Check your Neck before you Wreck your Neck

This one resonates close to me. It was the winter of 2013, excited for having cleared my board exam to practice as a physical therapist in the US, I had just landed my first job overseas. However, apart from being my first job this was not just anywhere in the US, I was to begin working in ‘New York City’ (Oh the dream, I recall). Not just anywhere in NYC, this office was in Manhattan, and if you know anything about that awesome city, it was not just anywhere in Manhattan, it was right in the heart of it all in midtown Manhattan. It came with its pressures, servicing a relatively high end clientele in a very busy office. And if there is one thing I could tell you about New Yorkers it is this, they are extremely driven, outcome oriented and unapologetically blatant. There was no ‘see me for 3x/week for 4 weeks to see results’ or ‘physical therapy effects take time to show’. They would have none of that spiel. No pressure right (haha)? Dead wrong.

Within the first week I crumbled under the pressure like a house of cards(though I didn’t show it to anyone). But that’s New York, if you have lived there, you’d know what I mean. Lest I digress more, part of the problem along with me just being a new kid on the block was that doing countless patient charts looking down for hours apart from the non stop physical work that comes with working as a physio, I started developing neck pain with a burning sensation down my left shoulder blade. With the passing weeks, it only got worse. The problem was that a lot of my patients were seeing me for more or less a similar problem spending hours on their workstations. If I couldn’t fix myself, how could I help them? I did what I could for myself and them but it was no walk in the park. A few years and grey hair have imparted some wisdom and learning.  Having seen hundreds of patients since then, I am now at a better position to tackle this issue. Below are some of the most common advice I give to patients/people who are at a risk of neck pain. A general advice though, these exercises and strategies are to prevent this unpleasant occurrence. If you are already in pain, You must seek professional help and not rely on the videos presented below. There could be many reasons why you could have neck pain and everything is not covered here.

We all have been in this position. It could be a busy day at work staring at your monitor for 8+ hours, staring down into your books pulling an all nighter before that big test, driving through endless traffic to get home ending up spending more time behind the wheel than you’d like to, maybe a car accident, a weight training injury at the gym or just sleeping wrong, very few have managed to escape this annoying and often debilitating condition. And just like if you hang around with the wrong company for too long, you’d find trouble, if the neck remains troubled and painful, chances are that the shoulders, upper back, arms and/or the head might feel some of that pain too. That’s right, often pain (or tingling/numbness) running down the arms, shoulder, upper back pain and/or headaches ‘might’ be because of that nagging neck pain. This is important so I’d like you to read that line again. However, like I mentioned before, neck pain is a complicated topic and beyond the scope of just one blog.

So today’s post and my first ever not for physios, but just people in general who might benefit from common advise we give to our patients is going to be preventative in nature. You probably won’t be surprised to know that a big chunk of neck pain clients that I have seen over the years come from just sitting wrong and too long, staring into a screen all day, snap chatting every few minutes etc than from car accidents (this might be different for the USA and Canada, there are a lot of MVA’s here).

So here are some exercises and strategies you could use if you are at a risk to experiencing neck pain or its related symptoms.

  1. Good Posture

2. Chin tucks

3. Chin tucks and extension

(If you feel an increase in pain, tingling, numbness, dizziness etc with every repetetion, stop!!)

4. If you look on one side for extended  periods of time, correction for that-

5.Thoracic extension

6. Neck stretches

7. Sitting posture and recommendations

(If you’re a image conscious New Yorker, I know your struggle. Don’t carry a sheet to work, shell out some $$ and get that lumbar roll, lol).

8. Setting timer/ reminder

9. Finally, don’t forget to MOVE!!

The key is to not think of them as exercises but as habits. Habits that are acquired and need to be incorporated into one’s  routine on a daily note. Foremost remember, if you are in pain, go see a good physio and get it assessed. Some of the above advice might not be right for you depending upon what is going on. If some of the exercises seem to increase your pain, stop immediately. Comment below if you have questions.

Until the next post and always

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

My current thought process on fixing Scapular Winging

Since my blog post on shoulder part 1 and 2 that you could read Here and Here, I have received a lot of questions on scapular diskinesia and recommendations on managing it. As I did not really cover it in my previous blog post, this blog post will be dedicated to just that.

Scapular dyskinesia, which means abnormal movement of the scapula can present itself in different forms but most commonly manifests itself as ‘winging’ of the medial or inner border of the scapula. ‘Winging’ means that the inner border of the scapula lifts off the rib cage. This could happen during a simple overhead arm elevation (open kinetic chain) or during an exercise like a pushup (closed kinetic chain).

In an ideal healthy shoulder complex, the scapula and the ribcage work like new lovers; always close to each other and ‘almost’ inseparable. The important task to kindle this romance is primarily bestowed upon the serratus anterior (SA) along with the rhomboids and lower traps. However, sometimes these muscles misbehaves creating some trouble in paradise in this relationship. The serratus anterior is supplied by the long thoracic nerve and on observation of winging in your patient, its prudent to check for some kind of long thoracic nerve issue by doing a neck screening.

However, in my experience if there is no H/O traumatic injury, systemic illness etc that might effect the long thoracic nerve; we might be dealing with an inhibited SA. In the past I would quickly get to work by strengthening SA with some of these classic exercises for strengthening.

  1. Theraband SA punches
  2. Theraband and pulley Rows
  3. PNF for lower traps
  4. ‘Y’, ‘T’ exercise.

This strategy could be a hit or a miss. It could work for some deconditioned/older patients who have general muscular weakness and strengthening the SA, rhomboids and lower traps  could fix the problems. Makes sense right. However, very often its a miss. Picture a client who is fit, could perform pushups until the cows come home, and is nowhere close to having muscular weakness but still shows signs of winging with arm elevation or with other CKC exercises. What do we make of this??

