#3 Fueling the Male High School Athlete

     Hey, everyone. This blog post provides a copy of the slides from a presentation I gave last week at a high school near my current clinic rotation. I have been spending some time with the high school's sports medicine team and the head ATC asked me to talk to students of the football and baseball team about diet and supplementation. The slides do not include my notes. Click the image below to advance to the next slide.

      As always, consult a Registered Dietitian for individual dietary needs. 

- Patrick Berner, SPT

#2 – The PT Homework Folder

     Hey, everyone. In this post, I wanted to share something that I have found unique to my current clinical site. They have recently adopted the use of a homework folder. Now this is just an ordinary HEP (Home Exercise Program), but they provide every patient with the tool to keep those loose handouts organized, a simple 2-pocket folder.  Almost every exercise we perform in the clinic is provided in print, with images and detailed instructions, which most importantly allows patients to continue care beyond therapeutic intervention. 

     Patients are asked to bring their folder into every appointment to facilitate the constant use of their HEP. This allows patients to easily and specifically identify any exercises that may be difficult to perform or cause pain. In addition, we can make adjustments to their exercises, such as changes to sets and reps or advising them to discontinue if necessary. 

     Without this simple 2-pocket folder, patients have an increased possibility of misplacing loose HEP handouts, decreasing HEP effectiveness. I believe this very small alternative approach to HEPs greatly benefits the patient, especially in regards to compliance and accountability. 

Thanks for reading.

- Patrick Berner, SPT

#1 Functional Rehab – Lifting Techniques

     Hello, everyone. This post is the first for my final round of clinicals and I hope to have at least 6-8 posts in regards to all that I’ve seen or learned while here. I am finally out of the state of Florida and temporarily living in South Carolina, a state that is very pro-physical therapy and open to all that our profession has to offer.

     The clinic that I am doing this rotation at is a private outpatient clinic that specializes in an extensive array of orthopaedic conditions, as well as workman’s compensation claims. The staff has a strong passion for functional movements and incorporating those into treatment, which I have come to respect tremendously.

     A majority of patients, whether they have an upper or lower extremity dysfunction, will receive training in proper lifting techniques. Because if you think about, lifting will always involve all of the extremities, whether in stabilization, movement, or a combination of both in order to move something, small or large.

The 3 main techniques include:

      1.     Box Squat

2.     Lunge

         3.     Golfer’s Lift

     The box squat is a position of considerable force production and should be used when wanting to lift a heavy object from the ground.  The most important key to performing this lift, as with all lifts, is keeping the back straight and generating force from the legs.

   

     The lounge, a staggered stance, is another position that can be used to lift an object from the ground, but also an excellent position to push an object away from your body.

 

 

     The golfer’s lift, another multi-purpose technique, is by far my favorite lifting technique to use throughout the day. This can be used when picking up something light from off of the ground, bending forward as if you were to drink from a water foundation, reaching out for something in front of you, and many others. An important thing to note, using this technique when reaching forward will allow you to maintain a straight back and decrease the stress applied to your outstretched arm, but remember to stabilize with your other hand.

Thanks for reading!

- Patrick Berner, SPT

#8 Top 3 Informative Tips - 2nd Clinical Wrap Up

     Hello again. This post wraps up my 2nd clinical rotation. I hope you have enjoyed them thus far. I have now started my 3rd and final rotation, where I hope to share with you my experience with industrial physical therapy and the world of corporate wellness.

     For my final post of internship II, I wanted to share the top 3 informative tips that I provided to my patients over the 8 weeks. As you may notice, all three of them correlate to the treatment and prevention of low back pain, but they apply to most healthy individuals.

     Towel Roll in Sitting – The use of towel roll in sitting is an excellent way to maintain the natural curvature of your spine, which is necessary to properly disperse forces or stress.  The lumbar spine, five segments of vertebrae found between the thoracic spine and sacrum, has a natural lordotic curve. A lordotic curve is one the turns inward towards the front of your body. Simply take a standard bathroom towel, fold it in half long ways, and roll it up. You can even duct tape it together so that it is always quickly available. When sitting, place the towel roll at the small of the back, where the natural curvature is found. Maintaining this force-dispersing curve will aid in preventing unnecessary stress and pull on ligaments and muscles of the back, as well as other structures of the spine.

