Overall, I was happy that he responded so quickly and positively to the intervention thus allowing him to return to play very quickly.

References

1. Crowner BE. Cervical dystonia: Disease profile and clinical management. Phys Ther. 2007;87(11):1511-1526.

2. Patel S, Martino D. Cervical dystonia: From pathophysiology to pharmacotherapy. Behavioural Neurology. 2013;26(4):275-282.

3. Dool JVD, Visser B, Koelman JH, Engelbert RHH, Tijssen MAJ. Cervical dystonia: Effectiveness of a standardized physical therapy program; study design and protocol of a single blind randomized controlled trial. BMC Neurology. 2013;13(1):1-8.

4. Pelosin E, Avanzino L, Marchese R, et al. KinesioTaping reduces pain and modulates sensory function in patients with focal dystonia: A randomized crossover pilot study. Neurorehabilitation & Neural Repair. 2013;27(8):722.

5. Godse P, Sharma S, Palekar TJ. Effect of strain-counterstrain technique on upper trapezius trigger points. Indian Journal of Physiotherapy & Occupational Therapy. 2012;6(4):77.

6. Iqbal A, Ahmed H, Shaphe A. Efficacy of muscle energy technique in combination with strain-counterstrain technique on deactivation of trigger point pain. Indian Journal of Physiotherapy and Occupational Therapy - An International Journal. 2013(3):118.

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Rock Tape Technique for Anterior Knee Pain

Hey Readers! I use a lot of different tapes, and taping techniques in my toolbox when dealing with athletes and their injuries. A lot of these things are just "tools" from my toolbox to help athletes cope with their injury(s). I don't think I can think of a single incidence where I consider the tape to be a fix to a problem but it does work as a great complementary treatment to reduce pain and increase function for my patient's when used in combination with rehabilitate/corrective exercises.

About two months ago I attended Rocktape's Fascial Movement Taping level 1 & 2 certification seminar (read that review here). Since then I have experimented with various taping techniques and have had results ranging from mediocre to outstanding for some of my athletes. One technique in particular that I have used with great success is one for anterior knee pain. I have used this with a number of athletes suffering from anterior and/or medial knee pain and they have noted definite rapid and dramatic differences in knee pain with activity. Some people might argue that this tape is purely placebo and if that is true, so what! I use a neuro-based model for a lot of the manual therapy and corrective exercises that I use on a daily basis. So if I am just tricking the brain into thinking that it is feeling less pain with this tape job then mission accomplished!

Without further ado, lets get to the tape job. I use Rock Tape myself because I feel from previous experience that it is stickier, better elastic recoil, cooler colors and patterns (more placebo power), and great construct quality compared with competing brands of "kinesiology" tape. Nevertheless, I feel that this technique would work when using those competing brands of tape as well.

Step 1 (After prepping the skin)

• No stretch at anchors/ends
• No stretch as you lay down the tape, just tension off tape.
• Rub down tape to set adhesive
• Distal/Proximal pull doesn't make a difference.

Step 2

• Repeat step 1 (above) but in the exact opposite fashion.
• Do not begin tape on top of tape if you want better results in terms of application longevity.

Step 3 (Final)

• Apply a "decompression" strip over the sight of pain/soreness
• This means you apply a stretch in the middle of the tape (25% - 75% stretch)
• No stretch to the anchors or ends of the tape
• Supposedly this applies a very nice "lift" to the middle portion of the tape where the stretch is at.

Here is a video I made for all of you that shows how to do this taping technique in real time! Check it out! Ignore my mint green shirt! It was made to support National Athletic Training Month 2014...which coincidentally is right now (March)! 

I hope you guys enjoy this post and video and I hope you are able to find similar results like the ones that I have. If you don't, then don't waste your time continually applying this method and find something else that works! When you find that something else...come back here and let me know about it so I can learn from you! In conclusion, this is a great adjunt therapy but it is important to remember that this isn't the fix and you should be doing other stuff to address the true source of the knee pain.