What this means to me is that the SA is unable to reflexively hold that medial border and inferior angle down on the rib cage during certain movements. In other words, its unable to provide the stability through the full ROM. It could be either an inhibited muscle unable to generate enough force to hold that shoulder blade down due to bad ribcage-scapula position or maybe a timing issue where its not firing well at certain periods through the ROM or more likely a combination of both. Hard to be exactly sure here.

But the key here is stability. In Human kinetics, I believe this means the ability of the body to hold the correct form through full ROM. And here lies the problem. Almost all the above exercises work on a single plane at about a 90-120 degree of arm in flexion. Hate to state the obvious but are they functional? Will they train the muscles to hold that scapula in a good fixed position on the rib cage in a overhead position in OKC exercises? My experience is mostly negative. How about you?

So where do we go from here? Below are some of the strategies that I have incorporated recently that I find extremely useful and better than the traditional exercises stated above. I demonstrate this in videos below on (1) myself  as I have some left scapular winging with arm elevation and (2) on my colleague and fellow Physio who is involved in competitive dragon boat racing.

In the video below, I do a Dumbell press of 40lbs with a plus (protraction) to demonstrate how my left SA struggles to hold the load compared to my right.

 

 

Below is a video of me doing an arm elevation test which demonstrates winging and how I correct it.

 

 

By pushing on the wall and protracting my shoulders, I am getting into a ‘locked ribcage’ position and reflexively activating my SA to hold that medial border down by creating a good congruent ribcage shoulder blade position. No theraband exercises to strengthen the muscle might be needed in my case. Just a favorable position for my SA to work reflexively.

Need another example? Sure. My colleague is a perfect example of a candidate who is not weak, in fact she is very strong and trains hard to compete in dragon boat racing. You think she’d have a weak serratus? Or that you could fix her winging with a theraband? I’m sure you know the answer.

 

 

Here I must report, she does not have any pain, just C/O weakness. Her winging does not seem to be excessively abnormal, it could be well within a certain normal range of winging which most of us might have but asymmetrical to the other side.

 

Now, I like to be a little more specific depending upon the clients needs when prescribing exercises to tackle scapular instability. To give a few examples, I’d prefer more OKC exercises for swimmers, volleyball players, rowers, cricket bowlers etc and CKC for gymnastics. Often, both as the situation demands. Here are some examples of my preferred exercises-

Closed kinematic chain-

  1. Cat Cow

 

 

 

 

2.  Quadripod knee lift

 

 

 

 

3. Plank plus-

 

 

 

 

4. Pushup plus

 

 

Open Kinematic Chain exercises-

  1. Kettlebell press supine

 

 

 

 

2. Kettlebell Overhead press- Now for some of my favorites, the press. Another excellent way to fix a winging problem if noted in a OKC movement is to load that pattern and let the shoulder fix the abnormal pattern by itself. Sound a little like RNT? I think so true. (While I don’t demonstrate winging with a press but more with arm elevation, I’m sure you have seen clients that show instability with pressing. If there is no pain, the best way to fix the instability is by… thats right, pressing but with a load. Try it out

 

 

 

Not convinced that pressing heavy load will fix shoulder winging/ instability during flexion? Watch the next video and reassess your thought process. Hopefully I can convince you to give it a shot.

Kettlebell press with opposite arm-

 

 

So, What do you think?

 

3. Arm bar-

 

 

 

Watch those muscle trying hard to reflexively stabilize. Its oddly satisfying.

 

Time to wrap this up guys, but before I leave you here’s something to ponder about. For long we have thought of scapular instability to be closely related to sub acromial impingement. Not trying to be the devil’s advocate here but recent research has shown that scapular instability might not have a major role in impingement or pain in the shoulder (https://www.ncbi.nlm.nih.gov/m/pubmed/24174615/?i=2&from=/16015238/related). However, I take this with a grain of salt and always keep in mind that there are fallacies and shortcomings with research and this does not mean that it cannot be a cause of the above. Alas, such is research. I will still work on fixing this problem with my patients as I am looking for symmetry on both sides of the body not just for injury prevention but also for better performance.

Hope this blog helps.

 

Until next time-

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

 

Reference-

1. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. Ratcliffe E, et al. Br J Sports Med. 2014.

MY CONTINUOUS LEARNING CURVE- REACTIVE NEURO-MUSCULAR TRAINING

Often introspecting my strengths and weaknesses within the realm of the rehab world, I had realized that one area that I needed to put some extra work into was to innovatively select and prescribe exercises for my patients. For a very long time all my attention and energy was focused upon learning new manual therapy techniques and improving my diagnostic skills. However, it didn’t take me too long to realize when I first started working as a physical therapist in NYC that simple SLR’s, knee extension and back extension exercises etc were not going to cut it when dealing with a relatively active clientele. I had to be able to prescribe progressively challenging exercises and to give clear cues and master the nuances of proper exercise execution. I was also in awe of some of my american physio colleagues  that I worked with. They were so easily able to progress or regress an exercise, tweak it to their patients needs and provide alternative exercise options to train a certain body part. I wanted to be able to do all of this and not be restricted to being just a ‘manual therapist’.

