The thoracic spine (T-Spine) is an interesting part of the body. In recent times it has taken the brunt of the modern sedentary lifestyle of being hunched over on a chair and working on a computer for hours in a day for many months and years. These modern sedentary lifestyle changes and new work/office setups have had implications on our musculoskeletal system. What is interesting is that the T-Spine itself presents only with a few symptoms like mid back myofascial pain, stiffness, loss of mobility etc. However, other joints in proximity of the T-Spine are affected adversely due to this. Here is a list of problems we often see in an physiotherapy office that our closely related to an excessively stiff kyphotic T-Spine.
Shoulder impingement- An excessively kyphotic mid back places the scapula in a downwardly rotated, anteriorly tipping and protracted position. This position of the scapula has shown to decrease the sub acromion space in the shoulder when performing overhead activities leading to a common problem we see often; shoulder impingement/pain. Try this little test, try elevating your arm up to the maximum flexion elevation with a straight Tspine and shoulders pulled down and back and then with an excessive hunched over position. Which one feels better and which is worse? See the video below and try it yourself.
Neck pain- A kyphotic hunched over posture tips the head (weighing about 10-12 lbs approx.) anteriorly and extends our line of sight downwards to the floor. For compensation, we tilt the head backward which increases Cervical lordosis and causes upper cervical spine to go into extension to have a regular straight field of vision. This causes increase tone/tension in the cervical extensors often compressing the greater occipital nerve and other important cervical structures causing symptoms like neck pain, headaches, radiating symptoms etc.
Low back pain- An excessive kyphotic T-Spine pushes the thorax anteriorly and causes compensatory increase in the lumbar lordosis due to increased tension in the lumbar extensors causing pain at the low back. This is the classic presentation of the ‘Lower Crossed Syndrome’.
Breathing- Along with the above compensation, the thorax lifts up due to inability of the abdominal muscles to provide inferior stabilization (lower ribs flaring) decreasing overall chest expansion and causing poor breathing quality and control.
Furthermore, if you follow the joint-by- joint model of training by Cook and Boyle, you can see that the thoracic spine is meant to be mobile but has a tendency to get stiff.
So, here our some strategies/exercises we can use to maintain general T-Spine mobility. The angles drawn in the video are not exactly accurate and are used for demonstration purpose only-
Bench/chair thoracic spine extension with stick-
T-Spine extension on foam roller
T-Spine windmill rotation
Four point T-Spine rotation
Threading the needle
Closing thoughts, the mid back is meant to provide mobility but tends to get stiff and excessively kyphotic given our contemporary lifestyles. This can open the floodgates to a myriad of musculo-skeletal problems. It is paramount to keep working on its mobility.
Part deux of this blog is not really a course review but my thought on taking the Certified Mulligan Practitioner exam. To begin, I’ll say this, you don’t need to be a Certified Mulligan Practitioner (CMP) to be a good therapist. I know many physios who are great clinicians but haven’t taken the CMP exam. The Certified Mulligan Practitioner exam is a test to check your competency in Mulligan concept principles and application of techniques passing which you get the title CMP. Like I mentioned in the last blog, the Mulligan concept does not cover a whole lot on assessment/diagnosis. So the testing skips that part too.
What to expect in the test-
I gave the test back in 2010 and back then the test had two components. I have heard that the format has not changed a whole lot but don’t quote me on this.
Written Component- consisted of 50 MCQ’s. The Multiple choice questions which seemed tricky and often felt like they had more than one correct answer (they did not) was the easier part of the exam in my opinion.
The practical component- I believe was demonstration of 10-15 techniques (approx). Successfully passing the exam requires the test taker to be competent in each and every technique of the book and one would be asked to demonstrate any random 10-15 techniques covering all bases. This included everything- NAG’S, SNAG’S, MWM’S, SMWAM, SMWLM, headache SNAG’S, belt techniques, BLR, taping techniques etc. The practical component was conducted by two Mulligan Concept Teachers Association (MCTA) members; in our case one local from India and one from Australia.
Passing requires around 80% scores (approx) and attention to detail is important making sure one applies all the 7 principles of the concept when performing the techniques.