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Concussion, Cervical, TMJ/TMD or a Combination Thereof?

Myofascial Release of the Temporalis

Welcome readers! Today's post is about a very recent case of mine straight from the clinic! This is a mini case-study about a 22 year old male collegiate basketball player. This patient took direct blow via an elbow to the anterolateral aspect of the cranium during a basketball game on Saturday evening. After the game the athlete presented with several concussion symptoms as well as TMJ pain and a palpable and audible click with opening and closing of the mouth.

The patient presented with these findings during the assessment:

• Cranial Nerve Testing all WNL
• Dermatomes & Myotomes WNL
• Concentration, Immediate Recall, Delayed Recall, Balance, and Orientation via the SCAT3 were all WNL
• Patient Reported Concussion Symptoms
• Headache, "pressure in head", "Not feeling right", Difficulty Concentration, and eventually added the symptom of difficulty sleeping the next morning.
• Glasgow Coma Scale: 15/15 (WNL)
• 1 Previous Concussion in the symptom prior where the patient suffered much more severely on the SCAT2 and had post-concussive symptoms for 2-3 weeks following initial injury.

Long before this case presented to myself I often wondered about possible connections between concussion symptoms, and temporomandibular joint(TMJ)/temporomandibular dysfunction(TMD)/ and cervicogenic headaches. I questioned whether a person could present with concussion symptoms due to potential muscle guarding/spasm and possible involvement of TMD/TMJ issues.

Obviously I still treated this patient as having a concussion and his symptoms had slightly increased the following morning(Sunday) as well. Nevertheless, despite the fact that I was treating him for a concussion and ordering complete neurocognitive rest (despite having perfectly acceptable objective test scores on the SCAT3) I decided to treat his TMJ and neck musculature using manual therapy. NOTE: Current policy with our team neurologist is to assume its a concussion and wait to imPACT test the patient with cessation of symptoms.

I only did a few minutes worth of manual therapy for this patient and they were done with very light pressure. I started with 1-2 minutes of light IASTM to the Masseter, and myofascial release of the Temporalis using my hands. (Both pictured in the above photos.) I followed these up with some light lateral mandibular glides bilaterally for about 30 seconds each.

Finally, I applied lateral-medial/posterior-anterior pressure with the pads of my second digit on both sides of the first palpable spinous process while the patient simultaneously performed an active cervical retraction or chin tuck, if you will. This was done in an alternating fashion with pressure on again/off again in 2-3 second cycles for about 30 seconds total.

The patient reported rapid improvement in their symptoms but not complete cessation and they started to slowly return about 40-50 minutes later...Which one might expect with a concussion...or with a rapid responding patient that wasn't given a HEP to perform after manual therapy. Which one is it? I can't be sure but I play on the safe side and assume the worst. Additionally, the click/pop of the TMJ was no longer present after treatment

The following day (Monday) the patient reported complete cessation of his symptoms and the TMJ issue had not returned. The patient underwent imPACT testing which came back normal and began the first step of a graduated return to play progression.

In conclusion, what does this all mean? I don't know. What if I wouldn't have chosen to treat the patient with manual therapy. Perhaps he would have awoken still with total cessation of symptoms and would have passed his imPACT as well. (This still doesn't even prove he didn't suffer a mild concussion!) Another potential alternative is that the patient could have continued to suffer from "concussion" symptoms for days at a time and perhaps this would have delayed his imPACT testing and subsequent return to play/activity/sport. 

This is not necessarily a bad thing because it is always best to play it safe. However, it also means that my patient/athlete would have had to suffer undue pain/discomfort related to his TMD/"concussion" symptoms. He also would potentially have to miss out on class/social activities/and experience a lot of undue psychological stress if I hadn't treated these findings. I am just curious if others if had these similar thoughts/case/experiences or what you all think of this? 

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Help Me, Help You: I'm on Google Help Outs!

