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I am just thinking out loud here (so to speak), but we have talked/read a decent bit lately on external cuing vs. internal cuing. Almost certainly all of us are cuing the excessive elevation prevention, or any and all scap motion for that matter, internally (e.g., don’t let your shoulder blade rise up too far, keep your shoulder blade tipped back, etc…) Is it even possible to provide an external cue that might be more effective?
I realize that somehow part of my post got cut off here.
Alex – “I wouldn’t avoid an exercise just because it increases activation of a specific muscle, as long as the movement pattern/motor control aspect doesn’t suffer.” Yes – my exact thoughts.
Oksana – I am certainly still trying to figure out the best way to prevent excessive scap elevation. I think we are going to have a very hard time preventing that if there is GH motion loss – the brain is going to find a way to get the arm at the same level, which it will almost certainly do through scap compensation if GH ROM is insufficient. Nevertheless, in patients for whom passive GH passive and accessory seems sufficient, and yet they are still excessively elevating, another tactic would be to manually inhibit and/or stretch the scap elevators. I have seen Eric do this a couple of times on patients and incorporate movement with it – kind of a soft tissue mobilization (or inhibition) with movement technique. It seems to work well.
only to a moderate degree. I hope to believe I choose exercises that promote an appropriate movement pattern and also that engage certain muscle groups based on my biomechanical knowledge of the what the muscle action is; I also want to make sure the patient feels relatively comfortable with the exercise.
For instance, I use the wall slide semi-regularly with cuing for scap protraction and upward rotation, and in doing so for SA contraction. Yes, pec minor does perform scap protraction as well, and therefore had higher EMG performance with this exercise. However, I am not sure I would back off the use of that exercise for that reason alone.
Again, with scaption I tend to focus on movement pattern vs. muscle activation. I think its quite alright if upper trap is active during scaption (as it is supposed to be assisting upward rotation); what I try and cue against is the excessive elevation component that is often seen. I frequently use mirror feedback for this. I feel I have had mild success with this.
Thank you for posting this Eric. This is certainly a keeper for any orthopedic PT. Similar to the consensus statement for rehab on arthroscopic capsulolabral repair.
I feel like this article exposed many areas of ignorance on my part, and will certainly change the way I practice. A few points of interest for me:
– I really enjoyed the references to the amount of tissue healing that occurs at given time points post-operatively. Repair strength is still only 29-50% of normal at 12 weeks.
– Only performing ROM if you need to. “Repeated cyclic loads can have potentially detrimental effects on the suture-tendon interface.”
– “Patients who exhibit poor compliance show a relative risk of re-tear or non-healing that is 152 times higher than that of compliant patients.” That’s a great stat to have when educating patients.Overall, my sense was that I am too aggressive in my rehabilitation of cuff repairs, and will certainly be more cautious moving forward.
For me reading the motor control article simply reinforced even stronger how I simply am almost using exclusively internally driven cues, not external. Part of the reason is that external cuing tactics and strategies are just not in my “wheelhouse,” and instead of trying to think outside the box I automatically resort back to that which I am comfortable with. In light of this, I particularly enjoyed the practical ways the authors provided on external cuing – things which I intend to practice in the clinic Monday (watch out for the cones…)
Observational video analysis is also something I never employ unless it is during a running evaluation. This is another straight forward and easy application I intend to use more frequently with different tasks.
I have seen the H-test referenced before – have yet to use it but am currently rehabbing a patient who had a hamstring injury in the mid portion of the semimembranosus. I intend to try and use some version of the test before clearing her for full return to sport. I think you probably could modify it and make it like the swing test – essentially performing it in standing instead of supine. However, I think the key to the test is that you absolutely have to encourage the patient to go full speed – as far and as fast as possible, to get a helpful measure. Don’t think I would rely on it alone for return to sport criterion, but could definitely be included as part of a test battery.
The running lab, although at times a little comedic, was actually a point of learning for me. The first point was that I was amazed that music truly did cue you to running a different cadence. That was very fascinating and definitely pushes me to use it as a tool if increasing cadence is a goal.
The second, and more substantial piece of information I learned, is that when you change cadence you necessarily change other factors, and I question whether that is always beneficial. It was very apparent that, for me at least, when cadence was increased hip motion was incrementally decreased. This goes against the concepts of increasing hip flexion in swing as the biomechanics article Eric referenced showed reduces impact peak/loading rate. This certainly might not be true for everyone, but it was certainly the case for me. My take home – there are a number of factors that we evaluate with running mechanics, not just one; and we must be sure that when we change one factor we aren’t sacrificing another beyond that which we deem acceptable.
AJ – thanks so much for the article post. Definitely has some helpful principles and specific communication tactics to employ when trying to help someone change.
I think that it is probable universal PT/health care provider experience that taking an authoritative approach often leads only to frustration for the clinician and maintenance of the status quo for the patient.
The more we discuss/I reflect on the subject, the more I realize how limited the Mike Evans video probably is for the patients we are mostly thinking need the video. It certainly could be helpful as a place to start some discussion, however its power in and of itself to produce change is probably extremely limited.
The pain science video, although certainly limited in and of itself as well, yet probably has more intrinsic value than the exercise video. Patients “know” that exercise is good and that they should be doing it. The video, while helpful, doesn’t in the end provide a new framework of thinking for the patient. An overly sensitive nervous system as the cause of someone’s pain vs. tissue damage, is certainly an entirely new framework of thought for most chronic pain patients.
MI seems to me like pain science education – I can see it has great value, I can name it when I see it, but to implement it into practice myself is very difficult.
I LOVE this video. My parents are overweight, inactive, and on the road to some serious health consequences. I sent this to them and will see how it goes with follow up.
Oksana – Dr. Evans has a number of such videos that you can browse through on you tube. He has one specifically on low back pain.
Although I love these videos, due to my new exposure to them I have yet to use them clinically. Thus, I am still trying to figure out when it would be appropriate.
My suspicion is that the videos only have limited effectiveness as a stand alone intervention (e.g, my parents are probably unlikely to change based on this 10 min video alone), but can be a helpful way to introduce someone to new concepts/ideas/research, and serve as a platform from which to routinely follow up/individualize the application.
It really ought be incumbent upon us that before we discharge anyone, we do our best to see to it that they are regularly exercising. EVEN IF they seem not to have central sensitization/pain catastrophizing type presentation, we are doing our patients and the entire medical community a disservice not to push people to becoming active.
Disregard the above post – got lost in all my tabs and posted in the wrong location!
#residentidiot
My take on the decrease use of health care expenditure with early PT and yet not necessarily superior outcomes: yes, our research could certainly be better, and if so may show an improved result. However, MOST cases of acute LBP have a predictable course of recovery, and that recovery timetable is perhaps only modestly improved by what we have to offer. A large proportion of what we are providing is EDUCATION/FEAR REDUCTION such that, though all patients must continue to go through the similar healing/recovery process, those who see PT’s have a greater understanding of that process and therefore are less vigilant about their condition/pursue less advanced imaging/meds/injections/etc…
Don’t get me wrong, I DO think that early PT in many instances does indeed improve the patient outcome, however I think a lot of what we do through education is what results in the reduced health care utilization.