Most of us think about exercise in this way. The same goes for home exercise programs given to patients in physical therapy.

This approach assumes that the body will make positive adjustments via continuous performance of an activity. While this may occur to a certain extent, the body will make these adjustments much faster and more effectively when sensory awareness is appreciated.

Motor output, in this case movement, is a reflection of the sensory input given to the body. For example, if one were to touch a hot stove, pain is detected (sensation) and the individual withdraws his or her hand (motor output-movement).

Similar interactions in response to less extreme stimuli occur with everyday movement. When walking the pressure of our body weight is sensed through the arch of our foot during the stance phase which triggers a cascade of events to advance the body onto the opposite leg. The arch of our foot is just one “reference point” that the body detects to trigger an appropriate reaction.

Being aware of these “reference points” during home exercise programs allows the brain to detect what is happening with greater ease. When the brain is in tune with what an individual is trying to accomplish, learning occurs and the objectives of the activity become more en-grained.

Next time you perform your home program, ask yourself, what is working? If you are standing, where on your feet is the majority of your bodyweight? If you are sitting, where is your bodyweight?

If you have been to physical therapy you should know the correct answers to these questions in great detail. Now you simply have to remind yourself to ensure that the body is continuing to get proper feedback so that optimal movement can take place.

I am very fortunate to work in the athletic physical therapy setting in Bethesda, Maryland. The Washington, DC region is full of incredible, intellectual people that often have very impressive jobs and lifestyles. As such they are often “type A” personalities (probably why we get along) that take a vested interest in their bodies and the condition that brings them to me as patients. Being educated and knowledgeable about the source and cause of their pathology, as well as understanding what they can do about it is important to this population
This makes my job that much more fun, as I love to “talk shop” about pretty much anything in the clinical world. Furthermore, a well-informed patient is typically very compliant with his/her plan of care that consists of an appropriate home exercise program, and suggestions for positive changes in their day to day lifestyles, such as workplace setup, standing position, sitting position, sleeping position, etc.

Despite these positive attributes, people with these personality traits do come with their own set of challenges. As alluded to previously, “type A” individuals, often seen in Bethesda, MD and the greater Washington, DC area have achieved a great deal of professional success, thus are typically very hard workers. As such, they often struggle to manage the stress associated with their jobs which is even further compounded by any of the usual stressors dealt with in daily life.

The human body perceives stress collectively. This can be physical, mental, emotional, etc. which can result in an overly sympathetic, or “wound up” physical state. A highly sympathetic state of activity is fine unless it becomes a fixed state. Unfortunately this is often what happens with a chronologically stressed individual. These folks can seem very hyperactive or “on edge,” often have accelerated heart rates, hormonal imbalances and a long list of bad stuff. The body is essentially in overdrive and it is unable to turn things up further to adapt to a current injury.

In athletic physical therapy, learning to “turn off” the body is often the first step towards getting pain free and functioning at a high level. This results in an improved state of systemic (total body) balance, thus enabling the body to properly recover from the current pathology.

So how do you turn things off?

At Cohen HP the first thing I often teach my patients is how to breathe properly. This will stimulate the parasympathetic branch of the autonomic nervous system (the chill out and relax part of it) thus allowing the sympathetic branch (fight or flight) to calm down.

Once this is achieved it is often necessary to teach the entire body how to flex. Increased stress and sympathetic nervous system activity commonly results in extension of the body which makes us very rigid and incapable of moving properly. A great example of an activity to assist with this is the 90-90 hip lift, popularized by the Postural Restoration Institute (look them up for great videos on this exercise). In this activity you lie on your back with your hips and knees flexed at 90 degrees, a towel roll or ball placed between your knees and your feet flat on a wall. When in this position you simply breath in through your nose and exhale through your mouth as you perform a pelvic tilt so that your tailbone is raised slightly off the floor. Be sure to dig down with your heels rather then press your feet into the wall so that the back of your thighs are engaged, not your hip flexors. Hold this position while you take 4-5 deep breaths in through your nose and out through your mouth.