Hey everybody! It's an exciting yet very interesting time for me right now. I am half way done with data collection for my master's thesis, and if I finish it on time then I'll be graduating in the beginning of May.

On top of that and the focus of this post is that I am trying a new hat on for size with an endeavor into the world of Google Helpouts.  Google Helpouts is a relatively new service where Google tries to pair up everyday people needing specific help with experts in the respective fields of need. For instance, if I needed help with my car Google would set me up with a car mechanic to see if they could assist me via video chat.

So here is the part where I come in... I want to use Helpouts to assist people with moving better, feeling better, and performing better. I believe with my movement based system of assessment (FMS & SFMA) I will be able to help others achieve these goals. I am going to approach this initially with an injury prevention, movement analysis, performance enhancement and nutrition focus.

I look forward to broadening my pool of people to work with and if that person is you I can't wait to get started in assisting you to achieve your goals. Google has generously offered me a code allow you to have your first Helpout session with me for free (ADAM99V). Each session will last a minimum of 45 minutes if needed at a rate of $25. Check out my profile and schedule a Helpout with me ASAP! Can't wait to see what this brings! 

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Where Have I Been?

Howdy Folks! I am sorry that I haven't been blogging even a quarter as much as I would like to be lately. However, in all fairness I have been pretty busy. What have I been busy with you might ask? Well...on top of being an athletic trainer for a collegiate basketball team (that is ranked #4 in its division for the entire country and likely to win their second conference championship in a row), I have been busy working on and trying to complete the research project for my master's thesis.

Dr. Erson Religioso over at The Manual Therapist has been interested in my research project and asked me to write a guest blog for him where I would discuss what I was doing with and looking at for my research. I was honored but it also gave him some time off from blogging to spend with his new-born baby girl! Congrats to him for sure! Anyways, here is a link to my guest blog where I talk about my research! I need to get back on the blogging train and finish my self-SFMA series as well! Sorry for the delay, everyone.

I've got some cool cases related to my patients, SFMA, PRI, and Rock Tape to blog about once I get some more free time! Can't wait to share them all!

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Rocktape: Fascial Movement Taping Levels 1 & 2 Course Review

Swollen Knee? Try this on for size.

Howdy Folks, this past weekend I had the opportunity to attend both levels of Rocktape's Fascial Movement Taping(FMT) Seminars. This was a Saturday/Sunday conference and to an outsider it probably looked like an odd waxing/hair removal ritual with the use of some brightly colored kinesio-tape. In the past, I have been very skeptical of things like kinesio-tape and other various magical fixes for ailments. However, I have a background with and an interest in using movement assessments as an integral part of injury evaluations, treatments and prevention work. Therefore, I found myself intrigued at the description of the FMT course and by the amount of respected clinicians that were beginning to incorporate this tape/taping school of thought into their clinical practices. Here is the description straight from Rocktape's website:

"...Not your average taping course. Fascial Movement Taping Certification is a 2-part certification process led by industry leading experts in functional movement assessment and treatment. Fascial Movement Taping (FMT) is based on the obvious yet largely overlooked concept of muscles acting as a chain. Say good-bye to thinking about origins and insertions and memorizing directions of tape. Say hello to a framework of ‘taping movement, not muscles’."

I was immediately attracted to what they were promoting ("Taping Movement, Not Muscles") and how they were separating themselves from the reductionist style of taping muscles via origin and insertion. So...I signed myself up for the most readily available seminar! I also noticed that Dr. Perry Nickleston, DC, FMS, SFMA, NKT was lecturing/teaching this conference. This excited me because I knew of his writings via his blog, Stop Chasing Pain, and I also knew that he was integrating this style of taping with movement assessments via the SFMA and FMS. Perfect. This seminar was hosted on the campus of the National University of Health Sciences in Lombard, Illinois.

