Wednesday, April 20, 2016

What Is Evidence Based Practice??

You go online or your read an advertisement that says something like "...our _________ work in an evidence-based practice and use the latest evidence to guide our __________."  You read this and may think, "this sounds good" or "sounds like they know what they are talking about." Would you be surprised to hear that evidence-based practice is standard?  So why would a clinic advertise that this is different from everyone else?  Maybe it is their implementation of evidence based practice that is different or the fact that they even do it (an unfortunate statement I know).  So what exactly is evidence-based practice or EBP?

Evidence based practice is the implementation of a practice that involves the melding of best research evidence, clinical expertise, and the values of the patient.  Implementation of evidence-based practice happens in multiple ways but the ultimate outcome is highest quality of care for you in a reasonable amount of time. 

Integrating the best research evidence is not always easy or "perfect."  

It is difficult to conduct a study that is perfect by all standards.  In medicine and health the targets of our studies are people, and as we are all aware, people are not all the same.  We call this variability and variability makes it very difficult to fit one thing to everyone.  Therefore, in research, we try the next best thing.  We try to see if the treatment or outcome fit the majority.  This is where things become a little sloppy because to look at the majority we have to minimize as many confounders as possible.  Things such as researcher bias (wanting to make something true to be famous, financial reason, or personal reason), subject bias (the person being studied wants to be famous, a financial reason, or personal reason), and other influences (too many to list quickly) play a huge role in the outcomes of a study.

Research happens mostly at universities or institutions that have an invested interest in the area.  This can be a good thing but on the flip side it can lead to fudging the numbers.  Now technically we can say that numbers do not lie but you should know that the people who interpret the data do.   Actually integrating the best evidence into practice requires a deep understanding of the strengths and limitations of research.  Without this discernment we can become victim to many of the myths that have perpetuated the headlines (such as eggs will kill you or vaccines cause autism).  That said, we must understand that research is paradoxically both important for advancement of knowledge and sometimes blindly overstated.  The way in which studies are designed also affect their applicability (and data).  In general, all studies should be designed to disprove the hypothesis (i.e. what the research wants to prove or believes will be true).  The best a study can do is to say that the hypothesis (the theory) still stands to be challenged another day.

What we should strive to do is critically look at the research and apply it based on the quality and relevance to the individual. Research should continue to challenge our beliefs. That is why we conduct it, distribute it, read it, and talk about it.

Clinical experience is a very important thing but ask yourself "do they have 1 year of experience 10 times or 10 years of experience?"

I've worked as a clinical instructor and mentor for several years.  The one thing that I see happen repeatedly is that medical and health practitioners become very algorithmic or stuck in following a pattern.  Early on in my career I was told that the most powerful tools I could have were my hands.  I believed this for a long time but now I believe it is the mind. Being able to think and have flexibility allows you to develop, modify, and help each individual.  However, many of you have experienced being treated exactly like everyone else and not getting anywhere.  I would partially blame the current health insurance system for unthinking  medicine by making it all about numbers and profitability.  This does not entirely take the practitioner out of the mix.   The practitioner should be flexible and be able to learn from their failures as much as their successes.  They should be able to admit to making mistakes.  Thinking should not be something only the few do.  Every medical or health professional that you work with should be able to give you a clear thought process on why they are recommending something.  Additionally, they should be able to explain what will likely happen with their plan of care...whether you improve or worsen, what it means and what the next step should be.  This is truly thinking.


Have you ever been to a medical or health practitioner and you felt like they did not listen to you?

