The Work of a Physical Therapist

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For all the talk about health care ethics and codes of conduct in physical therapy school, nobody ever taught me to care.

The tag line of the American Physical Therapy Association is "The science of healing, the art of caring." But how do you care for a relative stranger suddenly placed before you? No health science professor directly addressed where that comes from.

[Read more here at The High Calling.]

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technically inferior

Less is more when it comes to technology for exercise. Gadgets may help you be informed and design programs and track progress. But for the part where you have to physically do something, there's no app for that.

Take strength training. Most major gyms offer a line-up of resistance machines. Train your low back with torso rotation and extension machines. Choose one of many crunch machines for the abs. Use leg extension machines for the front thigh muscles and leg curl machines for the hamstrings. Hit the hip adductors and abductors with those inner and outer thigh machines that should be reserved for the obstetrician.

No wonder people are bored and don't have time for strength training.

And then there are lunges. The hip and quadricep (front thigh) muscles must generate force with most of the weight on one leg. Controlling momentum of the body (plus any additional loading like dumbbells) requires the abdominal and back muscles to stabilize the pelvis. The hip adductors (inner thigh muscles) and abductors (outer thigh/butt muscles) balance the leg so that you don’t tip over.

Lunges require no equipment and work all of these muscles functionally, rather than isolated along fixed lines of motion. Proper lunges help prevent problems and improve balance, walking, and running efficiency. 

Why use five machines to train in a less efficient, less functional manner when better results can be had with just one exercise? Do you really think that a giant "seated bicep curl" machine that's been specifically engineered to match the leverage of the elbow offers your tiny biceps something that some heavy iron can't?

Lunges and rows and chin-ups and pretty much anything that involves simple you and gravity and a maybe a little iron are uncomfortable. And plain better.

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pain and your three knees

One of my first anatomy lessons came from a rodeo clown yelling to an announcer.

Aaaauuuugghhh! He got my knee. That bull got me in the knee.

He what?

My knee!

Oh. You're walking kind of funny. Did he hit your left knee?


Your right knee?


What? Well then which knee did he get ya?

It was my HIGH knee.

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That heiney bit was hilarious when I was a kid. A recent experiment here at home has confirmed its continued effectiveness in young populations. But it's no wonder that many older folks groan and roll their eyes. The twenty seven million Americans suffering knee osteoarthritis (OA) are in no mood for dumb knee jokes. It has been estimated that of all joints, the knee is most frequently affected by OA and leads to the greatest loss in function.

The role of physical activity in causing and treating osteoarthritis has been studied and reviewed. What we know is what you could have guessed.

-High impact activities and traumatic injuries to the knee are bad.

-There's a downward spiral of pain, decreased activity, and generally poor health.

-Low impact exercise and not being overweight are helpful, so those with knee pain should walk and stretch and quit doing anything fun like tennis and skiing and mountain biking.

King hippo probably had bad knees.

-If you still have debilitating pain after you've quit doing anything fun and tried conservative treatments like anti-inflammatory medications and injections of corticosteroids and lubrication, then you're a good candidate for knee replacement.

-Knee replacements do reliably reduce pain and improve self-reported quality of life in 90% of patients. Yay.

-Knee replacement is a major ordeal. D'oh. You can expect about three days in the hospital, unless the new joint gets infected. Then you go home and have at least a month of increased crabbing around and depression due to pain, constipation, restless nights, and thrice-weekly trips to your  choice of rehabilitation specialist.

And here are a few bits of evidence that we probably wouldn't have guessed:

-Patients generally plateau in their recovery by about six months after surgery, and function begins to decline at about two years after surgery. A new knee won't keep you from getting older. Sorry.

-Although most patients have much less pain and recover to preoperative levels of strength and range of motion by about six months after surgery, they still exhibit the EXACT same level of functional limitations.

-"Preoperative level" does not imply good strength. People are painful and weak in the legs going into surgery, and pain free and STILL VERY WEAK well after surgery. It is thought that this strength deficit holds the key to the unfortunate stats below. 

-Compared to adults without significant knee pain, those who have had knee replacement surgery exhibit 18% slower walking speed, 51% slower stair-climbing speed, and a 40% leg strength deficit. They report having greater difficulty kneeling, squatting, moving laterally, carrying loads like groceries, exercising and playing light sports, dancing, gardening, and participating in sexual activity.

Don't ask me, that's just what the literature says.

I'm unsure what else we can gather from all this. Knee replacement surgery helps with pain but not with function. Some people are content with that. But I can add just a few points of personal observation for those of you kneeling on the brink of a trip to the orthopedic doc.

-Despite your neighbors friends uncle who experienced Job level devastation after having his knee replaced, the orthopedic docs are great at selecting appropriate candidates for surgery. In the clinic at three weeks after surgery, almost everyone regrets having gone through with it. On a scale of zero to ten, their pain is rated right around "you-know-where-you-can-shove-your-scale." And by about two or three months, those same folks very rarely regret having surgery.

-There's definitely an x factor here, an unknown. The x may have to do with expectations and other deep psychology that's hard to quantify. It may have to do with other unmeasurables involving blood chemistry and inflammatory response.

You may be a fit, active, and otherwise healthy adult. But that won't make an ounce of difference in how your body handles the pain, swelling, and other miseries due to the controlled trauma of orthopedic surgery. Some knowledgeable dude just subluxed your kneecap, hacked off the ends of your femur and tibia with a fancy saw, jammed a peg into the marrow, added some glue to hold everything together, and stitched it back up. Your morning green tea and years on the elliptical probably has little to do with all that (though your omega-3 fatty acids might).

Take ginseng in order to...do more pirouettes on the beach?

-Why is it that with or without surgery, those with knee OA function about half as well as people without significant knee pain? Is it ginseng? I truly don't know, but the literature indicates that it's NOT just the pain.