Is it worth it?
I can see why this question would cross someone’s mind. After all, one doesn’t need the title to practice in the profession or even to apply these techniques. You could just do the workshop/seminar course and still apply the concepts in your clinical practice. However, in my opinion it is worth it. Going through the extra grind has its advantages. I’ll give you not one but…. two!!
Early on in my career as a new grad, I always used my CMP credentials to bag better than average job opportunities and a little higher than average salary that a new physio would expect. To the new graduates starting their career in physiotherapy I’d say this, physio school will teach you the basics and how not to harm a patient but some of the curriculum is not up to date with the latest in the field and taking certifications will improve your overall clinical skills. It will also make you a more desirable candidate in the job market. Good physiotherapy offices value continuing education certifications and titles. CMP is a good title to have.
On becoming a CMP, you become part of the network of Certified Mulligan Practitioners. The database for a full list of CMP’s across the world can be found on the Mulligan website here.. This directory can sometimes be a good source of referrals for new patients/clients. I have had other mulligan practitioners refer patients who were around my practice and I have also had patients use this directory to find me directly. It can be quite a useful tool.
Hope this information helps. More course reviews to follow in some upcoming blogs. Lets keep the dialogue going. Until next time.
This is my first blog post review on a workshop/course so it only makes sense that I write about one of the most pivotal workshops early on in my career. Drum roll, ‘The Mulligan Concept’.
Before we begin, I would like to take you’ll on a little flash back in history back to 2009. I was in my 4th and final year and was about to graduate with my bachelors in physiotherapy degree. Needless to say, I was still trying to put all the pieces of the puzzle together (almost a decade later and I still am!) and quite frankly struggling at it. By now I was expected to be able to figure out what was going on with my patients. I could follow the SOAP procedure to get all the information like I was taught but was unable to put it all together. To make matters worse, the few things that I had truly mastered at the end of my 4 years was how to make near perfect loopy circles on the body while giving ultrasound and mastered not to electrocute patients on modalities (that’s right, a slight exaggeration). Modalities were the biggest arsenal in my ‘physio toolkit’ along with some very basic home exercises and frankly it did barely something if anything to my patients pain scores or any other outcomes. It didn’t matter if the machines now had digital panels instead of the knobs, they were all a let down. Maybe I relied on modalities too much (In fact now I know that really was the case). But what else was out there? I had not even started my internship and the future didn’t look so promising. I was looking for a way out. And then…
Enter the Mulligan Concept
This 8 day workshop was everything I need at that time (almost everything). It was a real game changer. Taught by a dynamic and engaging teacher who was also a great role model for a young physio student, the concepts looked pretty straightforward and gave me new hope. I began using the techniques right away and as many physios have reported alike, the results were just like how Brian Mulligan would describe it instantaneous and almost miraculous.
Before we proceed, full disclosure, I am a Certified Mulligan Practitioner and I am biased to this approach in physiotherapy. But I’m even more biased at presenting accurate information through my experience in this blog. So here is my take on what I liked and disliked in this concept-
The 7 general principles of the Mulligan concept apply to every technique on every joint in the body. Now there are many techniques (NAG’s,Reverse NAG’S, SNAGS, MWM’s, SMWAM’s, SMWLM’s, belt assisted MWM’s etc) and even more joints in the body. However, there are no exceptions to the rule.
When a particular glide is applied correctly and it works good to reduce pain with a certain movement, it works just great.
If you follow the general rules of the concept, chances of aggravating patients symptoms are slim. All movements must be pain free or should reduce pain with every repetetion.
The concept focuses on function and I’m a big fan of that. If squatting hurts, your glides will preferably be in squatting, if its walking that gives your patients some grief, the glide is applied in walking (a little difficult) and so on. I’m not a big fan of prolonged passive treatments on a bed if the chief complain is doing some activities. Weight bearing and movement is not just encouraged, its a principle.
Results are generally quick and instantenous.
Most of the techniques are joint biased. It does not address soft tissue work that might be needed on up-regulated, knotted muscles etc. (Brian Mulligan does mention that his techniques should be applied with other interventions). So this course will not address too much of your ‘manual therapy for soft tissue’ needs.
