No More Static Examinations
In school I was taught to lay someone down to initiate my evaluation. I quickly realized in practice putting someone in a static, non-weight bearing posture was not getting me good information. Static examinations have their place but not until after a movement assessment looks at the entire system. Looking at the neuromusculoskeletal system as a whole is truly the keys to the kingdom.
This type of movement assessment is analogous to taking someone’s blood pressure. We use the blood pressure as a screening tool to see if there is an underlying problem that needs further evaluation. If the screen comes out abnormal (ie. 220/160) we then take a closer look to see the cause of the abnormal blood pressure.
I think of my movement assessments the same way. In fact, I look at range of motion testing this way as well. If the range of motion testing is abnormal in a weight bearing posture, then I look at it non-weight bearing to see if there is change. Ultimately, this information allows me to break down the movement dysfunction into three distinct categories:
- 1. Joint Issue – Is the joint fixated and needs to be manipulated?
- 2. Soft Tissue – Are soft tissue structures truly shortened and need to be lengthened?
- 3. Neurological – Is the brain not communicating with the tissue well or is the brain asking muscles to tighten for artificial stability?
Understanding how a person moves in space will help identify areas that need to be mobilized, stabilized, or strengthened. Figure 1 shows my progressions from assessment through treatment. If you notice the base of the treatment is assessment that gets broken down into the three components or silos (joint, neurologic, soft tissue).
The power of understanding where most of the dysfunction is coming from allows me to maximize my treatment in the office. In addition, knowing what silo is the common denominator gives me confidence in prescribing a home exercise program.
Tools of the Trade: Home Exercise Prescriptions that make sense
We all know how important it is to get patients actively involved in their own recovery but patient compliance for their home exercise prescription is tricky. Will the patient remember what you showed them in the office? Will they ‘find time’ to do it. Do they really care about getting better?
Explaining the goal of the home exercises is important. Having the patient understand the prescribed exercises are augmenting what is done in the office is vital. Overall the goal of home exercises is to decrease treatment plan length and improve outcomes.
The provider can help the motivation if they make the exercises simple and easy to follow. In addition, keeping overall volume (reps, sets & resistance) low will help as well. Correlating the home exercises with the primary treatment goal helps to maintain consistency between home and office care.
So how does one know what home exercises to prescribe?
If I have a patient who is presenting with lower back pain and can’t touch their toes during the movement assessment because their hamstrings are too tight will be prescribed foam rolling and stretching for their hamstrings with lengthening (eccentric) exercises to groove the pattern. Patients love foam rollers and are easily convinced to add them to their arsenal of home care appliances.
Consider using kinesiology tape after any joint or soft tissue mobilization and before therapeutic exercise. The results are two-fold. First, the brain will now interact with the taped area at a higher level for as long as the tape is on (and possibly longer). This increased awareness of the brain expands the time frame in which the motor control enhancement that was achieved with the joint and/or soft tissue mobilization. Second the patient sees the tape on the body and remembers they have to do their part (home exercise) to make the rehabilitation process proceed swiftly. Taping can also provide a ‘trail map’ on the skin of where you want the foam rolling to occur. See Figure 4 for the ‘trail map’ of the Performance Back Chain that the patient may need to foam roll to improve toe touch range of motion.
After taping, I used a term ‘grooving the pattern’. What is grooving the pattern? In my opinion, anytime we put more mobility into the system we have to apply some resistance training to let the brain adapt this new mobility. Without this crucial step, the brain will just begin to tighten the structures again searching for stability through muscle tightness. I prefer to use eccentric (lengthening) exercises to accomplish this task. This gives the target tissue lengthened resistance which allows the brain to adapt to the new range of motion you have provided.
An example of an eccentric hamstring exercise that could be combined with hip mobility and hamstring foam rolling is a single leg dead lift. If the patient presents with joint restriction, prescribing banded mobility of the joint can augment the joint manipulation that is performed in the office.
In future articles, I will break down certain areas of the body and conditions and discuss how I attack them from one of the three silos. Keeping your home exercises simple and relevant to your treatment in the office will increase patient compliance and improve outcomes. Patients love when outcomes improve because they can get back to activities that they love faster and you look like the hero.
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