Was thinking about motor control and motor strategies today in the clinic. Here are some thoughts that crossed my mind.....
Mechanisms of injury are important to understand, they just are undeniable. So therefore avoiding those positions makes sense. Training motor strategies and strength to help avoid those positions for our athletes should be a no brainer.
Yet this doesn’t always carry over and there are still injuries that occur which will always drive the pendulum in the opposite directions to the next big “thing”. So why does movement have to be so complex and how can we help define it better for our brains to organize? If you look at what some of these great minds have already helped us with you will notice certain evaluations are good at one or two things. Take the Y balance for example. The Y balance is great at helping with movement symmetry. Great, we need that. Now what about movement skill? Well there is the FMS for that. However if one is dysfunctional and not healthy movement wise then the SFMA is available.
When we are trying to help an athlete improve motor control most of us would agree that environment plays a huge role. Yet I am confident that despite the environment, each athletes ability to learn is based off of their past experiences and mistakes. So if we are trying to provide a stimulus to learn and improve motor control how do we take into account an athlete’s learned behaviors? What I mean is that some athletes are motivated by fear of failure and some athletes are motivated by getting the instructions right. Now of course there are athletes in between and combos of those but how we instruct is just as important as what we are choosing to help the athlete learn. I’m not sure these are cookie cutter answers and as we have learned in school so often before, IT DEPENDS.
I guess the point I am trying to make is we must think about more than just the task itself when trying to help one improve motor strategies. What is the cost analysis of the task? More importantly, can the athlete even control his/her sleep? If they can’t, is it useful to try to learn a task that day?
My thoughts for today
Brian Schwabe, PT, DPT, SCS, CSCS
Concussions, ahhhhh! They can cause brain damage and memory issues down the road. Should we be holding our athletes back from participating in sports with a high risk of concussions in order to save them from the repercussions later in life?
Now that concussions are front page news, many physical therapy clinics are offering specialized “Concussion Rehab” programs with specific protocols to get athletes back on the field. These specialized programs and protocols are great, however, the parents are still coming in with a million questions and the athletes are still very anxious to return to sport. How do we address these external factors?
Educating the parent and the athlete is important, but including the coach is key! The coach is the one who needs to understand the athlete’s limitations and the implications of pushing them too hard too soon. One of the things we have found to be helpful is providing the parent and the coach with an informational folder. This folder outlines the process from start to finish: what happens the moment you sustain a concussion, the internal healing process, the rehabilitation process and things to be mindful of in the future. Although concussions are a hot topic right now, that does not mean that people fully understand what it means to sustain a concussion. The education of the front line people in athletics, like coaches, is instrumental in keeping our athletes safe.
Now that we have educated the parents, athlete and coach it is important for us to understand our roles in the rehabilitation process. Many therapists in the outpatient world have shied away from treating the vestibular population, or maybe there is only one person in your clinic dedicated to seeing these types of patients. If your clinic is going to offer concussion rehabilitation, that clinician needs to make sure they are proficient in all types of vestibular rehab, not just the most common diagnosis of benign paroxysmal positional vertigo, or BPPV. Previously, the most commonly used screening tools after concussion were the Balance Error Scoring System (BESS) or the Sensory Organization Test (SOT). The problem with these tests is that they do not address dynamic aspects of the vestibular ocular system or the vestibulo-ocular control which may cause us to overlook other contributing factors. The newest tool, which encompasses both vestibular and ocular motor impairments, is the Vestibular/Ocular Motor Screening Assessment (VOMS).
If you are not familiar with the VOMS, you should be. This tool looks at 5 areas: smooth pursuit, horizontal and vertical saccade, convergence, horizontal vestibular ocular reflex (VOR) and visual motion sensitivity. These are all assessments we learned in school, but when was the last time most of us have used them in the clinic? It’s time to dust off the cobwebs! If you are looking to stay on top of cutting edge treatment of concussions, it is imperative that you are proficient in the assessment of these areas. Unless you can accurately assess and determine the area of the deficiency, how are you going to be able to properly treat the athlete? We owe it to our athletes and referring physicians to be on top of the research. This may mean signing up for a vestibular CEU, or attending a talk given by an ENT or otolaryngologist who specializes in concussions. If nothing else, start doing some reading. It will surprise you how much has changed since you took your board exams!