After a simple activity such as this is learned things are stepped up further to more closely replicate normal functioning of the human body.

Implementing activities to achieve more balance can also be implemented into your day to day life. These activities must be something that you enjoy and help you relax. Some examples include meditation, relaxing walks/hikes or simply spending time enjoying friends/family. Anything that allows you to decrease the stress of the “weekly grind” will help create balance within the body and enable everything to function with greater ease.

In other words, go get out there and enjoy life!

For more information regarding this topic or any others please feel free to reach out to me via the contact information provided on the website!

This post is inspired by an Olympic lifter that I work with. She has been experiencing chronic lower back pain which did not begin until she began intensely training. We have been working on a great deal of things to address the cause of the “pinching” she gets in her left lower back which has been successful in eliminating her pain.

I recently was speaking with her regarding how to prevent her pain from re-occurring in the future and the topic of movement variability came up. Many sports require and consist of a great deal of lower back extension which compresses the lumbar spine and can lead to lower back pathology/pain.

My advice was not to avoid lumbar extension when in the gym as this is necessary for specific phases of her lifts but instead to ensure that she is not getting stuck in this pattern. Total lower quarter extension (lumbar, hip, knee and ankle extension) is required to perform the acceleration phases of her lifts however must be capable of flexing (ie. Doing the opposite) in other situations.

This is essentially the premise behind movement variability. The ability to move in many different ways is an extremely valuable quality. If we can extend, then we also need to be able to flex. If we can rotate left then we should be able to rotate just as easily to the right.

Our nervous system perceives repetitive movements and postures as stress. As a result neuromuscular tone will often be increased causing people to feel tight or uncomfortable. These repetitive movements will consistently stress the body in the same way, breaking down tissue over time. Just imagine a paperclip continuously being bent in the same direction.

The Olympic lifter I work with must be able to turn the extension “switch” on for maximal power development however must then be able to flip the switch off as she leaves the weight room. If she is unable to do this then she will be consistently stressing the same areas of her body, regardless of her setting and injury will eventually result.

Clinicians will often recommend simply avoiding an activity to prevent pain however this rarely works when this activity is an individual’s passion. Many times this is also unnecessary. Simply having many different options for movement when outside of the individual’s sport/activity will allow for stress to be spread throughout the body, rather than be centered in one area. This will prevent individuals that are at a high risk of overuse injuries, such as Olympic lifters to have successful careers.

“I just need you to dig into this spot, right here.” “This needs to pop, then I’ll feel better.” “It just needs a good stretch.”

Does this sound like someone you know?

I am constantly hearing this from patients when they initially come to see me. They present with pain and an increased sensation of tension and stiffness that gives the impression that it will be relieved with soft tissue massage, manipulation or stretching.

Nearly all clinicians, coaches and trainers, myself included are people pleasers. As such we want to make our patients/clients happy and oblige their requests. However it is essential to ask ourselves, why? Why does he feel that he needs to “pop” his back to feel better? Why does she feel she needs a weekly massage to manage her discomfort?

An area of the body does not simply become tight or stiff. Soft tissue adhesions and trigger points do not just magically develop. These things occur when the body is moving poorly. If an area is being abnormally stressed during a commonly performed activity such as walking or running the brain will increase muscular tension in this region to protect from a more significant injury. The real magic is discovering where these movement compensations are occurring via a comprehensive evaluation.

Now don’t take this the wrong way and think that I am saying manual therapy is bogus. Manual approaches are often warranted and I perform a great deal of manual therapy in my own practice. However blindly performing such techniques without having a reason to do so is negligent.

At Cohen HP we utilize dry needling as a soft tissue modality (among many others); however it is only implemented with the ultimate objective of improving movement and function. The immediate goal with this could be to reduce pain which would decrease soft tissue guarding. Perhaps the short term goal is to minimize soft tissue adhesions and tension that cause mobility restrictions. Both of these immediate goals allow the clinician to coach proper movement by gaining a full range of motion to work with.