You may have said you did not want to take medicine or do certain things and they just ignored you and did not engage you in conversation or offer a compromise.   Maybe they just talked at and not with you.   This is a common thing today.  The current insurance system has led to dehumanizing of medicine by reducing the time someone can spend with you.  However, the practitioner can still maximize the interaction by using intake forms that ask about your life and goals.   This form can help generate a dialogue in this time-constrained environment.  Your other alternative is to choose someone who will spend the time with you.  This is your health and someone should be willing to ask you what you think and/or want.   They should be able to explain to you why your goals are realistic or need modification based on their expertise.  Medical and health practitioners should be there to help you get to outcomes but you are the one that will make it happen. Good practitioners are like coaches that work with you to improve.  They should understand you and be able to work with your individuality and not just your condition or label.   


No one is perfect and your medicine or health practitioner should embrace this.  They should be there to help you achieve whatever it is you want to happen. 

The interaction should be evidence-based practice.  If one of the three aspects is lacking, they should utilize the best of the other areas to help you in the best way.  The practitioner should not ignore one of the aspects and you should always feel like you have a part in your care.   Your belief in what you are doing and having interest is the key to success in health and medical care.  Evidence-based practice is the way a practitioner provides you with the best and most appropriate coaching.   If you are a passive participant, then you will probably get the outcome that is given to you rather than the one you make. It's your health, so choose what you feel is right and make sure you work with someone that can help you in a way that make sense to you and you can truly participate in your health.  

Tuesday, April 12, 2016

Shoulder Mobility and Beyond

Shoulder mobility is necessary for a large number of tasks.  It is crucial for performance of overhead activities such as the overhead squat, snatch, and jerk.  Many people find it difficult to perform these activities and may even experience pain or discomfort.  It usually feels tight or restricted and the many people's initial thought is there is a mobility restriction.  This generally leads people to foam roll, smash tight areas with a lacrosse ball, and hang from a pull up to get the shoulder moving.  There may be varying degrees of short term success but the problem may not go away completely (unless you are perhaps one of the lucky ones).  As we often ask a treatment really working if the problem keeps coming  back?  What else could be causing the shoulder to feel tight if it is not simply a mobility restriction?  The short answer, motor control.  This is where the idea of stability comes into play.  For our purposes, we will use motor control to describe the intricate dance and coordination of the muscles in our bodies.  When we demonstrate that we have control in our movements, we naturally move with less restriction, tightness, and stiffness.

So how does motor control work exactly?  You can consider our muscles the tools, our nerves the messengers, and our brain the orchestrator.  To create controlled movement, our body coordinates both our stabilizing muscles and our primary mover muscles.  The stabilizing muscles tend to be smaller and located deeper within the body, closer to our joints.  They help us "centrate" our joints and keep things moving smoothly and without unnatural restrictions.  Our primary mover muscles are larger, more superficial, and are responsible for creating the big movements we can observe with our eyes.  Understandably, there is a lot going on to perform any simple task (such as raising one's arm overhead).

A key deficit for many people is that their stabilizers do not contract quickly or adequately enough prior to the larger muscles initiating movement.

When this happens, we lose some of our natural joint stability and the end result may appear to be a stiff or tight area.  But often what is occurring is really a disorganized movement pattern, not a true mobility problem.  Most of us work our primary mover muscles frequently but do not necessarily provide adequate training for our stabilizers.

So how can you test whether or not you have a mobility problem or a motor control problem when it comes to tight shoulders?  It's actually quite simple.  Start by holding a band between both hands directly in front of you, elbows locked straight, and get some tension on it.  Next raise your arms over head and pay attention to how your shoulders feel.  If you can move overhead with the taut band and you feel less tightness than you usually do, you my friend have a motor control issue (Overhead Testing Video).  But how exactly does this voodoo magic work?  By loading the band prior to your big movement, you help to activate your stabilizer muscles first.  If activating your stabilizers first improves your movement, than you've proven that part of your shoulder tightness lies in your muscle coordination.

But what about the people whom the band does not have a big effect?  Now I want you do pay attention to where you feel your tightness.  If you feel mostly tight in the upper back, you might start looking at your thoracic spine or latissimus dorsi mobility.  If your posterior shoulder is screaming at you, you may have a posterior shoulder tightness, chest, or latissimus dorsi tightness.  If it is in the anterior shoulder, you may have chest or upper trap tightness.