There are other, mechanical factors that do exist and can help, though they're extremely difficult to quantify. Are there nuances to your habits and how your body moves? What chewed up your knees to begin with? I bet there are imbalances in strength or flexibility or motor control of your ankles and hips and core. I bet you walk with increased transverse plane (torquing) motion at the knee and/or move with a knee dominant pattern that doesn't allow the strong hip and pelvic muscles to perform their stabilizing roles. It may not be the case. But if I were a bettin' man...

-Pretty much everyone with knee pain has to sit on the sidelines far more than they would like, and this sitting has propitiated poor balance and an "I can't" mentality. That's one of many reasons it's probably not a great idea to give grandma a new knee and then send her back home without a lot of ongoing work.

-Surgery or no surgery, it's worthwhile to explore these things. It's important not to expect a pain free existence. I've seen some people who have worked on their functional strength and balance and movement patterns, and despite a pretty bad x-ray, were able to manage quite well without knee surgery. And I would certainly think that even if the effort doesn't save you from surgery, it holds value for gaining peak recovery, so you're not functioning at half capacity like the literature reports.

-On a final note, us rehab folks focus a lot on getting that knee flexibility back. You need to get the knee straight to allow a grossly symmetrical gait pattern. You need at least 110 degrees of bending to allow stairs, stooping and such. But the literature suggests that the most important factor for improved function is not flexibility, but strength.
Get up and working on your feet, a.s.a.p.

"Successful" knee replacements with little pain and adequate flexibility still show limited strength, and strength dictates function more than anything else. So the latest thought is that really pushing the strength training is critical, especially in that first month after surgery when strength plummets the most. That means pushing 20 pounds instead of 2 pounds on that exercise where you sit and kick the leg out. It means challenging your limits in balance and doing lunge variations and steps-ups if you can, rather than 3 sets of 100 leg raises and heiney squeezes.

So there you have it. Osteoarthritis is a pain in the knees. I got lazy bones typing here at the end, but references are available upon request. Except for the heiney part. I refer you to the expert testimony of rodeo clowns.

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Coming this weekend, for a limited time only, while supplies last.

Increase growth hormone, blast fat, rev the immune system, extinguish inflammation, focus-in mental acuity, stave off emotional collapse, and increase your day by 4.1%!

No side effects!
Any one product or service that promises everything-and-the-kitchen-sink is probably pretty worthless. That's usually a good rule of thumb.

But not Z-Rx. Z-Rx is not a sleep aid, but sleep, clinically tested and proven in the kitchen sink, and more. And for a limited time this weekend, it's FREE.

Behold DAYLIGHT SAVINGS DAY, where 60 minutes magically appear from thin air. It's the one day of the year when nobody can throw up their hands saying, "if only there were more than 24 hours in a day." It's the one gift you will receive while unconscious at 2:00 a.m.

You will be sleeping, right? You can't afford to administer this gift any other way.

Seriously. Just go to bed.

When it comes to improving health and fitness, people spend hours planning and implementing exercise routines, nit-picking their diet, and searching (and shelling out for) the next big performance-boosting supplement. This can paradoxically serve to take them further from what's needed most: time to chill.

Do you imagine it's healthier to discipline yourself to chill or to wash down your gingko and vitamin B pills with another shot of 5-Hour Energy?

If what the National Sleep Foundation has to say is even the least bit accurate, most of us could use nothing more than some restful quiet. I would like to think we should pay more respect to sleep.

Before we diet hard.
Before we consider pretty much any supplement.
Before we start getting up at 4:30 a.m. in order to fit in a morning workout.
Before we start making major overhauls aimed at increasing creativity and productivity at work.
Before we stay up reading blogs of questionable content and quality.

It would take many moons to sight reference upon reference dealing with the ill effects of sleep deprivation. Sleep deprived athletes show decreased measures of mental and physical performance. High cortisol interferes with optimal repair, recovery, and growth from a number of angles. Even a single night of deprived sleep has people feeling hungrier and actually eating significantly more than those coming off eight good hours of rest.

Researchers suggest that changes in insulin resistance, as well as the hormones ghrelin and leptin, explain why higher rates of obesity, heart disease, diabetes, and high blood pressure occur in chronically sleepy folks.

You don't exactly feel up to the task of working hard when you're mentally exhausted. And it's difficult to be like Jesus when you're staggering around like a tired and irritable zombie bundle of hell because you were up all night goofing off on your bike.


Clinical sleep disorders are complex and really do have a wide grip on our health. But there are many who need to JUST GO TO BED. For those of us who stay up too late reading and typing and watching re-runs of House, fine, we've made our decision. But there's no room for complaining and puzzled looks when we're sick and crabby and making little progress toward our fitness goals.

This weekend really is the most wonderful time of the year, especially for parents with pre-school aged kids who love a good 6 a.m. cry fest right in their siblings ear.

Merry Day Light Savings Day to all, and to all a good, 60-minute longer night. 

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My six year old recently requested that his nickname be changed from Trout to Bike.

"Just Bike."

While he still enjoys fishing and playing ball and all that, Bike has found his first love. And I'm good with it. More than good.  Bike is gaining some initial confidence. He's motivated to get after his book-learnin' so he can go ride. He's building body awareness and multi-joint coordination that surely transfers to other playlists.

He's learning his limits too. Bike has a pretty good handle on what he should try and what he'll leave for the Youtube "fail" videos. This isn't due to some kind of stellar genius. I think it comes from the process of risk analysis that forms naturally when little ones know that they are allowed to try things without constantly being hovered over.

The concept of relative risk deserves a revisit. Sure, I worry about Bike getting wrapped up and breaking an elbow or ankle. I understand the tears and misery and other costs of the ER. But what of the risk of him living in fear or rebelling because we failed to let him try, and learn his own lessons? What about the fact that we drive our children everywhere? Like, at great speeds in giant metal(ish) machines? We stare down a far bigger, uglier risk on a daily basis, and say "bring it."

Somehow driving is acceptable, while allowing our kids to bike and play football and lift weights is questioned.

