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.


Awesome To You

My 33rd lap around the sun is nearly complete. It's a pretty unremarkable birthday, hopefully. I'll be having cake and ice cream with Amy and my 4 little friends and likely some neighbor kids.

It's time to reflect on leaving the court, weight room, field, etc., gracefully, and getting my 30 minutes of semi-vigorous activity like a good middle aged man.


Golf slays me. Since when are marathons and triathlons the measure of an adult athlete? I imagine that in a few days, at 34, I still won't want to do those things unless I have to.

Don't get me wrong. I can appreciate why bajillions of people love golf. I absolutely applaud anyone interested in pushing their bodies through the sweat and discipline and discomfort of new heights, whatever they may be.

Well, some exceptions are noted.

[editors note: don't do a Google search of the words "shake weight"]

But on the whole, I'm pretty sure that long drawn out cardio is overrated. Not that anyone should stop jogging or recumbent biking or Tony Little Gazelling IF they love to run or recumbent bike or Gazelle. I'm definitely still of the age where I'd like my fitness and leisure activities to pass the Awesome Test.

Most of the things you see people do for exercise don't pass the test. If The Bachelor and every other show involving long drawn out rose ceremonies can utterly butcher the word "amazing", then I'm allowed to stretch "awesome" into an 800 word blog.

I recently saw a dude at Planet Fitness plodding away on the treadmill. Sure, there is a lot worse he could be doing with his time, but I didn't think that was very awesome.

The next day I stood by an athlete repeatedly pulling 135 pounds right off the floor with perfect form. That was definitely awesome.

I saw a lady biking down past the Yellow Breeches. She looked like she was benefitting from the ride, getting from A to B in the fresh air, but I wouldn't say it was awesome.

I caught a neighbor kid jumping his bike off the side of a ramp in our yard. He fell in the grass and that was awesome.

118 mph controlled tennis serves? Lifting 95 pounds from floor to over head fifty times in less than 10 minutes? Rapid fire flips and backward somersaults on a narrow balance beam? Fade away jump shots in the eye of lanky behemoths? Awesome, awesome, awesome.

Nine iron from 30 yards for an eagle? Swimming for more than, like, 15 minutes? Driving around other guys driving? That...thing people do on an elliptical machine? These are either difficult or physically challenging, but not both. And not awesome.

I don't even try to be awesome at everything that's awesome. I think advanced yoga and extreme cheer leading are pretty awesome. You don't have to be formally trained to know awesome when you see it. In fact, ask anyone less than 18 if a certain activity is awesome, and they're probably right.

Of course, what passes the awesome test for an adult is far from hard science. The problem is that the common denominators for my preferences are not words you think of with aging. Speed, skill, strength, intensity and risk. Not exactly "take the stairs instead of the elevator" type of activities.

What can you do, when nobody is getting any younger here, and slowing down is inevitable? Slowing down to a stop, in fact.

No matter how hard we fight aging, we will experience a gradual closing of that precious window of time between warmed-up and tired. We will get stiff and achy and not feel like hitting the ground.

You can do something! While I won't deny that there's nothing awesome about torn tendons and fractured bones, I will say that these types of injuries shouldn't be viewed in isolation. It was usually (but not always) a set up.

There's plenty of evidence that fitness, strength, and power can continue to increase, especially if you're previously untrained. The thing I'm trying to do is to not except the plight of the middle aged. Chronically too many responsibilities (by choice, not necessity), slow twitch, no butt Khaki pants wearing, looking like a dad.

I won't even drag the couch potatoe Homer Simpsons into this. Take a look at these guys. I'm pretty sure they're more awesome people than I'll ever be. But they look like dads:

It's a dad's life.

If you don't want to look like a typical dad you're going to have to make your physical and mental health a priority and revolt against the forces of (only) long drawn out cardio.

You can do high intensity activities if you're wise about it. Wisdom means arranging your life, if at all possible, to allow some time to play. It means gradual progression and consistency; not expecting to lay around all winter then sprint out a triple on a cold day in March. It means knowing good pains and bad pains and working hard toward a few identifiable fitness goals that are a fit for your mind and body.

But please don't do random long drawn out cardio on an elliptical or just sit around for the majority of the year and then blame flag football for your achy knees or torn ligaments.

Also remember that while you can walk in the mall every day, by their very nature, high intensity, high impact activities were never meant to be engaged on a daily basis. No one, at any age, should lift heavy things or take big hits day in and day out. The whole cycle of exercise, rest, and recovery is an essential, beautiful, and satisfying thing. So let it be, let it be.

I won't deny that no matter how many daily battles we win with our most intelligent and disciplined efforts toward fitness and vitality, old man time wins the war. He always wins. But for now, I say go hard, as hard as you can. Go hard while it's in you, because someday you absolutely won't be able to. Going hard is a gift, so don't waste it on yet another round of boring long drawn out cardio.