While on this path I came across RNT. It stands for reactive neuromuscular training. I have found it very beneficial and find myself prescribing it often. So lets start by describing the main principle behind it. We often find our patients falling into a dysfunctional movement patterns when performing exercises. To correct them,  we rely on verbal or visual cues. Often these cues are enough to correct the dysfunctional pattern. However, sometimes even though our patients understand these cues, the body is still unable to correct itself. We are so used to moving in a certain way that its hard to break that dysfunctional neuro muscular pathway that is embedded in our brain. This often manifests itself when our patients might say something like ” I understand what you are asking of me, but I just can’t seem to be able to do it” or “my body just refuses to move that way”. This can often lead to disappointment and frustration for both you and your patients. If you have found yourself in this position, RNT can be extremely useful.

Instead of relying on cues that might not work or may sometime be too complex and confusing, we can use external force to push the body even more into that dysfunctional pattern! Yes, you read it right, physios and trainers often describe this as “feeding into the dysfunction”. By doing that, you now let the body figure it out on its own what it needs to do to get out of that dysfunctional movement pattern. The body reacts to this external force by self correcting itself by firing the right set of muscles to seek stability and control. What a novel way to retrain a movement patterns and neuro muscular pathways. The external force can be applied either manually, using elastic therabands etc. They are plethora of possibilities and it gives you many opportunities to get creative. Below are two examples of applying RNT to two popular exercises- the lunge and the over head squat (OHS). Ok, so less writing, more watching. Here goes-

The Lunge-

 

 

 

The Over head squat-

 

 

These are just two examples to begin with. I’ll cover more exercises in a following blog post. What are your thoughts on this form of training? Do you incorporate this in your practice? If you are interested to send some of your own videos of using RNT in your practice and would like them to be featured on this blog in the following post, please leave a comment and we can talk more.

Keep the dialogue going, I like where this whole thing is headed! I have interesting thing lined up for you in the next few blog entries. Stay tuned and if you like the content, subscribe to get the next post to your email.

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

My ever evolving thought process on headaches Part deux

Sometime last year, I wrote a blog post on how I managed cervical headaches which you can find Here. Having often been at the receiving end of this mostly bad and sometimes extremely painful condition, I have played around with the position I suggested in my last blog post and I have realized that there may be an even better way to manage a painful acute flair up.

Before I proceed to discuss this position, I want to give full credit to my father for this light bulb moment. Here’s how it happened. He was suffering from some dull 2-3/10 pain at his right shoulder for a few years now which of course was intermittent. He would often also complain of tingling and numbness along the median nerve root on his right hand but only around the fingers and palm. So after some assessment I put him on a textbook McKenzie chin retraction and side bending program which did provide him relief but not completely. I noticed that as he wore a turban, the extra weight on the head along with the way it was tied, prevented him from getting into a retracted neck position. Now this, along with sitting at work for 8+ hours for six days a week (ya, that’s right, 6 days, maybe we should stop complaining about our long work weeks, maybe. Lol) was putting him in the dreaded rounded shoulders, blah blah blah … upper crossed posture. So apart from the exercise and manual therapy, I put him in my headache posture in supine hoping for the positive results that I was getting for me and some of my patients.

 

Alas, to my great dismay, this was only minimally helping him. He still complained of shoulder pain and in fact didn’t like to lie in that position for too long (he didn’t want to tell me it wasn’t helping so instead he just asked for a little break. He’s a solid dad). Now, I often saw him place both his hands over/behind his head on numerous occasions and when I inquired about it, he said this was the only position that made him feel better. This got my neurons firing; how could this simple position make him feel better when other advanced physiotherapy techniques had fallen short? This warrantied some investigation and the answer wasn’t too hard to figure out.

 

 

So lets try and break it down- what are some of the conmon postural dysfunctions that we suspect causes headaches, neck pain, shoulder pain and symptoms down the arm?

  1. Forward head and upper cervical extension
  2. Protracted rounded shoulders
  3. Rounded kyphotic upper and middle back region
  4. Downward rotated scapula
  5. Internally rotated shoulders.

On careful observation of  his favorite ‘shoulder pain relieving position’ (For the sake of simplicity, I will use the term-Dad’s position) I realized that this position was putting his body in the exact opposite of some of the above mentioned shoulder dysfunction.

  1. Minimum benefit in correcting forward head position.
  2. Dad’s position forces the shoulders into retraction
  3. Forces some extension at the thoracic spine.
  4. Arm elevation causes scapular upward rotation.
  5. Shoulders comfortably in an externally rotated position.

All of the above seem like thing we recommend to our patients all the time, no wonder his shoulders and arm were happy in this position. However, there were still a few things that had to be tweaked. I asked him to tuck his chin in and to avoid shrugging his shoulders so that the upper traps didn’t tense up. Even better, he reported after trying it a few times!!

Now if you have been following my blog posts from before, you’d know that I almost always consider a shoulder problem as a neck problem and vice-versa. They generally go hand in hand and are my ‘usual suspects’. So given this logic, I applied this on myself and some of my patients for neck related issues , headaches and got some extremely encouraging results. After all what better position to get the neck into retraction then in supine and gently force the thoracic spine into extension with a small pillow under it?? Adding heating packs could be the cherry on top if your a cherry person.

So with the explanation out of the way, I would like to present to you my modified position for cervicogenic headaches (also for neck and shoulder pain).

 

 

 

IMG_9059
My new preferred position for Cervicogenic headaches
IMG_9062 e
Watch out for excessive cervical extension which may look something like this!
IMG_9058 e
Tuck that chin in ‘gently’. Do not retract too hard
IMG_9060 e
Check for elevated shoulders like in the picture. Avoid this.
IMG_9061 e
Push down the shoulders gently.

 

So after a through assessment, if your patients fit the bill, I recommend you try it out and please let me know your thought on this subject.  As always,

 

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

The science of training (strength matters 2)

Welcome back,

Ready to go down the rabbit hole?