I still think that the biggest risk is couch-TV syndrome. And putting our sons and daughters into a batters box for a showdown with a flighty, uncoordinated, but strong for his age 12-year old on the mound.

Development. Confidence. Performance. Lessons in baseball. Injury rehab.

This whole entry is kind of how I make a living.

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Confident Does Not Equal Competent

[A guest post from Kyle Wagner.]

When you're involved with baseball you invariably run across all types of coaches. Some you seem to like right away and others you'd just rather not have dinner with.

I'm always skeptical of the coach that seems to have ALL the answers- especially those involving the hitters. The one that doesn't hesitate to offer any little bit of advice that he feels is necessary at that moment. At times like that I always remember the old adage by Abraham Lincoln, "better to stay quiet and let people think you're a fool, then open your mouth and remove all doubt."

It isn't that they don't have good intentions - they do. It's that they believe, at least that's what I can only assume, that by being loud and quite confident in their opinion they are a vastly superior coach.

Let me explain why I believe this coach is victim to the "confidence" illusion.

Hitting a baseball requires many skills for sure. But, gameday is not the time for major wholesale swing changes. Gameday is the time to make sure the player is ready to compete against the pitcher. It's not about the stride or the hands too high or the head pulling off the ball. It's about competing in the batters box. Yet, coach after coach seems to offer technical advice to these young kids and if it wasn't so darn devastating it would be comical. Paralysis by Analysis.

Hitting a baseball is a timed event. You need to apply your skill in a given amount of time. It is not golf where you can swing on your own terms. You have a ball moving at you in unpredictable locations. If you want to help your player in the moment you must give him something that will help his quickness to the ball. For the most part, on gameday, these pieces of advice sound like this...

"Turn it loose"

"Free and easy"

"Get a good pitch to hit and hit it hard"

"Don't give up your strength" (In other words - "look fastball!")

These pieces of coaching advice are vague by nature. They are supportive, subtle suggestions to make a hitter more focused and less pre-occupied with unnecessary swing thoughts.

When the ball comes out of the pitcher's hand a hitter needs to react to what he sees. It's this reaction time that separates the great hitters from the good hitters, the good hitters from the average hitters.

The easiest thing a coach can do to improve a players reaction time is to improve a players anticipation strategies. In other words, give him better things to think about if you want to make his swing faster and quicker to the ball. As the ball moves towards home plate the three primary elements that effect how quickly your barrel moves in the direction of the ball are 1) anticipation (Green Light Hitting strategies) 2) swing quickness (mechanical efficiencies) and 3) bat speed. Are you really going to change variables 2 and 3 in 10 minutes? Very, very doubtful. It takes time. A lot of time.

So, the only thing left to impact as a coach is a players anticipation strategies. Give your player's a thought process that makes them quicker to the ball- not cues of doubt that WILL absolutely slow them down. Here are some doubt producing cues for sure.

"Make it be there"

"It's gotta be perfect."

"Don't swing at the high pitch"

"Don't chase 'em out of the zone"

"Watch out for the curveball."

The "competent" coach knows not only what to say but when to say it. And, when to roll their eyes at the "confident" coach.

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Cinnamon Toast Crunch

Is there anything better to "consume" after a workout that Cinnamon Toast Crunch?

[Or insert your favorite sugary/junk cereal.]

I really don't think there is. After years of trying out and studying up on expensive recovery supplements and fooling around with blenders and what not, I can tell you that none of those are any more (or less) effective than Cinnamon Toast Crunch.

I'm resisting the urge to write a parody, like I did here in an attempt to get across the proven effectiveness of chocolate milk.

Some may read this and judge me a dimwit. What about high fructose corn syrup? What about the ratio of protein to carbs and the milk, with it's supposed suboptimal amino acid profile?

What about the fact that after intense exercise, your body benefits greatly from a surge of insulin with some easily digested carbs and protein in store. How about worrying a little more about getting the rest of the week right, eating and drinking mostly non horse-sized portions of unprocessed foods, before ruminating the minutia of post workout recovery formulas.

Others may read this and go around telling people that Cinnamon Toast Crunch is the "secret" to fat loss, muscle gain, and many other great mysteries of the universe. But make no mistake, Cinnamon Toast crunch is primarily good for, above all else, cinnamon sugary goodness. And it happens to fit the bill for a moderate amount of high glycemic carbs and protein.

If you're regularly training hard for the purpose of weight loss, have a bowl of cinnamon toast crunch. Go ahead after a workout, because that's the time when eating a moderate amount of pretty much whatever you want will actually work for you.

If you're training hard for the purpose of gaining size and strength, have two bowls of cinnamon toast crunch and a normal dinner an hour or so later. The common themes here include regular, hard work and Cinnamon Toast Crunch. Hard work, not like the recumbent bike or a stroll through the mall. Hard work, like, there were at least a few points where you felt pretty miserable and would have loved to lay down and create a pool of sweat on the floor.

The timing is important. Total calories count, and you don't want to eat like that all the time, whatever your goals. But it can totally work for you. And since the window of optimal recovery is open for about 30 minutes immediately after exercise, better go get you some

cinnamon and sugar
we're baking up a bunch
baking homemade taste
in the Cinnamon Toast Crunch.

Testimonials. Do you really need to see a series of exaggerated and completely fictitious testimonials?

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This week I'll be speaking to pre-physical therapy students at Messiah College about interpersonal skills in the clinic. I'm certainly not the expert on this, but chose this topic because:

1) It's relevant for all health care providers and especially so for this profession. It applies on a daily basis whether you're a PT or intern or volunteer. I succeed and fail with this stuff every day.

2) It's not another academic fact binge. They're probably getting their fill during all the rest of the time they have to sit and listen to middle aged people talk.

3) Although things may have changed since I was in school, interpersonal skills don't get much coverage, at least not practical, realistic, honest attention.

So for 30 or so hopefully not too boring minutes, it's gonna go a little something like this...