“If it hurts then stop doing it.”
That is the phrase that every physical therapists will repeat throughout their career. Whether we are referring to exercises in a home program, basic ADLs, or part of a patient’s normal routine at the gym, that phrase is the disclaimer that we use to make sure our patients are not taking a step back in their recovery. However, there is one patient population that will never listen to this phrase…..our crazy runners. We say, “You need to stop running,” they think we are just another health care provider who doesn’t understand them. Here is where you prove them wrong. Being a “crazy runner” myself, I know that if someone told me to stop, I would smile nicely and act like I was totally on board with everything they were saying. In my head, I would be thinking, “yah right, I have a wedding in 3 months and I have to fit in that dress! Running is the only way I can maintain my weight, so I am not stopping for anyone.”
Before you tell a patient, especially a runner, that they have to completely stop doing the one thing that they love, you better come up with a backup plan. Believe me, you will gain a lot more respect from your patient and their compliance with your plan of care will significantly improve! Giving your patient options will set you apart from the other health care professionals they have seen. Their physician told them to stop running and go to therapy. The patient has probably continued to run right up until their appointment with you. Now, you have done your examination, discovered their deficits and attempted to explain to them why it is so very important that they stop running. But, you have forgotten to address the most important part, what they can do in place of running.
Rowing machines are all the rage these days and although many people associate them with the 1980’s, they are a great way to get your heart rate up while minimizing the impact on your joints. And, if it is done the proper way, it can be really intense.
Swimming. So many people dislike getting in the pool because it is such a hassle, but what they don’t realize is that it is just as good, if not better than going for a long run. The major difference is that you do not feel yourself sweating, so you don’t think you are burning as many calories. Wrong.
Cycling. Although not the best choice for everyone, depending on their diagnosis, it is still another great low impact choice that if lead by the proper instructor, can be very challenging.
And last, but not least, if you are lucky enough to have access to one (and I am) The Alter-G Antigravity Treadmill. For those of you who haven’t seen one, this overpriced piece of cardio equipment allows patients to off load themselves and run with as little as 20% of their body weight. It is great for nursing injuries as well as working on speed training.
Always, always give them some type of return to running program before you cut them loose. You need to make sure that they are able to log a few middle distance runs prior to discharging them. I like the University of Wisconsin- Madison program which can be found on their web site, http://www.uwhealth.org/files/uwhealth/docs/sportsmed/SM_Runners_Training_Tips.pdf
So before you say those words that no dedicated runner wants to hear, provide your patient with some options to get them through the next few weeks while you address their deficits. They will leave not only with an appreciation for our profession, but for you as the health care professional who didn’t make them stop doing what they love.
- Cara McInerney, PT, DPT, SCS, CSCS
Tendinopathy is a very frustrating diagnosis to treat as a physical therapist. However, it is even more frustrating to the patient. There is a lot of ideas out there on tendinopathy and how to treat it but what is more concerning is that many treat with "evidence" without even understanding what the evidence is telling us. The truth is, we don't know everything yet about these conditions. Fortunately, over the last few years, more and more solid research on clinical applications to diagnosis and treatment for tendinopathy has been published.
As a sports therapist that has dealt with triceps tendinopathy myself, I am particularly interested in this subject. Often when clinicians think about tendon issues they think about overuse. Sounds pretty simple right? I mean, we overloaded the tendon. The problem is we must identify what the overload was. What I mean is how was the tendon overloaded? Tendon's are typically overloaded by two mechanisms: energy storage & release and compression. But I doubt many clinicians understand the compression mechanism. To understand the compression mechanism of tendon pathology, see this video. It is a perfect explanation to how this occurs.