Optimal movement patterns can now be restored. When the body is moving optimally joints are being stressed normally, soft tissues are being shortened and lengthened through a full arc of motion, and a neurologically rich environment is introduced which allows for optimal motor learning. The sensorimotor system will now be constantly adjusting to full ranges of motion which allows for mastery of optimal movement. Movement compensations are no longer necessary however these old motor programs are still present in the brain so they must be watched out for. The new and improved ways of moving will allow the brain to develop new motor programs or patterns (software) to control the body (hardware).

Often times the first step of utilizing manual therapy can be skipped altogether. If the patient/client possesses no significant soft tissue abnormalities, mobility restrictions or abnormal pain responses then treatment time would be best utilized elsewhere. This allows for the clinician/coach to immediately address the root cause of symptoms.

Weekly massages, multiple sessions of getting “adjusted” and constantly feeling the need to pop joints should not be essential. Having a massage is a great thing however if you fall apart without it then a larger issue is staring you in the face. All you have to do is ask why!

In my previous post I wrote about the how the word tight is a useless symptom description. This sensation of “tightness” is due to musculotendinous shortness or stiffness. While shortness is physiological and more difficult to address, excessive stiffness is correctable via movement and exercise.

First it must be understood that a degree of stiffness is acceptable and often desired, specifically within an athletic population. An acceptable amount of stiffness allows athletes to be elastic, generating maximal power with minimal effort. This often what separates great athletes from average joes and is something coaches and clinicians must be sure to keep in mind.

In other words, do not assume that an area with a degree of stiffness must be mobilized or stretched, as these athletes rely on their stiffness (Remember, do no harm!).

However problems occur when stiffness is excessive, altering alignment and leading to dysfunction. The most effective plan of care is achieving tissue mobility through movement.

Tissues often become stiff due to poor stability, motor control and movement patterning. A lack of stability results in musculotendinous structures becoming stiff, providing the stability that is not present from the appropriate areas. As described in my previous post, the hamstrings become stiff in response to a lack of proximal stability at the lumbo-pelvic region. The pelvis may migrate into an anterior pelvic tilt due to poor pillar stability resulting in an unstable proximal hamstring attachment at the ischial tuberosity. Therefore the central nervous system increases hamstring tone as a protective response in an attempt to provide stability through stiffness.

Traditional stretching will not address this issue as the cause of excessive stiffness is due to a lack of pillar stability/motor control.

The most effective method in treating this issue is achieving mobility through movement. For proper movement patterning to possible, the body must be able to dynamically stabilize through the available range of motion. Therefore the smaller, instrinsic musculature will function as it designed, activating before the prime movers to provide proximal stability, enabling the larger muscle groups to do their jobs and generate the force for movement.

For shoulder movement to be performed appropriately the trunk (transverse abdominus, multifidi, pelvic floor musculature, etc.), scapulo-thoracic, and rotator cuff musculature must activate to create a fixed point (punctum fixum for you DNS and PRI practitioners) allowing for the deltoids, pectorals and/or lattisimus dorsi to generate movement.

An athlete may have excessive hamstring stiffness in response to poor pillar stability and dysfunctional hip extension patterning (think sprinting). Similar to the previous example, the trunk musculature should fire first, providing a stable base for the lower extremity to drive off of. With a stable proximal attachment, hamstring tone is decreased allowing for appropriate gluteal activation to generate hip extension. Therefore hamstring dominance is decreased, as well as further hamstring stiffness related to overuse.

Correcting one’s dysfunctional movement patterns requires appropriate joint stability and associated muscular tension. Therefore teaching an athlete to properly squat, lunge, roll, etc. normalizes his/her subjective complaints of “tightness.” The athlete is forced to dynamically stabilize through the range of motion addressed in the pattern, thus will keep any mobility achieved during the pattern.