In my mind the biggest short coming in the concept is the lack of understanding of why it works so well when it does. It is based upon the older mal alignment, ‘positional fault’ leading to pain model of explanation which we now know is not the best model to explain something as complex as pain. We have better understanding of these concepts now. I’m not sure if the Mulligan Concept Teachers Association (MCTA) has now changed their explanation/narrative in light of the new pain science research coming out. There is still some ambiguity there.
Unlike some other concepts like the MDT, Maitland etc that focus on the assessment part as well as intervention the Mulligan Concept is more of a treatment system. It won’t do a whole lot in terms of adding to your diagnosis or assessment skills.
Some techniques are too specific and in my humble opinion too subjective from physio to physio. Here’s an example, some glides like the rotational MWM’s require the practitioner to isolate say the L/R transverse process of the C6 vertebral body. This gets even harder by the time we get to the lumbar spine as now we cannot use our digits but gotta use the ulnar border of the hand on specific spinal and transverse processes. Try this with a bunch of your physio friends and see if you can agree upon your palpation skills every time on every segment of the spine. I struggle with some of these palpatory methods that need us to be highly specific and have such subjectivity. Another example is the PA mobilization (sorry not Mulligan but I had to throw it in there). I have found movement based observatory method more quantifiable.
I am not the biggest fan of the Mulligan Taping techniques. Some of the taping techniques are supposed to ‘hold’ the joint in the correct position. I don’t think a tape on the skin can keep for example a shoulder in a postero-lateral position and keep it from falling back in a ‘mal-position’. There are other examples too and I can state a few but I wont. You get the point. There are better taping courses out there with better explanation of why we belief taping works. Also, baring a few conditions, I like tape that permits motion not restrict it.
There is no ugly.
To sum it all up I think the Mulligan Concept has some shortcomings but is all in all a great concept. It definetly changed the trajectory of my professional career and taught me a lot. I will endorse it to anyone who cares to hear my opinion. Its a good concept to be familiar with.
Now would you want to go the extra distance to get recoganised in the system as a Certified Mulligan Practitioner (CMP), go through the pains of going through a written and practical exams like I did? More on that in part two of the blog post series. Until then
As we already know, the problem of glutes amnesia has reached epidemic proportions. Our lifestyle is not like what it used to be. More work gets done sitting on our behinds all day than ever before. Spend too long in sitting and we slowly start to lose the important movement of hip extension. In this blog post I would like to discuss two conditions that I have often seen in the past which can be directly or indirectly related to loss of hip extension (both lack of active control and loss of ROM). Seen in the general population and often perpetuated in runners. Lets begin-
Low back pain– while the causes for LBP could be endless, we will discuss the role of inhibited glutes and lack of proper hip extension in LBP. If we spend 8+ hours a day sitting on a chair (hip flexion), the glutes will be in an overstretched position and often inhibited. To add to those woes, the hip also gets stuck in a flexion position with classic ilicaus and psoas tightness. Now to maintain a upright posture and to compensate for tightness caused by excessive prolonged hip flexion which would put our trunk in a forward lean, the back extensors have to work harder to keep us upright. This often manifests as an increased lumbar lordosis (low back curvature). Prolonged time in this position can cause increase in tone of the lumbar erectors and could potentially cause low back pain. I see this often with recreational runners or those who are new to running. During running, if your hip do not go in to enough extension, the back begins to arch and the erectors being part of the posterior chain have to work extra hard. Remember the body is a great compensator but over time this catches up. This, I believe is often one of the common reasons why recreational runners come to see us for low back pain with running. If you are an athlete or a runner, this is not the best situation for running. Your glutes have lost their VIP status. No one likes weak glutes, unacceptable.