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The American Physical Therapy Association attempts to summarize the essence of physical therapy with a little blurb under the APTA logo. Has anyone seen it?

"The science of healing. The art of caring."

I think it's great. I REALLY like that motto. What therapist (or any health care provider) wouldn’t do well to take it seriously and examine themselves by it? 

How do you feel about "art" and "caring" being put up there with equal status of "science" and "healing?" 

Things may have changed a lot since I was in school almost 10 years ago, but I would bet my gluteals that all of you can guess if it was "caring" or "science" that occupied 99 percent of training. We heard a lot about ethics and codes of conduct, but nobody even tried to teach us how to care. I can understand why it's that way, and I'm not so sure it could be any other way (especially at a state school). 

The assumption, I guess, is that you do care. You want to help people, right? But I can tell you that when you're put in any kind of competitive environment; when you're asked to walk the line between efficiency and quality of care; when you're up against a schedule full of folks with arthritis on a rainy day and everyone is achy, the caring isn't always foremost on your mind. 

Art, really? What professor or clinical expert confesses to art? Are you going to mention your artistic ability during entrance interviews? Maybe you should.

In defense of science

There's no substitute for clinical competence. All else being equal, what person with a miserably sore knee would pass on a top clinician with poor bedside manner in favor of a kind chap who uses the Magic 8 Ball in his clinical decision making? 

There’s a reason why much of our weight is planted on science while art barely gets a toe touch. We believe that PT can help many people function and that it makes sense economically. We believe that our methods are reliable and valid. But believing does not make these things true. After all, therapists have a vested interest in doing a good job, even if their “caring” only concerns themselves.

Art and caring are soft and non empirical. Neuroscientists may track electrical activity in the brain that are vague evidence of some thoughts, but who can calculate caring? You can quantify caring no more than you can see a ground reaction force. Employers and insurance companies don't reimburse you for caring.

The caring of science

Or do they?

The problem with the above scenario is that all else is not equal. The bridge between science and caring is the reality of two whole people. Go ahead over to Medline and search "bedside manner." Notice the number of studies that pop up, and the trouble they have with even defining, much less studying bedside manner in purely humanistic terms. 

Caring isn’t just the spoonful of sugar that makes the medicine go down. It's a vital ingredient in the medicine itself. It’s science that now confirms and helps us understand the complex interaction between the body and mind. Among many mysteries, we now have an inkling to how experience, expectation, stress, and other purely mental “events” have an effect on pain perception and other facets of healing.

So we're learning and practicing in terms of clinical pathways, prediction rules, and confidence intervals. And the patients...nobody cares. Really, nobody cares about how much you know until they know how much you care. In a decade of treating patients, I can tell you that people, whether they want to admit it or not, care far more about how you make them feel as a person and how you satisfy their personal needs than they do about how well written and effective your treatments are. Just watch. You don't need an MRI to see that.

So care, damn it

If healing and caring are a package deal that were never meant to be sold separately, what are some practical suggestions for caring?

1) Stand on evidence, yes. You have to. But stand at the edge, where you can still reach over and wrap both arms around a whole person in need of some caring (the hug may be metaphorical at times).

2) Our caring should have feet. External validity, if you will. Does your life generally validate your work? Do you highlight research journals on weekends and catch yourself analyzing the gait of strangers? Does your physical appearance affirm that you know something about body maintenance and repair? Do you offer your services to your closest friends and your own mom for no other reason than because you think you can help?

3) Maybe you need to seek or create an environment that leaves a little room for art. This may be difficult to do as a student, but again, watch and learn. I'm certainly aware of clinical models that have PTs "treating" four patients every hour, many of those patients going out and telling their friends that rehab doesn't work.

4) Do you care enough to look them in the eye and listen? Part of INTERACTING "in a confident yet respectful  manner" entails your mouth being shut. Wisdom knows how to pull off engaged listening without getting caught up hearing about a sisters sons cat for the third time. I could certainly use some help here. But I can say that if your caring is mostly just about your competitive drive and need to defend your chosen profession and pay the bills, the clients can tell. And sooner or later, so will your "outcomes."

5) It all counts-the type of person you are developing into along the way toward your PT license. Credentialing exams don't test you for caring, by the way. I think that seeing PT as a calling is the only route to this caring. Otherwise, it’s just a bunch of knees and backs and shoulders. I suppose it's possible to get by that way, but it can't be very easy and rewarding. Or fun. 

The logo captures far more than the academics of PT. I’m humbled and challenged.

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Respect Recovery

Most serious athletes and fitness fanatics are either training too much or not enough. I'm pretty sure it's one of those. "Optimal" improvement lies on a razor thin line somewhere between training and rest. Athletes can't know for sure if they are walking that line, but it's easy to tell if they stray far in either direction.

While it will always be easy to make excuses that result in laying around with a bag of chips and unreality TV, there are growing numbers of driven and devoted athletes who would benefit from nothing more than a day or three of rest.

On one hand, a certain amount of consistent training is needed to stimulate the body to adapt and reach new heights of performance. On the other hand, too much training and competition tears the body down before it has had time to recover, much less improve. Outside of technique, nobody gains or improves during training. The magic happens in all the other hours of the day; when the athlete is sitting in class, playing video games at home, and especially while sleeping.

Athletes, parents, trainers, and coaches would do well to remember that actual results are determined not simply by how much training is performed, but by how much training an athlete can recover from. Sorry coach, but an athletes recovery ability is determined by far more than what you can program. Age, gender, genetics, diet, stress, and the amount of sleep all play a large role.

So before you schedule those 5 a.m. workouts before class, please consider the 6 to 8 hours of classwork, hour of social time, minutes of family time, and hours of homework that will be wearing on the athlete until well past 11 p.m. If you want a thin 18-year old to gain 15 lbs of muscle before the spring season, don't have him or her running bleachers for 40 minutes 3 days per week on top of practice and weight training. Athletes who can tolerate, much less improve from, such a schedule are truly outliers.