Today’s blog post is a follow up on the last blog post ‘Strength matters’ where I wrote about why its a great attribute to work on strength and its benefits. If you didn’t get a chance to read it, I recommend going through it first (You can find it Here). What is the difference between hypertrophy, strength and power and how to train for each of these attribute? Let me give this a shot-

Hypertrophy– it is a form of resistance training which primarily focuses on increasing muscular size. The by product of this is also an increase in strength no doubt. It is most often seen in the sport of body building where the competitors are judged based upon biggest muscular development, definition etc. This training can help athletes during off season to gain some mass and is can be utilized by athletes to jump to a higher weight classes in sports like wrestling, boxing etc. Also, a great option for patients recovering from injury or individuals who have no prior experience with weight training. This training ‘generally’ utilizes isolation exercises to focus on very specific group of muscles like dumbbell chest press for pecs, bicep curls for bicep brachii, tricep extensions for triceps, hamstring curls etc etc. Most of us our fairly familiar with this kind of training. Here’s a good example of someone training for hypertrophy.

 

arnold
Remember this guy!

In my opinion most of us are fairly comfortable with prescribing exercise for hypertrophy, but know this, the most ripped guy is not the strongest or fastest, he just has better muscle definition and less body fat then the rest. This does not dictate improved athletic performance.

Here is where it gets interesting!

 

Strength –  in its simplest definitions means the ability of the muscles to generate/produce force to overcome resistance. This form of resistance training is different from hypertrophy in a way that it helps build strength in a person without gaining a lot of muscle mass. In other words, here the primary focus is on getting stronger, not bigger (muscles). The intention of this training is force production and activation of neuro-muscular pathways. The strength is generally measured by the amount of weight a person can press (bench, overhead press), lift (squat, deadlift) etc. It is generally trained with compound multi joint movements which are specific to the athlete’s sports.  Strength training is given preference during off season (few months prior to games, series, matches) as it utilizes high intensities and loads. Here is a video of a strongman competition from Europe. Notice how these guys are not ripped and muscular like Arnold but they could outlift most of the bodybuilders. These are the men that break world records and are also summoned by Queen Cersei, queen of the seven kingdoms and the protector of the realm to be her queens guard (hope you recognize the giant from game of thrones. I’m sure he will put his strength to display this season cracking some more skulls).

 

 

Power– is work done per unit of time. Earlier, I would often use the terms strength and power interchangeably but know that both are not the same. The key difference is that power training requires generation of force as fast as possible (Strength training focuses on force produced but not the speed). This form of training has great benefits in athletic performance as it works on explosiveness. When does an athlete need the above mentioned power you ask? They need it the most in the first 2-3 seconds of a hundred meter sprint as soon as the shot is fired, the sprinter’s lower body must produce the maximum amount of force as fast as possible, they need it to produce enough speed to throw a short put or a javelin  as far as possible (upper body strength alone wouldn’t be enough), a batsman needs the upper body explosiveness to swing the bat hard and fast on a relatively slow/spin bowl to make it go the maximum distance and cross the boundary. There are many examples as most of the sports require some sort of explosive power. Some exercises that can be used to develop power are Olympic lifts (snatch, clean and jerk), plyometrics (box jumps, lateral hops, clap push ups, broad jumps etc) However, unlike hypertrophy and strength training which can be very beneficial for our patients and the average joe/jane, power movements are highly skilled movements (as you will see in the videos below) which require weeks if not months of training and are generally used to improve athletic performance. This kind of training does not carry as much benefits for the patient population. Here are a just a few examples of power exercises-

 

 

Understanding these concepts is great but lets discuss  how can we train for these attributes individually in terms of sets, reps and weights lifted. What I present to you below are NSCA general guidelines (slightly modified) that are followed by most of american college level strength and conditioning coaches, physical therapists and personal trainers.

Type of training             Load (%1RM)             Repetition           Sets

Hypertrophy                   65-85                           6-12                        3-6

Strength                           > 85                              < 6                          2-5

Power                               85-95                            1-3                         2-5

(Needless to say, one must calculate the 1 repetition maximum of a person before prescribing the above.)

I don’t know how you feel about all of this information, but the first time I was introduced to all of these concepts I was bewildered but extremely excited. I realized I knew so little and there was so much to learn. After all, up until I started to delve into this subject had someone asked me to train a high school basketball or cricket team for sports specific fitness, I would have most likely advised the team to go hit the weights in the gym doing bodybuilding exercises like bicep curls, leg extensions and other fairly unproductive isolation exercises along with some running around the cricket field to train cardio. This would be just very bad exercise prescription on my part which would barely improve any physical preparedness for these school athletes.  Lets be honest, in college we learn how to treat low back pain, knee pain etc etc but as physios we are often expected to prescribe training protocols to athletes and I know that a lot of us are not fully prepared for this. I also want  to reiterate that even though I have been harping about athletes, using strength training safely on our patients has tremendous benefits.

My hope with this blog post series is to help shed some light on this aspect of our work so we can be more multi faceted physiotherapists. We have just barely scratched the surface here, in the following blog posts in this series I would like to talk about what exercises have the maximum influence on increasing hypertrophy, strength and power and how they can increase athletic performance; training cycles, sports nutrition etc etc, the list is endless. Meanwhile, I hope this blog will stir some discussion which is mutually beneficial to everyone as I would love to hear inputs from other sports physios who are already in the trenches. Leave a comment.