Plantar fascitis– I often find people with plantar fascitis have well developed calf muscles. It appears like its ‘calf raises’ day everyday for these folks however on further questioning you may find that they might not have been doing any calf strengthening exercises. If such is the case, I implore you to check for their active hip extension in walking or running especially during the midstance, heel off and toe off of the stance phase. This is the time when the leg should start to cross back behind the body due to hip extension. This is the primary movement that propels us forward. Now if the body lacks this crucial movement, due to weakness of the glutes max or tightness of the ilio-psoas etc the calf seems to become a more significant driver to push the body forward. Now multiply this a few thousand times a day (even more if you are a runner) over a few weeks, months or years and we have a overworked calf complex. As we all know, the calf exerts a pull on the plantar fascia (remember its a two joint muscle) and that irretates the PF blah blah, we all know this. So improving active hip extension and utilizing the full potential of the glutes is crucial to give the calf a break and in turn might relieve some stress of the PF.
The take home message is simple- Hip extension is a crucial movement for many daily activities and a lack of which might cause LBP or PF. When treating these conditions, don’t make the mistake of running after the symptoms like I have so often in the past. Here’s a little video to give you an idea of my thought process when analyzing hip extension in running.
(PS- this is not the only thing I look for, I’m only focusing on Hip extension here).
This blog post had a very organic origin. In the last few weeks I have seen/heard of too many people ‘pulling their hamstrings’ then I can recollect. In my little world, it seems to have reached epidemic proportions (not quite really, but thanks for indulging me). So let’s intervene. Now this is a big topic to tackle. For the purpose of keeping it short, we will only discuss exercises here. Before we start though I would like to make a disclaimer for my non-physio readers, please consult your physio if you have already injured your hamstrings. These exercises may not be the best approach to your rehab goals depending upon what stage of recovery you are at. For the rest of you proactive people who have no pain and want to train for injury prevention or just try some new exercises and are tired of the same old hamstring curls etc, give these a shot.
For the most part, hamstring injuries are seen more in a ‘generally’ active, athletic population. Research seems to indicate that most of the hamstring strains occur not when the muscle is contracting (concentric) but when it is lengthening under tension (eccentric). An example during running would be when the heel of the forward leg is about to hit the ground. During this motion, the hamstring muscle is lengthening under tension.
Now logic dictates that we train this muscle similarly (eccentrically). Over the years, more and more research seems to indicate that eccentric exercises are a good option for injury prevention and hamstring strain rehabilitation (other muscle strains too). Plus, your athlete patients will love the challenge as it breaks the monotony and are difficult to perform. So start slow and gradually progress. If it hurts, do listen to your body and stop.
So here goes-
Hamstring walkouts –
2. Bilateral hamstring sliders-
3. Single hamstring sliders-
4. Eccentric hamstring on physio ball-
5. Eccentric hamstrings on TRX
5. Nordic Hamstring Curls- This one is modified/ scaled down to make it easier. Its a difficult movement to perform so I begin performing this by not going down on the floor completely. Start small as you develop control and strength and then work through the full range of motion.
Worth a try? Now work those hammies.
Woods, C., Hawkins, R.D., Maltby, S., Hulse, M., Thomas, A. & Hodson, A. (2004) The Football Association Medical Research Programme: an audit of injuries in professional football – analysis of hamstring injuries. British Journal of Sports Medicine. Vol. 38, No. 1, pp. 36-41.
Chumanov ES, Heiderscheit BC, Thelen DG. Hamstring musculotendon dynamics during stance and swing phases of high speed running. Med Sci Sports Exerc 2011;43:525
On this edition of #techniquetuesday we will discuss the Lunge. The lunge is a great lower body exercise that works some of the major muscle groups of the legs- the Quads, the Hammies and the glutes. In addition to this, it also trains dynamic single leg stability and motor control and depending upon the variation you chose to perform one could also throw in half kneeling stability work and eccentric quadriceps work into the mix. All in all its a great exercise.
However, it doesn’t seem to be the most enjoyable exercise as many seem to hurt themselves while doing it. So lets try to do em right.
Avoid these common mistakes-
WATCH OUT FOR-
Knees going past the toes
Heel lifting of the floor
WATCH OUT FOR-
Knees going past the inner border of the foot (aka excessive valgus)
INSTEAD TRY THIS-
TRY TO –
Shift your weight back on to your heel with the heel of the front leg flat on the ground.