For these reasons, I rarely perform any static stretching with any of my athletes/patients. The majority of manual treatment techniques that I perform involve Dry Needling or ASTYM to normalize muscular tone, desensitize nerve endings, decrease swelling and/or stimulate heeling. Exercises then follow these manual techniques allowing the true cause of the tissue dysfunction to be addressed.

I may perform a Dry Needling treatment on an athlete’s glenohumeral joint capsule or any associated musculature that is contributing to mobility restrictions or abnormal joint arthrokinematics before following it with closed chain exercises such as downward facing dog or side sits to bear. This results in proper scapulothoracic and glenohumeral muscular co-contraction to be achieved, resulting in maximal glenohumeral joint congruency for maximal weight bearing/functional capacity.

Therefore next time you are feeling “tight” or hear an athlete/patient report these complaints think movement, not stretching!

As you can see above this head/neck position can not be a good thing.

Most clinicians and coaches understand the importance of achieving and maintaining an optimal spine position during exercise and daily life. Appropriate lumbo-pelvic posturing is often the initial focus towards correction however this will often take care of itself (or make correction much easier) when optimal cervical spine posture is achieved. Many rest in upper cervical extension and lower cervical flexion, manifesting as the typical forward head posture often seen. This results in a lack of joint centration or stability throughout the cervical spine, leading to overactive upper cervical extensors/scalenes and sternocleidomastoids, while the intrinsic stabilizers are inhibited, most notably the deep neck flexors.

The cervical spine is an area rich with proprioreceptors, and therefore plays a large role in the sensorimotor system. Afferent information related to cervical positioning is relayed to the central nervous system resulting in a predictable motor response, whether functional or dysfunctional.

When the cervical spine is positioned appropriately, balanced activity between agonists/antagonists, flexors/extensors and tonic/phasis muscles are achieved and the rest of the body follows suit.

The body also follows accordingly when the cervical spine is in a dysfunctional position. The forward head posture described previously occurs frequently with those sitting at a desk for extended periods of time. The individual is looking at a computer screen resulting in a tendency for the eyes to drift forward as gravity takes over and he/she continues to slouch resulting in a chain reaction of increase spinal flexion and posterior pelvic tilt (correlating with stiff hip flexors and inhibited glutes among a host of other issues).

This is often most exaggerated in the weight room with squat variations and Romanian Deadlifts (RDLs). Excessive cervical extension is commonly seen with squatting due to the old saying of “head up!” and it is often further increased with RDLs as people wish to keep their eyes level with the horizon. These dysfunctional cervical positions result in over-activation of the global extensor system, most specifically the paraspinal musculature leading to a host of other dysfunctions/pathologies.

Those that lack appropriate pillar strength/stability may require this for stability to perform these exercises with load as their internal stabilizing system is shut off. Therefore training of appropriate pillar stability, beginning with correcting the breathing stereotype is often necessary while paying particular attention to cervical positioning.

However others may simply require cueing, specifically for those coaches working with a group of athletes to “pack the neck.” Packing the neck is similar to the sensation of creating a double chin. The athlete/patient should feel as if someone is pulling him/her vertically from the hair on top of the head. When standing this would be towards the ceiling and when performing a correct hip hinge it would remain in line with the spine.

A helpful tool can be to give an athlete/patient a ball or some object underneath the chin, having him or her hold it there by performing a small chin tuck while elongating the cervical spine. This works tremendously with RDLs where this is most exaggerated and feels un-natural to many.

Correct cervical positioning leads to optimal joint centration, allowing the rest of the body to correspond accordingly resulting in improved activation of the internal spinal stabilizing system and overall movement patterning. Next time you are working with someone displaying dysfunctional cervical tendencies, have him/her pack the neck, waking up the central nervous system to make it easier on you in correcting the remaining dysfunctions. Final step, have the athlete/patient maintain this position throughout the day!