I understand the value of extreme pre-season conditioning practices that build character and team unity and act as a self selection process for the final roster. There are certainly times for those lessons. There is certainly a time when an athlete must decide if he wants to work to get better or just have fun. But whoever signed up for getting worse while not having fun? The "more is better" approach, where athletes are chronically pushed on 5-, 6-, and even 7-day per week programs is worse than useless. Mental toughness may be worth the price of physical stagnation, up to the point where somebody gets injured.

All the glory and applause given to training, willpower, dedication, and hard-nosed coaching leaves little opportunity for us to hear the stories of drop-outs and injuries that are largely due to a lack of intelligent planning. They are stories of ibuprofin and arthroscopic debridement. They are stories of well-intentioned but unwell PEOPLE dragging themselves around day to day, beating their head against a wall, wondering why they're seeing such little return for all their efforts toward something they use to love.

Those stories do exist.

I see them most days in the clinic.

And I was one of them.

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It's Gotta Be The Shoes

I've had much to say about the limitations and (sometimes) foolishness of common fitness products these days. It's for good reason, because of all the claims for simple, easy, and comfortable substitutions for the "problem" of disciplined, patient, and thought-out effort. While I'm no big fan of programs, supplements, braces, supports, and splints that promise the world to aspiring athletes, I really don't want to be known as the Fitness Nazi.

No Reps For You!
So here's one on the other side of all the marketing hype and junk fitness products, based on legitimate biomechanical principles.A recent study published in the Journal of Strength and Conditioning Research looked at the effect of certain footwear on vertical leap.

Following the lead of a few other investigations, researchers measured the vertical jump while subjects wore (a repeated measures design) standard shoes and "experimental" shoes that place the foot into slight dorsiflexion. If you were standing in the experimental shoes, your heel would be about a half inch lower than the ball of your foot.

The vertical jump of the the group of "generally fit but not elite" women being tested was almost two inches higher when wearing the shoes. This is a pretty drastic improvement. What's more, the researchers also gathered data while the subjects ran. The jumping shoes had no adverse effects on running economy, pain, or perceived exertion. So there were no drawbacks in this population of people, at least for the time being tested.

It's ironic that most high falutin' high tops rest the foot in the opposite direction (about 4 degrees of plantar flexion), which has been suspected of contributing to the acquired ankle inflexibility and knee pain seen in basketball players. Isn't it cool to think that a little tweak of the ankle may produce an immediate increase in vertical jump without the body "paying" for it elsewhere?

As compared to typical hoops shoes, flat old school may be better for the health of your knees and vertical jump.

"Little" being the key word here. A little scientific evidence from a little tweak, without major complications, will get hundreds of thousands of people suddenly up and jumping  more, which tends to create an increase in vertical jump. At the same time, if the shoes catch on and are bought up in those numbers, there will be problems.

I mean, can you imagine these things being picked up by Reebok and a multi million dollar ad campaign? The average Joe looking white kid is suddenly throwing down in traffic.

The body almost always pays for any extreme additions or subtractions, and even a subtle tweak risks the chance of pushing underlying movement dysfunction (like say, those who are already restricted in dorsiflexion) over the threshold to injury and pain. Poorly conditioned (okay, fat) boys and girls will wonder why their heels are sore and they're not hitting their heads on the (basketball) rim. Some men and women who were just hungry for a little performance edge will get a big serving of tendinopathy from the increased load to the achilles.

And still, the concept is cool. The shoes hold promise as the first product of its kind, well beyond shoes, that may legitimately help you get more air.

Promise, with reservation.


Discomfort: Priceless

There's really nothing comfortable about our basement. This man cave is not equipped with a high-def TV or EZ chair, X-box or pool table. Walk upstairs and help yourself, because there's no bar or mini fridge.

The Green Room out back.
But there is a barbell. And a bench, a few adjustable dumbbells, several hundred pounds of weight plates, a 90's-era CD player, and gravity. The workouts often can't be contained, blowing out through the back door. The Green Room offers graded surfaces, rocks, obstacles (including kids) to accommodate plenty of running, jumping, hitting, and throwing. The "natural" climate control is just perfect, especially when the days are not sunny with a high of 75.

Attempting to make physical exercise soft and cushy misses the point. The body adapts to both comfort and discomfort. While discomfort deepens us, smoothie bars and cardio theaters and fancy chrome exercise gadgets are blood letting for the anemia of modern times. Discomfort grants us the opportunity to develop will and grit that's readily transferable to everyday life.

Time is a gift. So if you sit indoors for the majority of your work day, please don't drive (sitting) to a climate controlled gym to sit or recline back on some resistance exercise gadget, crunching your pelvis even further toward your rib cage. I don't care how well it isolates the lower obliques. Unless you're older than 70 or with a serious disability, swear that you'll never be seen reading a magazine while riding a recumbent bike, especially People Magazine.

[Sure, it was a cool down.]

If you're going to work out, for heavens sake, WORK out. Learning the joy of misery suddenly gives you time for a fitness program. Fitness doesn't even mandate an electrical outlet, much less your own TV and PlayStation (like the ridiculously equipped for a roster of 14 Dallas Mavericks training facility). If you have gravity and some ledges, rocks, or steps, you have plenty of gear for a solid level of fitness.

In general, the less fancy gear you need to exercise, the better. Therefore, yoga mats are probably a good return on investment. As is lifting barbells and other heavy things. And while I'm no fan of distance running, I have to hand it those who willingly engage prolonged periods of the most fundamental push against gravity. That's why they call the natural, exercise-induced rush of endorphins a "runner's high," and not a "Thighmaster's high" or even a "Cable Cross Overer's high."

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Mike has embraced this particular odd form of discovery and made the journey his own. I think it shows.