As always my friends

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

 

Strength Matters

Hi everyone

When I was working as a physiotherapist in India, the bulk of my interventions were primarily electrotherapy based modalities in rehabbing people with disability. As I look back now, while there is a place for electrotherapy (but very little, in my opinion), overly relying on these modalities had a negative impact on my learning curve and overall development as a therapist. It steered me away from interventions like manual therapy, corrective and functional exercises strength training, injury prevention and improving quality of life. Anytime I was uncomfortable and didn’t know what was going on with my patients, electro therapy seemed like a ‘safe space’ to fall back on where I could tell my patients that the ‘machine would reduce the inflammation’ and to ‘give it some time’ to avoid questions I couldn’t answer or problems I couldn’t treat.

I started learning and utilizing the aspects of strength training, functional exercises and injury prevention when I volunteered with the strength and conditioning coach of Long island university’s athletic teams, learning from coaches training high level UFC fighters and boxers etc. Today’s blog post is dedicated to one such neglected aspect of overall rehabilitation which is  strength training. Not just pursuing the goal of getting our patients stronger but working on this attribute ourselves.

To build on this case further, before anything else, I would like to ask you all a question, who in your opinion will not benefit from getting stronger?

  • Some would say children (not you though, you know better than that). While there is scientific evidence to prove that loading a child with weights could be detrimental to the growing epipheseal plates, there are a lot of ways to incorporate strength training in children. Body weight exercises is a good example. Not only is it a good exercise to build strength but it also helps with learning skills. Learning requires repetition and this helps create new neuro muscular pathways. These pathways help ingrain movement patterns in them. After all, why are we able to brush our teeth so well with our dominant hand and struggle when we tend to do the same activity with the other hand. Do you think that the toothbrush is heavy that makes it so difficult? Of course not, it is because we have used our dominant hand a gazillion  times and that motor patter has now been mastered by our brain which makes the task smooth and effortless. By keeping them away from some sort of a ‘reasonable’ training program because  we fear it will ‘impede their height’, we delay the foundation on which we would like to build upon. We should look at China as an example, they start training their athletes at a very young age. The early years are spent perfecting skills without putting too much stress on the body and when the time comes these children are better prepared to handle exercises and out perform their peers. No wonder they win the number of gold medals they do at the Olympics.

 

  • Some might say older people (though I cannot imagine who). Lifting weights could be one of the best things that could positively affect grandma and grandpa’s health. We know some of the major effects of aging are sarcopenia (losing muscle mass) or weaker bones with older adults and what better way to slow down these processes than lifting weights? (No, not going on leisurely walks). While aerobic exercise has its benefits, its not the preferred form of exercise to mitigate the negative effects of age related sarcopenia or osteoperosis.

 

  • People trying to lose weight? I think they are excellent candidates for lifting heavy weights. When trying to lose weight, what we are truly trying to achieve is losing body fat. Instead of  slow paced jogging on a treadmill for 1 hour, how about doing high intensity sprints for 1 minute and then walking for 1 minute to recover and repeating it for maybe 15-20 minutes ( of course, rule out any pre-existing heart conditions). High intensity training seems to have a better outcome in burning fat as it puts a higher demand on the metabolic system and the intermittent slow and fast running causes heart rate variability which is  good training for one’s cardiovascular system. But we are missing the icing on the cake (sorry, bad example when we are talking about losing weight but I love chocolate cakes). Lifting heavy weights increases muscle mass and size. Now when someone asks you what that has to do with losing weight you are in a position to educate them that bigger muscles needs more blood and nutrients (energy) and this increases their overall metabolic rate. So people with more muscle mass tend to have higher basal metabolic rate even at rest. This means even when they are not working out, their bodies our burning more energy than a person who has less muscular mass.

 

  • How about athletes? No debate here. A good strength training program can help a football players outrun his opponent, gives the cricket fielder that explosive power to dive  higher for that ‘highlight match turning catch’, a batsman the rotatory power to smash that ball outta the stadium (and win that price money cheque $$$) etc, the list is endless.

 

  •  Even us physios.  Keeping aside the obvious benefits of strength training to meet the rigors of our job, we are more likely to be consulted  by fitness and gym enthusiasts if they know that their therapist shares their passion for working out. If the last time we entered a gym was in our second year of BPT education, it would be hard to convincing our patient who blew out his back squatting 80 Kilos that we are the right therapist for him; and rightly so, if we have never felt that load ourselves, how could we be in the best position to help others? After all, don’t we learn from experience? Here in the US/ Canada, I have seen this all to often. Runners will seek out therapist who were former runners, athletes injured playing a specific sport will look for therapists who were athletes themselves, people hurt in the gym lifting weights will try to look for a therapist who has some experience in bodybuilding type of exercises etc etc.

 

  •  How about that skinny guy trying to impress the girl in his class? Gaining a few extra pounds of muscle mass won’t hurt at all.

To know the nuances of strength training and to be creative in program design is paramount for a sports physiotherapist in India, because unlike north america and many other parts of the world, where athletes have a entire team of professionals like athletic trainers and certified strength coaches (I have written briefly about these professionals Here), we don’t have such luxury. We must be a one man sports medicine team. We must be the the guy who prescribes an off season strength and conditioning program to make our athletes run faster, jump higher, lift heavier etc and educate about injury prevention, and despite all this if the athlete does get injured (which most likely they will) we must now put on our therapist hats and get to our treatments. Hence, the importance of the  knowledge about good exercise selection and prescription cannot be overstated.

To cut a already long story short, almost everyone could benefit from lifting heavy weights. However, what are these exercises that make our patients functionally stronger, faster and can also be incorporated by athletes for their individual sports specificity. It cannot be bicep curls, triceps extensions, abdominal curl exercises, lat pull downs etc (these are more of body building exercises) that might help somewhat, but there are better ways. My intention with this blog is to take it in a new direction where I cover both aspects of what a physiotherapist might encounter,

  1. Topics which are purely based on physical therapy rehab, like new assessments and techniques that I find beneficial.
  2.  Topics on S&C (strength and conditioning) and exercise prescription for health and performance in otherwise healthy individuals.