Day 1

Both days the course started at 8:00am and while I usually like to arrive to things like this at least 20-30 minutes early I have to admit that I ended up being about 5 minutes late for this course. There were primarily two reasons for this, a fresh blanket of snowfall left us with undesirable travel conditions and I ended up getting lost on the campus due to the poor communication of the room location. Fortunately, it seemed as if the bulk majority of people got a little lost including Dr. Perry himself!

The first day of the course followed a rough outline of these topics:

• History
• Effects & Potential Benefits of Taping
• Differences between other kinesiotaping schools of thought and FMT's
• Importance of and the interplay between the brain, skin, the nervous system, pain and the relationships with human movement.
• Tape Properties
• Taping for Acute Care/Fluid Dynamics/Edema Control
• Indications
• Contraindications
• Precautions
• Taping for Acute & Chronic Pain Control
• Taping for Proprioception
• Taping for Posture
• Neuro-Taping
• Scar Taping

That is a lot of stuff to cover in just the first day alone but in reality so much of the different topics build upon one another and have a lot of interplay. Also, this is a rough outline of what Dr. Perry went over...in reality Dr. Perry jumped between topics, subjects and ideas at seemingly random times. Not because he was unorganized but because he wanted to promote critical clinical thinking that sometimes begins as unorganized and seemingly random observations. Skilled clinicians must then take these random puzzle pieces and turn them into something meaningful for both the patient and themselves.

Edema strips...I pretended to have some bursitis for my partner

Dr. Perry also delivered the content with an energetic and interested tone. He wasn't the boring monotonous type but you could tell he had a vested interest into what he speaking about. While he did use colorful language at times it was definitely not tasteless and provided some much needed levity for when your brain started reeling from all of the knowledge bombs being dropped upon it.

For this review I can't go into everything that I learned nor does anyone want to read that much about it. I also don't want to spoil all of what we learned but I would like to highlight some of the things that I really liked.

• Integration of many schools of thought, such as:
• Regional Interdependence
• Tensegrity Theory
• Current Neuro-Pain science
• The works/ideas of great minds like:
• Shirley Sahrmann
• Vladimir Janda
• Lorimer Moseley
• Gray Cook
• David Butler
• Karel Lewit
• & More
• Movement Assessment

Things were both practical and philosophical.

Day 1 was definitely a day for developing a framework or laying the foundation for what we would learn on day 2. However, there were many universal concepts and taping techniques that we learned on day 1 that could be used and applicable after walking out the door that night. In fact, that is exactly what I did...Let me set the stage:

In the morning when the conference had begun I had received a text message from one of my patient's (a collegiate basketball player) that their back was very stiff, painful and locked up. They were barely able to dress themselves because of this. This wasn't pleasant news considering I was 2 hours away at the conference and wouldn't be able to treat him until that night...even worse was that he had a basketball game to play that night at 7PM. However, one of my colleagues was going to travel with the team and prep them before the game. He was able to help treat him before the three hour bus ride began and when they finally arrived. The bus ride was reportedly miserable and the athlete had to stand up or lie in the aisle for the bulk of the ride. With 30 minutes to go before tip-off the athlete was better than that morning but still wasn't sure of his ability to perform.

This is when I arrived to the game, I had been thinking of applying a tape job that I had learned that morning that involved taping the thoracolumbar fascia and the paraspinals for pain control and muscle spasm. I thought it was worth a shot and would hopefully work in synergy with the other various treatments he had received that day. I didn't have any Rocktape with me and just used some cheap kinesiotape from my kit(ended up starting to fall off halfway through the game). Nevertheless, the athlete reported that he felt much better and more comfortable with the tape and subsequently was able to play the entire game. Could this have been purely placebo? Possibly. Could it have been related to the prior treatments from my colleague? Absolutely. However, I don't care if it was just a placebo that made him able to perform...There was no downfall to trying and he wasn't suffering from an injury that should have removed him from participation. The entire experiences was a giant +1 for how I felt about what I was learning from the seminar.  Potentially I am even biased because of this experience but pain is a construct and I was able to help alter how he assessed his status.