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How dare any fitness or infommercial person try to sale us on "quick and easy," stealing away what's priceless? Comfortable exercise never delivers the full dose. While we can't derive a mathematical relationship between discomfort and "benefit," such a formula is certainly worth considering in the context of an individuals abilities and goals.

Of course this can be taken too far. I don't recommend Fight Clubs because the side effects are pretty awful. And not everyone should prepare for a solo climb of K2, or even deadlift 400 pounds, intentionally bloodying their shins with the knurling of a barbell (as I once witnessed at the now defunct Slippery Rock University Barbell Club).

But I am asking for a some middle ground here.

Speaking of bloody shins...

This is not the counterfeit discomfort of masochist ascetics. A recent accidental drop of a heavy dumbbell on my toes caused me to doubt that the purposeful infliction of pain holds much positive psychological value. Though the extreme saints, mystics, and barbell nut cases may disagree, I would argue that "gift" discomfort always comes riding on a productive act where pain is not the primary intent.

                THIS video: 300 framers per second, Kyle Wagner probes the limits of discomfort.

Embrace and deliberately manipulate discomfort as a controlled variable. Most of us should progress slowly and focus on the journey. As an alternative, you can ramp discomfort from practically 0 to 60 in mere seconds, like this:

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I'm all for the basement. It's ridiculous how much happens down there. I, personally, have never felt a place as comfortable as my basement floor.

Ahhhh...the floor!

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Thanks to those who got down(stairs) with discomfort:

Mike M, Mike S, Mike H, Dave T, Andrew C, Eric B, GG M, Amy G, Marie V, Ben C, Cort, Rose, Ryan H, Tim B.

The blogger, finding discomfort.

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Eat. Play. Love. (Part II)

The premise is that Ben probably BEGAN working on his hops a LONG time ago...

Shortly after moving to Harrisburg, Amy and I strolled purposefully through Sofas Unlimited. We stressed over color coordination and texture. Nobody needed a drink or had an emergency pee. In those days we cared, really cared, about our sofa, love seat, and over sized chair.

Now days, the precious furniture takes a beating at the hands and feet of four little ones. Especially on rainy days. Obedience is a top priority to us (no jumping on others sofas or on ours until we say). Furniture is not. And it's more convenient and less costly than 4 memberships to MiGym.

No furniture or bones have been broken yet. I'm just not up for the battle of going gently on the furniture, a relentless, thankless battle indeed. Perhaps we'll prioritize the sofa some day. But not right now. What a shame when furniture is outdated and demoted to the basement without having taken some hits.

Bear in mind that I'm a PT/trainer guy and not an interior decorator or furniture person. It's understandable if furniture is important to you. But for the kid's sake, have a horseplay couch in the basement. If you find it hard to let go of the whole furniture situation, go ahead and cheat by just starting with a 10-year old ugly couch. Think of your ugly old basement horseplay couch as an investment in their future.

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Side note, as ironically, I had to pause to address my 4-year old after he literally rolled out of his bed while asleep.

Risk is inherent in almost everything. Video games can become addictive. Kids ride in vehicles every day. I'm sure there are stories of kids getting horribly injured by falling from furniture. I don't know those stories, but there are many kids in close proximity to many couches, so I'm sure they exist. The key idea here is relative risk. 
Horse play on a couch has it's relative risks and rewards.

Encourage (OR discourage) it at your child's own risk. 
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What do couches have to do with athleticism? As stated in Part I (below), athletic potential in adolescence and adulthood has much more to do with acquiring an early love of physical activity than it does with genetics. The fundamental elements of athleticism are tied directly to natural sensitive periods in the development of the nervous system. The actual existence of these critical periods for motor development has been academically debated, but it makes sense and fits my personal observation.

Couches are the perfect gear for tuning little brains to spatial awareness, movement synchronization, and rapid acceleration and deceleration. Cushions awaken the smallest ones to the consequences of gravity.The process occurs conveniently and naturally, with far more stimulation than standing around waiting for a turn during "practice."

So leap. Chase. Hang. Lift. Throw with one and two hands. Any activity that your old aunt Edna yelled at you for doing in the sitting room is probably what kids should be doing. And often!

The best fuel for young athletes is frequent servings of a wide variety of physical activities. That's why starting them young does not have to mean soccer camp for toddlers and after school gymnastics. There are certainly worse things that 3- and 5-year olds can be doing with their time. But what I'm suggesting has little to do with organized anything. Quite the opposite, in fact.

Think couch.

I'm not saying that learning to cooperate and work as a team is without value. Those are needed lessons, but they are not lessons in motor control. Waiting your turn is probably a concept that should be introduced in the home and classroom before it's attempted during active times. We should expect a 12-year old to be patient and organized on the field during play time, but not a 6-year old.

Luke had to wait his turn.

So protect the kids, but don't hover. Let them learn about their body and gravity while the stakes are relatively low. Far more than any coach or trainer, you know how to challenge your little one in a way that also sets them up for success. And make it fun.

Mom and dad, be active yourself and look to praise their attempts at physical achievement. Encourage the horseplay, to some extent. Help them see their body as a performance machine good for more than sitting in front of electronics for 44 hours per week (the reported average for kids).

[Above] The author succeeds as an active model for the kids, but fails as a show boat.

On that note, send the kids outside. A lot. This link includes a referenced compilation of the benefits to being outside as well as many problems associated with the fundamental move of childhood to the indoors.

The brothers getting some fresh air.
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Lastly, point the little athletes toward the best finish line. You can train an athlete to run faster, but let's just go ahead and say that it probably won't make them a super star someday. Or content.

His Super Bowl ring is not what's making him happy right now.

Athletics truly helped keep me out of trouble and doing my homework. They still help me to get through long days, working as a father and a PT. The real value in training and competing is in the journey toward wellness of the body and mind. Lets set our children up for the love of physical activity without plastering them with commitments. Should they decide to pursue athletics, the foundation of higher level skill will be in place. '

The Promised Land is not some championship destination flowing with champaign and money. Anyone who is fed, loved, and given the opportunity to play is IN the promised land. And there, if you find that sweet spot between having fun and working hard...