In my following blog post, I will discuss about certain exercises, training principles  for building strength and basic terminologies that are often incorrectly used like hypertrophy, strength and power. Until then.

Pursue excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

My ever evolving thought process on Headaches

I have had a long standing history of suffering from headaches. Since I was little, I have had these bouts of headaches at least once a month, where nothing seemed to help. Nothing except medication. I had been to numerous  doctors and was diagnosed with migraine, tension  and sinus headaches. No matter the diagnosis or the subsequent interventions (I have tried quite a few of them; from different manual therapy techniques working on my trigger points/taut bands at the neck ,to steam inhalation for stubborn sinuses, proper hydration, breathing techniques in a sensory deprived atmosphere, Kinesiology tapes to making dietary changes) the one thing that has provided me relief over the years is, medication. Some of the remedies  have helped me a little but I’d be lying if I said that any of them took my pain away except medication.

As a therapist treating people with headaches I have often found a strong co-relationship between headaches and neck pain. Now for those of us in this profession, this is hardly a breaking news. There is tons of research out there that points out to the fact that a lot of headaches start from the neck and a lot of neck pain symptoms mimic migraine pain. Sure the neck muscles feel stiff and tight and you might find a few trigger points at the upper trapezius, levator scapula, the SCM’s and the other usual suspects. However, the challenge lies in the management of the condition when someone is experiencing an episode of headache.  In my own experience working with patients, when someone walks in my office with a headache, any kind of hands on intervention around the head, neck, TMJ, especially the aggressive kind has yielded me less than favorable outcomes.  I have done this before only to make matters worse and have also been at the receiving end of such treatment interventions. I didn’t like them.

Sticking to the mantra of ‘less is more’ principle as it relates to manual therapy, I have been using a lot of McKenzie treatment principles which has been a game changer for me in managing my own headaches and that of my patients. So now, when I see a patient with headaches, I prefer a more ‘hands off’ approach as I do not want to trigger an already sensitized neuro-muscular system. So instead I do a quick postural assessment and I try to correct what I think are the more common dysfunctional patterns that I have come across in people with cervicogenic headaches. The common pattern resembles our typical upper crossed syndrome pattern of –

  1. Forward head position with increased cervical lordosis and resultant upper cervical spine extension causing compression of important cervical nerve roots and sub cranial dysfunction.
  2. Increased kyphosis of the thoracic spine.

How do I correct them? If the headaches are sever and the patient is highly sensitized, I have them lay down in a supine position with a small pillow under the upper/middle back with no pillows under the head making sure that the chin is in a retracted (tucked in) position.  Now, some of your patients might tolerate this position better than others. For the geriatric population or with people with highly kyphotic, stiff thoracic spine you might want to consider giving them a few pillows under the knees to reduce the tension on the lower back by causing an anterior pelvic tilt (remember, making a person as comfortable as possible helps). Ask them to lay in this position for about 5 minutes. If their symptoms of headache/neck pain seem to subside with this position, chances are that their migraine headaches might be arising due to faulty posture and neck pain. I could and often do classic chin tucks to see if the symptoms subside but again in my experience in the trenches, the less I do, the better. Hence, I regress the chin tucks in a non weight-bearing position and leave them be for a few minutes in a nice quite room. Having your patients do diaphragmatic breathing in this position may be the icing on the cake.

 

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Needless to say, this is not the only method to manage headaches (not to forget there are different types of headaches). However, it is one of the easier ways to do it, very well tolerated by patients compared to the traditional ‘hands-on’ during an acute episode and also a good diagnostic tool to see if the patient will respond well to repeated loading strategies. As the symptoms subside, I’ll start doing some soft tissue work (always gentle, of course) on the hypertonic upper traps, levators and upper cervical muscles etc and follow with exercises. More on that on my subsequent blog on this topic.

I would love to hear your feedback and some of the strategies you use to treat this condition.

 

As always, pursue excellence

Abhijit Minhas

(BPT,MS,CMP,FMT)

 

In the spotlight- Mobility Bands

Having been on a hiatus for a while it only seems natural that my next blog post be on a subject that has helped me a lot not just during my practice but also has great clinical applications for manual therapists, patients, personal trainers etc. The edge mobility bands/ voodoo floss bands are great elastic compression bands to use as an adjunct to IASTM/ kinesiology taping etc to decrease pain, improve ROM and improve overall function and quality of movement. Good enough reasons to use them? I would think so.

To begin with, they are about 7′ in length and 2′ wide made of rubber. The voodoo floss bands and the edge mobility bands serve the same purpose just different manufactures. However, the distinguishing factor for me is the application technique. The voodoo floss bands, made famous by the rock star physical therapist ‘K-star’ is now a gym essential for crossfitters worldwide( FYI it’s ‘box’ and not ‘gym’ in crossfit lingo). The biggest advantage of this in my opinion is that people can now tackle ‘some’ of their own mobility issues without waiting to see a PT. I’m all for that, more power to the patients. However,  very tight compression can cause some discomfort and pain ( which sometimes is seen as a batch of honor by some in crossfit). Moreover, wrapping it too tight can hinder blood circulation to a body part limiting its duration of application.  The edge mobility band application by Dr. E resonates well with my principles. Very light compression of about 20-30 % stretch on the band ensures  minimum to no pain/discomfort. As mentioned in my previous blog posts, I prefer intervention that cause minimum pain and discomfort (I really follow the mantra ‘less is more’). Gone are my days of digging my elbows into sore tissues and trying to ‘release’ tight muscles. We now know that it is impossible to really release tissue in the body with our hands. If you stand behind the idea that one can cause true facial deformation or release with one’s hands, here’s  some food for thought.