Pre-FMT Seminar.

Post-FMT Seminar...Much better.

Day 1 Memorable Quotes/Knowledge Bombs:

• Tape Movement, Not Muscles (Rocktape Slogan)
• "Movement Never Lies"
• "Treating scars is really cool s#^t!"
• "Movement is the common denominator of injury"
• Your body is always training and working out...against gravity.
• "If you have a body, then you are an athlete."
• "...you need all of that s**t to be STABLE!"
• "If I change your posture, can I change your mood?"
• "You need to have blueballs if you want to stick out"
• Go stronger, longer - It's viagra for the whole body.

Day 2
Because I already made a novel out of day 1 let me try and keep this short and sweet. While day 2 definitely was full of mental "sweets" it definitely did not come up short. Day 2 was more dedicated to assessing movement and then applying taping techniques in attempt to change movements.

Applying the spiral chain tape job to one of my athletes.

To start off Dr. Perry began with a segment on the importance of movement for life, how movement is a behavior, and how we all have our own unique movement habits or patterns. All things I whole-heartedly buy into and believe in. He then tied that part all together nicely by throwing this classic Gray Cook quote at us, "It took a habit to make that pattern, and it's going to take a habit to break the pattern."

Dr. Perry then had a great slide where he compared using the Snellen Eye Chart as a vision assessment to using movement as an assessment. He stated that if you weren't able to read the letters he knew you needed corrective lenses and if you can't move well then you probably need corrective exercise. Albeit he admits that some people can't reach perfect, whereas some only need a tiny tweak.

Let me outline the major areas of what we learned about on day 2:

• Movement Science
• Fascia and Fascial Anatomy
• Big influences from both Schleip and Thomas Myers here...
• Fascial Chains/Slings
• Movement Assessment, Taping Movement, and applicable Rehab/Corrective Exercises
• Maybe you don't like the SFMA or FMS...Doesn't matter, the importance of testing any motion that is used for ADL's or sport specific exercises is just as beneficial and vitally important.
• The Importance of Breathing and the role of the diaphragm
• Releasing the diaphragm
• Taping the diaphragm
• Tweak Taping
• Process of testing and then taping various skin glides to improve movement or patient's asterisk(*) sign
• Pregnancy Taping
• A nice tape application to assist pregnant women with low back pain, etc.
• & Performance/Sport Specific Taping

We were not discussing abstinence, yet.

There was a lot of discussion during these two days about the importance of the brain & nervous system and the role they play in both pain and movement. I really appreciated a lot of the theories that this course was basing its methods from. There was a very simple slide at the end of the first day that summed up the differences between FMT's theories and other brands or styles of taping:

• Functional vs. Structural
• Movement vs. Muscles
• Sensory vs. Mechanical
• Assisting vs. Resisting
• Elastic vs. Rigid
• Integrated vs. Isolate

There was a lot of SFMA/FMS type movement tests and many of Dr. Perry's own favorite movement tests thrown into this day. We discussed important aspects of the movements, potential compensations, movement lynchpins, and ways to approach correcting and taping said movements. There was a lot of moving and not a lot of sitting during this course.

Here I used the "Big Daddy" 4 inch tape, for posture.

Overall, I would say that I definitely enjoyed the course and I have found myself practicing a lot of what I learned in the clinic this past week. I don't think the tape is a be-all-end-all treatment and it is definitely not taught as one but it is another tool for the toolbox. I enjoyed the discussion and dissection of movement, nerves and the brain, and the implications of everything combined. Would I sign up again if I had to remake the decision? In an instant. Do I recommend it to others? Yes, but I feel like I definitely benefited from having previous exposure to the SFMA/FMS. There were a few massage therapists and personal trainers in the class and I couldn't help but wonder if they were able to digest everything as easily.