....ooooh! You can let go of all the rest.

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From Over At The High Calling


This is the first of five legs in our Pilgrimage series. Today we’re led by physical therapist and High Calling member, Bob Gorinski.

It’s hard for me to imagine a pilgrimage or journey without movement. As a physical therapist and trainer of athletes, I help a wide variety of patients achieve new limits in movement. I play bio-mechanical detective, attempting to solve problems in the function of muscle, nerve, and bone.

Most of my clients are on a serious journey toward change in their physical form and function. And do they ever ask questions about health and fitness products, many of which guarantee results. Fast!

Why aren’t the orthotics fixing my heel pain? When can I pitch again? Will protein drinks help me lose weight?

I offer straightforward opinions and evidence-based answers. But often I simply don’t know. It’s challenging enough to keep pace with advances in rehabilitation and sports performance, much less the latest claims in homeopathic supplements and mattress technology.

“Optimal,” “comprehensive,” and “transformation” are permanent buzz words in the health and fitness industry. Transformation, really? Not even yoga is comprehensive. And sorry, Chuck Norris, but the Total Gym is still just a gym, and rarely do gyms help a person achieve peace.
Physical therapists pride themselves on treating causes of pain and dysfunction instead of symptoms, yet the root causes sometimes go quite deeper than we can dig.

Filling the hole

While there’s plenty that I don’t understand about the human condition, a decade in the clinic has shown me that even intelligent people buy into good and bad fitness products in order to fill a hole elsewhere.

Middle-aged moms imagine that getting into their college jeans is a realistic and worthwhile fitness goal. Couch potatoes think PTs and orthopedic surgeons can fully atone for years of bad decisions. Desk jockeys assume that simply being in a gym is equivalent to the inevitable discomfort of getting fit.

Similarly, fitness fanatics believe that glucosamine and more exercise is the solution to their repetitive overuse injuries. (Even PTs – ahem - take ibuprofen when the best prescription for aches and pains is a few days of rest.) And then there is greed, bitterness, and many other conditions less apparent yet more physically damaging than a soft midsection or flat feet.

In all seriousness, who has ever ab-crunched or low-carb-dieted their way to contentment?

Holistic means…

If (as the apostle Paul writes to Timothy in I Timothy 4:8) Godliness has value for all things – holding promise for this life and the life to come – then the body certainly stands to benefit from spiritual exercise. That makes a lot of sense, and I don’t think we have the capacity to will ourselves to any kind of transformation. Sooner or later, the body tells the truth.

But be careful now. If the body were always a testimony to the spirit, then we could identify spirit-filled people by their physique. Of course that’s not the case. The lives of my kindest, gentlest patients have taught me that an (apparently) strong spiritual life does not fix the genetic and life circumstances we’re dealt. By no means are injuries and the wear and tear of life always earned with laziness or neglect. I’m pretty sure that even the saints get arthritis.

The truth is that whole people are far beyond PTs, nutritionists, doctors, and the guy in the Facebook ad selling Acai Berry. While we can be helpful or even critical in handling the details, we know that a fit body requires more than diet and exercise. That’s why the “just” plans for health and fitness are always a lie: Just seven minutes of exercise per day. Just two pills before major meals. Just one spinal adjustment per month….

Even the oddest fitness products sell because they’re supported by an “expert” in a white lab coat (or a sports bra) and promise a “new you.” They look kind of fun and cost only three installments of $39.99. Yet being made new transcends the scope of physical medicine. It’s why I never make promises with my treatments. Besides, who is an impatient, chronically late, caffeine- and activity-addicted PT like me to guide anyone in mastery of life?

Health is a lifelong journey that demands daily attention; the kind of attention that costs more than the price of diets and exercise gadgets. Fit bodies are a worthwhile pursuit that can easily be forged into idols. At the same time, exercise and effort is a blessing from above that helps us manage the hard realities of our life and times.

As much as I’d like to prescribe what people need most, I’m fearful of writing Jesus into my medical plan of care. I wouldn’t want it to be another quick fix. What I can do is take the posture of washing feet. That just may be the best bio-mechanical and spiritual response toward wellness there is.



The Business of Symmetry

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The idea of symmetry is prevalent in the sciences and is woven into the very laws that govern our universe. Symmetry promotes mobility in living organisms. It makes snowflakes and mathematical equations beautiful.

Do you think about symmetry?

I've obsessed over symmetry for a long time. In gradeschool I taught myself to write and shoot basketball about equally well (or poor) with either hand. Every photo between the ages of about 12 and 20 has my hair parted smack down the center. I still catch myself unconsciously making trivial stabs at symmetry, like putting each contact lens in with the opposite hand. I can hardly clean up toys and sticks in the yard without keeping a running tally of which leg is forward when reaching down.

No baby, baby: Salt N Peppa haircuts irked me...
before their music even had the chance.

So it's little wonder that I grew up to work in physical rehabilitation and sports performance. Much of my time deals in the business of symmetry; identifying and minimizing musculoskeletal asymmetry.
Injuries, habitual postures, repetitive activities, and dominant movement patterns disturb the natural balance of the body, leading to inefficiency, tissue overload, and pain. Beyond human movement, scientists have found associations between structural symmetry and various measures of mental health, attractiveness, social skills, and cognitive ability in old age. But no, I never claimed to treat ugly, mostly because I believe that ugly is a state of mind.

On the other hand, all brains that ponder symmetry have two halves; with hands and brain halves each being quite asymmetrical. While I'd like to be able to make a neat fold between the the two "m"s, even the form of the word "symmetry" hints of an ideal. It's hard to deny the different structures in each half of the body suited to take on different demands.

So maybe we shouldn't get too caught up in symmetry. And I mean that with all my left sided heart, which itself is larger on the left.