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So how does it really work? Well, we honestly don’t know as there isn’t enough research evidence. But I will refrain from trying to convince the ‘EVIDENCE BASED POLICE’. To explain in the simplest possible way,  through the work of Butler and Lorimer Mosely we know that pain, muscle tightness etc are controlled by the central nervous system which locks the body down when it detects threat following an injury/trauma etc. This is the body’s own defense mechanism trying to protect the body from further harm. This threat perception could persist long after the injury has healed and cause the brain to put the body part on a ‘lock down’ manifesting itself as tightness/pain/dysfunction. With the band we try to modulate the pain perception to the brain at a neuro-physiological level. With the help of the intervention, as the brain detects no threat, it slowly ‘lets go’. At this point we see some of the almost magical effects of the mobility bands. Very similar to the modern concept of manual therapy and kinesiology tape (Rocktape is my brand!!). It is believed that the mobility band/floss band also helps with better skin gliding by stimulating mechanorecptors which helps with range of motion.

Here are three quick video of my hip internal rotation pre and post using the floss band. And yes, I am pretty restricted in my hip IR.

The few negatives of using the band are sometimes it could pull on patient’s skin or hair if used too aggressively (you know how I feel about that) and cause some discomfort. Also, rolling it back up after using it on a patients seems like a humongous task for lazy therapists like myself. It should also not be considered a panacea for all conditions. My favorite part about using the band is you could play around with it; with your patient laying down doing single joint passive movements, to performing functional exercises or during mobilizations etc.

In my limited imagination, the analogy that comes to my mind is that of an artist drawing on a canvas. You are the artist, if you will, your patient is the canvas and armed with your band that doesn’t come remotely close to resembling a brush, the possibilities are limitless.

Feedback is always appreciated.

Pursue excellence

Abhijit Minhas

(BPT,MS,CMP,FMT)

My two cents on Kinesiology taping

Healers

Hope you had a great week and abolished some major pain and misery wherever you are. Keep up the good fight. Today I’d like to discuss one of my favorite tools I incorporate in my practice every day. Not only has it helped my patients immensely but it has taught me a valuable lesson which has changed the way I treat my patients (more on that later). If you have not guessed it by now my opinion is biased in favor of these colorful pieces of tape. Like most, I first saw it on TV watching sports sometime in the summer of 2010 and like most I was intrigued and confused by it at the same time. To convince myself it was more than just some athletes attempt at fashion I decided to go for my first workshop and have never looked backed ever since.
I learned taping from two different schools- K-active (European based) and Rock Tape (American). Rather than stating their differences I would say the two schools of taping have more similarities in principles then differences. Both taping techniques have no set protocol to tape like the original kinesiology tape which teaches taping from origin to insertion and vice versa. This meant the direction of my taping is based on my assessment and not dictated by some preset protocol (I have tried that too, not with the best results for me and my patients).

Taping for neck and shoulder pain.
Taping for neck and shoulder pain.

Reasons why I love kinesiology taping (rock tape) and incorporate it in my practice –

1. If manual therapy and soft tissue work is a big part of your treatment, taping helps in locking down any progress that you make with the patient who might not be very compliant with home exercise program. It’s like taking part of your therapy home with them.

2.The assessment that I learned from K-active and tweak taping @ rocktape is a quick assessment (does not take more than 1-2 minutes) that helps me differentiate between pain originating from soft tissue structures and muscle guarding (most of the times) compared to patho-anatomical and bio mechanical reasons like disc herniation, nerve compression, arthritis etc as seen and exaggerated by MRI’s and other diagnostic imaging (less common).

3. It’s a great tool to quickly reduce pain, increase ROM, control swelling and bolster movement. I love the fact that it does not restrict movement like rigid elastic taping.

4. The teaching principles of K-active and rocktape resonated well with me as they are based upon modern concepts of manual therapy and movement science and incorporate the work of gray cook, janda, sharmann, lewit, Tom Myers and likes. I love the fact that it teaches us to tape movements over individual muscles and function over structure.

5. It generates great interest among people when they watch someone sport a colorful tape. Rest assured people will ask you or your patients about it and kinesiology tape might help bring in more business for you ( at rocktape you could also design your own custom print on your tape- a brilliant marketing idea but a little pricy).

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I was clearly too excited for this course.

If the above reasons were not enough, one of the best things that came out of learning this technique was how it influenced the way I perform my manual therapy and soft tissue work. Gone are my days of deep tissue myofacial release and elbow kneeding to alter fascia ( hopefully, we now know we can’t alter fascia). Not only did these old techniques leave some of my patients with soreness and often times bruises and discoloration, it also took a toll on my hands (mind you I am a new professional and I’m in it for the long haul). It made me believe that if a simple tape on skin could alter pain perception and improve movement, I didn’t have to dig my hands into my patients skin. light pressure during soft tissue manual therapy works way better than deep pressure for me. If you haven’t incorporated this in your tool box yet, I highly recommend it. As always comments are welcome and if you like the content please feel free to share.