TRY TO –
Keep your knees aligned over your feet
The above lunge exercises seem to work the anterior chain with the focus on quadriceps (Don’t get me wrong, you are still working all the muscles). As a variation, to get more of my posterior chain muscles (Hamstrings, glutes) or to avoid straining sore knees/quads I like this variation-
Keep at it, do it right and do it often. Until next time
The week ahead is long and there is much to do, its only Tuesday. So we like to keep it short and sweet on #techniquetuesday. Today we discuss the plank. Plank is a great core exercise but often faulty techniques negates the true benefits of the exercise. In my mind, the true purpose of the plank is to engage the core to brace and protect a ‘neutral’ spine. However, I often find when performing a plank that the hold time supersedes good form. There’s a lot of excessive arching, ribs flaring out, more than desired hip flexion, cervical extension etc all for the sake of getting that extra 30 seconds. Here are some example-
Excessive lower back lordosis and cervical Extension
Excessive hip flexion
Try this instead-
Remember, the spine is not perfectly straight so a little ‘natural’ arching is acceptable. A cue I often use is to gently pull the front rib cage down towards the feet, I’m not a big fan of the cue ‘drawing the belly button towards the spine’ because it interferes with normal diaphragmatic breathing (which is important for proper core engagement).
If the plank off the feet/toes is hard, regress it to ‘off the knees’ like this-
On #techniquetuesday part duex, we discuss pushups.
In the 1st video you see some of the common mistakes when performing a pushup. Elbows are not close to the body but flaring out, not going deep enough and not going down and coming up as a whole but instead bending and arching from the back which might be indicative of weakness or improper engagement of the core.
2nd video shows corrections for the above along with finding a proper neutral starting position for the pushup
If you are unable to perform a push-up with proper form, regress by doing it off a bench, table or mats as demonstrated in the 3rd video.
4th video is another regression of the pushup off the wall.
The intention of #techniquetuesday is to highlight mistakes and demonstrate corrections for common exercises that I see often. For the very first one, we will discuss everyone’s favourite, the quadriceps stretch and the hip flexor stretch. Here goes-
To say that I wanted to write a blog post on hamstring flexibility would be incorrect. In fact, this is a issue I avoid like the plague. Why? I’ll tell you. I have pretty tight hamstrings. And since I make all the videos on this blog myself with my friends and not just throw in some you tube video of someone else doing these exercises, I’m nervous to look bad. And my hamstring flexibility makes me look bad, at least in my head. But then again, there’s also frustration. The frustration of doing repeated static stretching and not really getting much outta it. Not to forget, I have tried to be aggressive thinking if I yank on that muscle, maybe it will finally give. What it has often given me is pain instead of flexibility, and soreness. I’m sure many of you will agree with me, that for the subset of people who are on level 0 on path to becoming a yogi, this process is discouraging. So we avoid it. I can’t argue with the fact that if we keep up this torture, we might get better, but I know many people who have not made significant strides with this approach, myself included.
The reason I wrote this blog is because I had a few of my readers respond to my previous blog post reporting that one of the major reasons they were unable to hip hinge was due to those disobedient, stubborn hamstrings that were preventing people from hip hinging. So essentially this blog came from a need to hinge better. It would be great if one could touch their toes but that’s not up in the front on the priority list. The point is to hinge from your hips to learn correct lifting form so you don’t throw your back out.
If you have been part of my writing journey so far, you know that I don’t like interventions that are too painful. After all, a lot of ‘hands on’ intervention that we do is desensitizing the nervous system. Why cause deliberate discomfort (with good intentions of course) to ‘release things’ only to set the warning alarms off on the CNS. I’m not saying this is the only way, I’m saying its an easier, non/less threatening option. Hence I tread the path of lesser resistance.
So without much more blabber, here are some lesser threatening, novel approaches to improving hamstring flexibility. I like to wrap the mobility band on the hamstrings and do my neural glides, SLR’s, some hold relax etc. I will let you be the judge, practice these strategies and retest your hinge,dead lift, possibly toe touch etc.