Day 2 Memorable Quotes/Knowledge Bombs:

• The brain wants to feel safe, there is no safer place than the ground
• "Pass your finger through the fuzz" - keep moving.
• "If you don't own breathing, you don't own movement"
• "The feet are the window to the soul/sole." - Karel Lewit
• Flip them over and tape their yang.

Dr. Perry, Myself, and Dr. Nick...Both of them making me look tiny.

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My SFMA: A Case Study - Multi-Segmental Flexion Breakouts

Today's post is the fourth part of my self-SFMA(Selective Functional Movement Assessment) case study series.  Specifically, We will look at and break out my dysfunctional Multi-segmental Flexion movement pattern from my SFMA Top Tier Post.  

I'm jealous of those that can do this.

Here are the links for the first three posts of this series:
SFMA Top Tier Pattern Assessment

SFMA CervicalSpine Pattern Breakouts

SFMA Upper Extremity Pattern Breakouts

Assessment:

The SFMA works by assessing 7 general top tier movement tests. All tests are rated and ranked by two broad categories of dysfunctional or functional, and then two sub-categorizations of painful or non-painful. This means there are four basic appraisals of FN, DN, FP or DP. From there you perform a "breakout" of each dysfunctional pattern to determine the cause of dysfunction. Dysfunctional movement patterns are broken down using an algorithm that funnels and filters the problem into either a mobility dysfunction or a stability &/or motor control dysfunction (SMCD). 

 

This video will look at the dysfunctional multi-segmental flexion pattern.  Here is the latest breakout video:

Results:

Multi-Segmental Flexion Top Tier = DN (Unable to touch toes. Why? We don't know yet. Other Criteria for passing: Uniform Spinal Curve, Posterior Weight Shift, < 70 degree Sacral Angle)

Single Leg Forward Bend Test = Bilateral DN, yet symmetrical (Still Unable to reach the toes or floor. Why? We don't know yet. Proceed to the next test.) 

This test helped to determine if the forward bend was an asymmetrical or symmetrical dysfunction…in the presence of pain with the top tier assessment we could also use this test to check for symmetry with pain provocation.

Long Sitting Test = DN (Still unable to reach toes. Why? I don’t know yet but we did pick up on a few things.)

We still do not have a clear cause of dysfunction yet, however we do know that I cannot touch my toes and I do have < 80 degree Sacral Angle. This would indicate limited hip flexion and/or limited spinal flexion, or both.

If I had been FN with this test we would have proceeded to the rolling patterns to check for a fundamental motor control dysfunction.

Active Straight Leg Raise Test: Right=DN, Left=DN (Looking for at least 70 degrees of Hip Flexion)

Passive Straight Leg Raise Test: Right=DN, Left=DN (Looking for at least 80 degrees Hip Flexion and to be within 10 degrees of the Active SLR)

It is observed that my passive SLR has more than a 10 degree difference from the active SLR. This would indicate a possibility of a core stability, hip flexion strength problem, excessive hamstring tone, guarding or a hip mobility dysfunction.

Supine Knee to Chest Holding Thighs Test = DN (Unable to bring knees and thighs to chest while supine.) This test is used to check the mobility of the hips while they are in an unloaded or non-weight-bearing position. Doing this also helps to differentiate a difference between hamstring mobility and hip mobility dysfunctions.

Breakout Findings: If we follow the breakouts one would deduce that I have a hip joint mobility dysfunction or a posterior chain tissue extensibility dysfunction or both…as well as a possible hip flexion strength or SMCD dysfunction. But that isn’t as important considering that we would need to treat the mobility dysfunction before addressing any SMCDs.

Do you have any ideas/suggestions/thoughts? Let me know in the comments below!

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A Year in Review: 13 Lessons of 2013

Happy New Year and welcome to 2014! This is my first post of the year and my 75th post overall.  This is going to be a reflection on some of the things that I learned in the previous 365 days. I was inspired to write this post after reading many of Mike Reinold's similar posts over the last few years. I guess I learned a lot this year because this turned into an epically long post. Sorry.

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