So what about classification of tendons? Well as Jill Cook (a tendinopathy research/expert) explains, there are reactive tendons and degenerative tendons. Understanding where the athlete is on the continuum is the key. Knowing where they are can guide your treatment. For example, an athlete who is reactive and in-season would benefit from isometric exercise. The thought behind this is that isometrics help with cortical inhibition. There have been studies to show immediate decrease in pain with isometrics. This is particularly important for the management of in-season athletes because isometrics can be applied before practices/games without loss of muscle strength, which would potentially be the case with isotonics.
Here is a great short 15 minute interview with Jill Cook on reactive tendons and degenerative tendons and how to treat them. In an ideal world you would want to structure your treatment plan like this:
Isometrics to Isotonics to Strength Endurance to Energy Storage and Release to Functional Exercise.
Basic Ideas to remember:
- Tendons are load bearing. Collagen takes the load. When the collagen matrix is disrupted, change in mechanical strength and capacity to take load can change.
- With injury to the tendon, cell proliferation occurs which can lead to proteoglycans causing swelling of the tendon. If overload continues to occur, the number of cells in the tendon will disrupt the matrix leading to neovascularization.
- With rehab, isometrics help with immediate pain relief. Work the entire kinetic chain for best results and improved assistance to tendon.
- Brian Schwabe, PT, DPT, SCS, CSCS
I always get asked the question: How do I get into a sports residency program? I remember asking the same question when I was in physical therapy school at Saint Louis University. While a residency is not the only way to become a sports physical therapist, it is in my opinion one of the best ways to truly learn about sports physical therapy. Here is my advice to those interested in pursuing one....
- Speak to as many sports residency directors as possible. Have questions for them and follow up with them. If you have the chance to meet them in person (conferences) introduce yourself. If you see them again, re-introduce yourself (but ask a question too).
- When you find programs that you're interested in, contact the current (or former) residents to see what their opinions are.
- Volunteer at as many athletic events as possible. I think this is crucial in showing consistent dedication. You may have to make some sacrifices. I remember driving to Butler to work on my brother and his football buddies one night and driving back to St. Louis early the next morning to go volunteer at a soccer tournament. If you really love sports PT like I do, this should be easy.
- Shadow and/or assist other members of the sports medicine team (doctors, strength coaches, athletic trainers, nutritionists).
- Know what your career goals are. You have to have a vision of why you want to be a sports physical therapist. Everyone says they want to do sports PT but don't have reasons why other than "It'd be cool". If you love football, check out southern sports residencies. If you love skiing or snowboarding check out like a Howard Head for example.
- Each residency emphasizes some components more than others. Some may emphasize research, others may not even have you do a research project. Some have on-field coverage at the college level, others have it just at the high school level. Find out what you value most in a sports residency and why those components fit your long term goals.
- Find out where the past residents are now. This is often overlooked IMO. If you are looking at a residency for a stepping stone then did the past residents move on or stay? If you think you may want to stay at that clinic or university did the former residents stay?
- Learn how to create a quality resume. Most PT schools do a poor job preparing students for how to interview and create a resume. I spent months learning about resumes, Linkedin, business cards, marketing and interviewing. I know many of my friends and even my colleagues Chris and Jim (The Student Physical Therapist) thought I went overboard in this area. Fortunately I knew that this was key. You could be the best PT candidate in the world or have better skills then the next guy but if people don't know who you are its tough to get that interview/job. Don't forget that you have to market yourself. Create your own brand!
- Finally, find a way to make yourself unique(your brand) to other candidates. You could do this many different ways. I have additional certifications and run a blog with Jim and Chris; maybe that made me more unique. Or maybe it was all the on-field experiences, etc. The point is your never going to know what the residencies think is unique so find your interests and pursue those within sports to the best of your ability (and time). This will help you in the interviews to explain why you are the best candidate for the program.
Good luck and don't hesitate to contact me for advice!
We all have our favorite influencers in the field. Here are mine that I most often read and learn from......
1. Stuart Mcgill
2. Charlie Weingroff
3. Gray Cook
4. Bill Hartman
5. Mike Reinold
Who do you follow?
Have you checked out the Return to Sport Functional Testing Videos? See them here!