Unless that's what's awesome to you. And especially if that's really all you can do, then more awesome to you.


Ain't Too Proud to TENS

"Now tell me again. What's this supposed to do?"

Patients often pose this question in the clinic, right after I've slapped electrodes on a sore spot.

The rationale for electric stimulation can get pretty technical, of course. But to keep it simple, I usually just tell patients that it helps with swelling, muscle spasms, inflammation, and temporarily masks the pain.

"Oh. Okay then."

And it's true.

How a little voltage accomplishes these things is really less mysterious than you would think. Neuromuscular stimulation (NMES) is a strong electrical current that's proven to help with recruitment of weak or injured muscles. We use that in the clinic too, but for now we're only talking about using transcutaneous electrical neuromuscular stimulation (TENS) for pain relief.

The TENS current causes the spinal cord to release a natural endorphin called encephalin, which reduces the reactivity of pain pathways. TENS also provides sensory overload at or around the painful area, effectively bum-rushing the nervous system so you notice relatively less pain. Lastly, the electricity causes constriction and dilation of small arteries by way of a few mechanisms. The increased blood flow leads to decreased swelling and increased metabolism of toxic and inflammatory substances.
So yeah, it's not just a distraction. Well, sorta. But nobody can bill for an empirically proven, much needed, and highly demanded therapeutic nap.

But looking past glorified naps, inflammatory substrates, and decreased sensory perception, TENS is not exactly an evidence-based procedure when you try to put numbers on functional outcomes like lifting at work or jumping on the court. More than that, TENS doesn't give rehab people anything to brag about. It's not technical or highly skilled. There are no costly continuing educations tracts where medical professionals get to show off lots of letters for their E-stim certification.

I've never seen a fellow PT "market" the use of E-stim as a strong point in their treatment programs. I mean, could you imagine...?

"My clinic is unsurpassed when it comes to turning this dial and pushing that button."

You could prop any monkey or reader of People Magazine into a rehab setting, teach them a few contraindications, and they could slap electrodes around painful body parts. Oh, and turn the unit on. Yeah, uh...nobody has ever had to remind me to turn the thing on.

PTs do have other good reasons for the backlash against E-stim and other passive modalities like ultrasound. I've learned that the 80's and 90's sometimes had PTs charging insurance companies for 24-plus visits of "treatment" consisting of E-stim and a hot pack for 30 or 60 minutes. Again, therapeutic nap not withstanding, this practice over that many visits is lazy at best and deceptive at worst.

Working on your feet is...work.

One of my past writings was published as a guest editorial in Advance Magazine for PTs. It was a tongue-in-cheek call for PTs to quit acting like they have all the answers and with that, experience the freedom that comes from embracing the limits of our profession. I wrote a sarcastic "about the author" blurb that said I was certified in Ultrasound and E-stim.

Most PTs (and only PTs) would get the joke; the idea of specializing in something that no therapist takes great pride in. To say the least, I found that the editors at Advance are not PTs.

The bottom line is that I use E-stim in the clinic, always as a component of a comprehensive treatment program. Most people love it. Patients often comment, sometimes with creative expressions, on how it works. I do feel it's good practice for PTs to give full disclosure on the matter. Mine usually sounds something like:

"E-stim is not essential in your treatment if you don't prefer it. It doesn't address the root cause of mechanical pain; the poor strength, flexibility, or movement patters. Problems that are mechanical in nature really do require a mechanical change to fix. Manual mobilization of the joints, flexibility work, and ugh, conditioning exercise, are a lot more effort for the patient and the therapist, but they ultimately treat the problem instead of temporarily helping the symptoms.
...and who can deny the power of the therapeutic nap?"

There. Was that so bad? So now lets zap away if it makes you feel good.

Extreme forward head posture with severe kyphosis. And blue. E-stim will definitely fix this dude.
E-stim won't likely be proven alone to be effective for functional outcomes. I don't care. There is an extensive research base of TENS for pain relief (not necessarily functional outcomes) in both the clinical and laboratory settings. If it helps with pain, albeit temporarily, what's the harm in that? You go ahead and try living in pain 24/7 and see if a few hours of nonfunctional, temporary pain relief is worth it.

There's an exciting area of study regarding the use of a slightly different type of electrical current that, rather than stimulating the muscles and nerves to "fire," acts as a specific electrical signal to all tissues in the body. The signal causes those tissues to inhibit or accelerate what they do, which may be a promising way to circumvent the side effects often see with medications.

Until then, if aches and pains cause you to seek a PT, I would probably try to zap you, and would definitely try to get you to move differently.
It's Mental REPS, not Mental Laying Around on TENS.
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[Here's the bio that was actually published in the Advance editorial.]

Robert Gorinski is a physical therapist in private practice in Harrisburg, PA. He specializes in ultrasound and the use of other passive modalities. He is creator and founder of the Common Sense Method of Recuperative Rehabilitation Therapy.
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