Asymmetry often rules the details. Some is explained by this thing we call "dominance." For a number of reasons, the body settles into a preferred or dominant patterns that favors one arm, leg, ear, eye, etc.

Caffeine: beautiful asymmetry

The dominant patterns are often task specific and they may be consistent or mixed. That is, an individual could be right handed with scissors but a lefty stirrer. They could be left footed and right eyed. In terms of muscle size and performance, like jumping, up to 15% difference between the right and left sides is considered normal.

Much of the asymmetry that I deal with in the clinic is simply the result of the body gradually adapting to the demands placed upon it. Sometimes this proves to be unproblematic while in other areas the asymmetry is a warning sign. For example, asymmertry in shoulder flexibility is a fairly good predictor of pitching injuries while an uneven resting posture of the scapula is not. Asymmetry of hip movement has proven to be relevant in the diagnosis and treatment of knee and low back problems, while anywhere from 2 to 6 millimeters is an acceptable difference in leg length.

There’s some evidence that folks can usually fill their left lung easier than their right. The right diaphragm uses the liver for “leverage.” This results in some of the right ribs having a subtle rotation, which in turn affects thoracic and scapula position.

Scientists have found that healthy runners show about the same amount of asymmetry as injured runners. The fact that injured runners have increased joint loading forces as compared to healthy runners suggests that high impact loading is the primary problem, with asymmetry simply influencing the side on which injury first appears.

Some asymmetry is due to trauma and developmental issues. My right pointer- and pinky fingers have been fractured and now turn inward, giving that hand a semblance of the tower of Orthanc. But they don't hurt, at least not yet. Just don't ask me to point out the guilty party in a line of suspected criminals.

Webcam: Wherever I go, I carry
Orthanc with me.

And so it seems that body symmetry is often an ideal with no hard and fast rules. Yet there's something about symmetry.

Despite dominance, structural adaptations, and subtle deviations, it does appear that we're balanced through the integration of whole system imbalances. Yes, symmetrical asymmetry! Plus, a truly amazing ability to adapt.

The torso, for example, is balanced with a liver on the right and a heart on the left. Extremity dominance is balanced through reciprocal function; the left arm moves with right leg and vice versa. Fine coordination on one side of the body often appears with more absolute strength on the other. Dad taught me to throw righty and bat lefty, and now that's just what I do.

Identifying structural or movement asymmetry is a relatively straightforward process. Trained therapists recognize these imbalances and typical patterns. The challenge is determining whether or not an asymmetry is modifiable and worth modifying.

I've found that moving toward symmetry helps. It helps a ton. I witness this reality on a daily basis. I'm often surprised when a patient with right hip bursitis has never noticed how "flat" their left foot is; or fails to relate their right side neck pain to leaning on the left elbow when driving.

It makes sense that if exposure to repeated loading in the same direction does indeed cause microtrauma, movement dysfunction, and eventual pain, why would you not at least try to redistribute the strain? Why shouldn't athletes bring their weakest link up to snuff for both injury prevention and peak performance?

Uneven structure can often be accommodated or improved with specific corrective exercises, if not "fixed" to be perfectly even. Even partial reversal of habitual postures and ingrained movement strategies is often enough to allow healing of weakened or overworked tissues.

Reversing mechanical forces. Modifying movement patterns. Lengthening restricted joints and strengthening/stabilizing weak tissues. Do you understand why lasting relief for your painful spine or unstable knee is rarely a matter of simply cracking that baby back "in?"

In conclusion, instead of aiming for symmetrical movement, we should technically be aiming for more symmetrical movement. And a PT guy is fulfilled when he attempts to unite truth with beauty, and in doing so, helping someone along their way.

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Mental Reps - Patriot News

If you're interested, here's a link to the Patriot News (slightly edited) versions of some of the work that I've done here.


There will be one column per month for the next 6 or so months. Then we take it from there, I guess.

I've submitted You Should Probably Wear Shoes as my next entry for August.

I enjoy my time here thinking and typing. If anyone has

suggestions or pressing fitness/rehab comments or questions, certainly let me know.



Baseball Advice

[Some seriously good stuff by Kyle Wagner. Plenty more at gowagsbaseball.com]

Post Season Analysis

As a coach, you should always sit down after a season and discuss with your players what you see as their strengths and weaknesses. This way they have some direction with which to work.

Here are some post season general thoughts to whom it may concern.

1- Why do coaches constantly tell catchers to block everything? Nobody on base and the ball gets past the catcher and I hear coaches yell " block it." Why? To practice? Obviously those coaches never caught before. It's hard work catching all those potential dirt balls when you NEED to block let alone when your coach would like to see you practice.
Coaches, please let your catcher relax a little when he can.

2- I believe one of the most overlooked aspects to coaching is instructing the outfielders on where to throw the ball in crucial late inning situations.

Example: 5-3 game. Last inning. Runner on 1st base. Single up the middle. Center fielder throws to 3B to try and throw out the 4th run allowing the 5th run to move into scoring position. Ugh! How about an "all throws to 2nd base defense" coach!

3- The changeup is not a 2 strike pitch. Unless you've got yourself a Cole Hamels changeup, don't throw it when the batter is looking to protect. The changeup needs to be thrown in "hitter advantage" counts when the fastball is expected. Think 1-0, 2-0, 2-1. And if you're really, really good 3-1.

4- Who started all the cheers in the dugout stuff? It's baseball. Seriously, when did this happen?

5- Please, please, please stop telling your kids to not look at the ball when they run. Good baseball players hit the ball and take a peak at the ball so the position of the ball guides their decision making. The 1B coach should not be the only person to see it go through the shortstops legs.

Furthermore, I witnessed two separate ocassions where a baserunner was hit with a ground ball because he wasn't looking at the ball. Please!

6- Don't be afraid or embarrassed to say "I'm sorry." We've all been in a competitve situation where we've acted inappropriately. You're not alone. And as long as you didn't go Billy Martin on the umpire it goes a long way to apologize.