The tightness in these areas could still be originating from an over reliance on stronger superficial muscles to stabilize the shoulder.

When this happens, you still end up with a similar problem of properly coordinating your stabilizers and your prime movers.  But in this case, you may require a more in depth movement analysis to find out exactly why you're cheating the movement.

We have a few examples of exercises for the shoulder that have been shown to improve motor control.  The key in their execution is quality repetitions and demonstration of control during the actual movements.  It makes sense right?  To improve shoulder control you want to practice controlling the shoulder.  Here are some exercises to help you.  Click on the exercise to see the video.

Scapular T

Scapular Y

Scapular I

Shoulder Flys Alternate

Seated Cross Legged Alternate Arm Raise

Upper Body Rolling


After you gain the motion with the exercises, it is time to work exercises into that motion.  Work exercises that you are able to move the full range of motion without degrading form. 

If your form degrades, go back to the exercises and back off whatever made you degrade.  It is a good idea to perform these exercises at the end of a session as well to "recover" and fight off any stiffness.  

While proper shoulder motor control practice can often improve the problem, if you're not noticing a difference or still have persistent tightness, you may need a little extra help.  If you are in the Colorado Springs area you can get personalized attention with one of our movement assessments.  Our movement assessments are designed to look at your whole body movement and tackle the areas that may be causing or perpetuating compensations (and leading you to not succeed in your program).  You'll get personalized homework from these sessions to help you achieve actual, lasting results.  It's like going to the dentist...but for your whole body.  See our services page to learn more.

Thursday, April 7, 2016

Knee Imaging is Not An Examination or Absolute by Itself

Many times we see patients that have had imaging done (sometimes costly) after having a minimal examination by their doctor.   Then they are told they have a...insert your diagnosis.... based on the imaging results, a very brief exam or a combination of both.   The knee is one of the most commonly imaged areas of the body. The infamous diagnosis of the knee is a meniscal tear.  However, there has been shown to be a high incidence of meniscal tears in non-symptomatic knees as well as symptomatic knees.  Additionally,  lateral or medial joint line tenderness and end range of motion joint pain seem to be the best indicators of meniscal issues.  There are other tests such a McMurray’s and Thessaly’s test that has some usefulness as well.  

One of the biggest problems we see is that people come to me with pain in the front part of the knee yet they are told they have a meniscal tear and that is why they have pain.   However, if you look at the anatomy of the knee the menisci do not go all the way to the front of the knee and there is actually joint capsule and a fat pad that take up much of the anterior knee.  So if the pain is felt toward the front of the knee it is almost impossible to palpate meniscus there.
Meniscal tears actual occur for two main reasons: trauma or overuse.   The trauma kind is usually caused by a loading of the knee vertical with a twisting motion with the knee extended or flexed.  A pop is usually felt but swelling may not occur hours after the injury.  If the swelling occurs immediately, then more likely some ligament injury or anterior knee structure irritation has occurred.  The overuse kind is degenerative and occurs over time.  Overuse meniscal degeneration is usually seen after the third decade of life but can be seen early in individuals that perform high impact activities to the lower extremities (lots of jumping or constant twisting).  However, degeneration is common in people without any pain or issues.   Remember there are many soft tissue structures on the front of the knee and if they are compressed by the knee cap, they can cause debilitating pain and swelling.
The problems that should concern you with a meniscal tear is if the knee is locked in a position or unable to move through the full range of motion with help.   This would require a visit to an orthopedic surgeon.  Surgery is not always thebest course and complications do arise from surgery.   If you just have pain with certain activities and the motion is full, then an individualized thorough examination and rehabilitation is the best course.  If you are barely touched or someone tries to tell you what to do based on imaging alone, I would be wary of this.  It is your body and you have to live with it.