Pursue Excellence –

Abhijit Minhas PT

(BPT,MS,CMP,FMT)

MASTERS IN THE USA- Are you confused? Part 2

Sorry for the short hiatus people, but I am back with my first ever guest blog post by my fellow PT and a good friend Pulatsya Maliwad. He currently resides in charlottesville in the state of Virginia  and did a good job on going over his curriculum in the university of Pittsburgh. Here’s what he has to say-

Hi Friends,

First of all, I would like to thank my dear friend  Abhijit Minhas to provide me an opportunity to write a blog about my experience pursuing masters in physical therapy. A little about myself first, I am physical therapist and I have earned my masters degree of M.S.P.T. from University of Pittsburgh and B.P.T from M.S.University, India. I am here to share my experience pursuing M.S.P.T at the University of Pittsburgh.

As Abhijit has already mentioned in his blog, it is true that there are not many universities providing Masters in physical therapy course in USA, and as per my knowledge these are the available master’s courses-

1) University of Pittsburgh, Pittsburgh, PA.

• Course – Master of science in Rehabilitation sciences

• Concentration – Musculoskeletal Physical therapy or Neuro-muscular physical therapy

2) MGH institute of health professionals, Boston, MA.

• Course – Master of science in physical therapy for international students

3) Loma Linda University, Loma Linda, CA.

• Course – Master of science in rehabilitation

4) Oakland University, Rochester, MI.

• Course – Master of Science in physical therapy.

My program at University of Pittsburgh in Musculoskeletal physical therapy is a 1 year course with 3 semester starting from August to July of the following year. This course is a little hectic as the school has tried to shrink a 4 semester course into 3 semester pattern and also it is a little expensive tuition wise . I finished my course in August 2011 and I paid almost 50,000 USD for a one year course (I apologies for the jaw drops). And I might be wrong but the university has already increase tuition fees by 5000 USD so far ( again I might be wrong, please contact university for accurate information). Yes, the tuition is a little steep but it is worth the money. The things that I learned in the area of physical therapy in this course, I wouldn’t have learnt anywhere else. Basically, the musculoskeletal course is more leaned towards Manual therapy techniques in physical therapy but that is not the only thing it entails. I also had one neuro-muscular subject which taught me how to get approximate area of brain damage or level of spinal cord injury just by knowing patient’s symptoms. Yes I know what I am writing, but that is true. Many Neuromuscular masters PT’s will say that is not a big deal  but as an Orthopedic PT, it simplified a very complex topic I always had a tough time wrapping my head around. Well getting back to my favorite topic, Orthopedic course is basically divided into three major divisions – Upper extremity, Lower extremity and Spine. (I think that wasn’t very hard to guess!!!!)

1) Upper extremity

The part of Upper extremity is covered in the last semester. The course covers basic anatomy and bio mechanics of shoulder, elbow and wrist. Then it leads to common disorders of every joint and pathology behind it  followed by  the treatment part which majorly includes postural correction (Abhijit has already discussed this part very effectively), exercises and manual therapy. Now, whenever I heard about manual therapy in India, I always thought of Mulligan or Mckenzie. But that is far from the complete picture. There are different schools of thoughts and not all of them are supported by evidence which is a big deal in USA. So most of the techniques I learned were from different concepts and were all evidence based.

2) Lower extremity

This part is taught by Dr. Fitzgerald – a Knee genius. He has spent all his life in research for knee rehabilitation. His midterm exams still wake me up at night but all in all he was a great guy and his knowledge is amazing. He teaches only knee joint and for hip and ankle joint he either calls a specialist to teach or asks his teaching assistance. Once again, the course includes same stuff as UE like basic anatomy and bio mechanics leading to discussing different conditions and treatment options. One of the most interesting thing I learned was different patho-mechanics during daily activities and sports leading to injuries. This course covers common outpatient injuries but does not include orthopedic inpatient population found in hospital i.e total hip or knee replacement, fracture cases or congenital deformities etc.

3) Spine

This is my favorite part. At University of Pittsburgh, the spine is covered in two semesters.Cervical and thoracic spine in the last semester and Lumbar spine in the first semester.  These semesters deepened my understanding regarding bio mechanics of the spine. Honestly speaking, after my B.P.T. and mulligan workshop I knew only few treatments for low back pain – Short wave diathermy, Back extension exercises and Mulligan MWM’s. Sometimes I had no idea why I was even giving those treatments. But the course empowered me to perform better, more through assessment of patients with back pain complain and decide which treatment will get rid of the cause of pain. So in simple words, I learned to treat cause of pain instead of treating a symptom.

So this is just a brief review about what is covered in the orthopedic physical therapy track of the course. Other than these there were other subjects like

1) Falls and balance dysfunction (small portion covered in Musculoskeletal PT program but a major subject for Neuro PT program) covering causes of falls, different test for falls risk and treatment options.

2) Research subject including how to do a research, types of research and crazy mathematics about data.

3) Case presentations (kind of boring sometimes), and also an options to get one elective course for which I took cardio-pulmonary physical therapy (as I was always interested in pulmonary drainage techniques and have done them in hospitals in India. In USA they have respiratory therapist for it so mostly we don’t need to worry about suctioning or draining patient’s lungs).

I hope my blog will provide you with a brief idea about the M.S.P.T. course  offered at University of Pittsburgh, and if anyone has question please put it in comment box and I will try my best to answer your questions. One again thank you Abhijit for inviting me to write a blog and I would like to wish you good luck for your new endeavor.

Thank you

Poolatsya Maliwad PT

(BPT, MSPT)

 

Pulatsya Maliwad

I would like to thank Pulatsya for taking the time out of his busy schedule to contribute a very informative blog in this series. You can reach him at poolatsya2007@gmail.com. Hang tight while I try to get other great PT’s to write their experiences in this series.

Pursue excellence-

Abhijit Minhas PT

(BPT,MS,CMP,FMT)