     Supine-to-Sit – Supine-to-sit is a transition where you adjust your body from lying on flat your back to sitting up on the edge of the bed. I was astonished at the many different ways I observed patients come into a sitting position, most of which caused me some of my own back pain.  Due to changes in spinal column stress at different positions, the most appropriate way to go from supine-to-sit is first to roll onto your side, towards the edge of the bed you will be sitting. Once in a sideline position, fully lying on the side of your body with knees bent, you will move into a sort of pendulum motion. As you bring your feet forward and off the edge of the bed, you will push your body up and away from the surface. You should then be in sitting. A typical response I received from patients was, “this is how I get out of bed when I hurt.” This statement should show you that your body knows the best way to move, and you should always utilize this maneuver.

     Core Musculature Activation – Some professionals do not like to use the term “core” and I can agree with them when the term is used incorrectly. When I say core musculature, I’m specifically identifying those muscles responsible for direct stabilization your spinal column. Now in order to provide direct stabilization, the muscle needs to be anatomically attached to the vertebral bodies of the spinal column. I’m sorry to inform you, but the superficial rectus abdominis muscles, those 6-pack abs, are not attached to your vertebral bodies. The three main direct stabilizers of the spine include transverse abdominis, internal oblique, and multifidus. Now even though research is currently on the fence about whether or not local or global musculature strengthening improves back pain. I believe local activation yields the best results. Now in order to isolate these muscles, specifically the transverse abdominis, you need to draw in your stomach. Think about bringing in your stomach as if you were putting on a tight pair of pants or about to absorb a punch in the gut. An excellent way to check yourself and whether you are activating the correct muscles is to put your fingers on the front part of your hip bones and slide off the bone towards your belly. At rest, your fingers should sink in, but with activation you should feel the muscle push into your fingers. Activation of these muscles will provide stability of the spinal column and should be performed during all movements, especially lifting, whether from the ground or overhead.  


As always, seek the help of a licensed healthcare professional.  


- Patrick Berner, SPT

#7 Pain - Is it That Intense?

     Hey, everyone. Over the past eight weeks, the majority of patients that I have treated came to therapy due to complaints of pain. Some of them stating pain levels so high I wondered how they even came to therapy. I want to share with you a TED Talks that was introduced to me during a course last term and I believe it is a presentation that everyone should see. Enjoy.

- Patrick Berner, SPT

#6 Treatment Progressions - Build a Foundation

     Hey there. Tonight’s post is going to be a brief overview of my 2nd clinical rotation in-service. I’ll be presenting this in-service tomorrow during lunch, and my audience is employees of the clinic, including physical therapists and physical therapy assistants. This topic was chosen after several weeks of observing improper advancements of treatment interventions. In this post, I’m going to focus on sharing information from my primary source and leave out the details that are unique to my clinic.

     The presentation starts with an overview of treatment progressions. I included progressions for balance training, spinal stabilization, and sit-to-stand because the majority of people seen within my clinic include patients who have a fall risk, low back pain, or lower extremity weakness.

Spinal Stabilization Progressions:

Non-weight Bearing -> Weight-bearing

Local Musculature -> Global

 Simple -> Complex

 No External Load -> Resistance

 No Stimuli -> Perturbations

 Non-Functional -> Functional

Balance Training Progressions:

Bilateral Lower Extremity -> Unilateral

Eyes Open -> Eyes Closed

External Support -> No Support

Stable Surface -> Unstable Surface

No Stimuli -> Perturbations / External Stimuli

Slow -> Fast

Sit-to-Stand Progression:

Sit2Stand Machine -> Standard Chair

Elevated Seat Height -> Standard Height -> Decreased Height

Lower Extremity Biasing with a Step (Target leg on the ground surface)

No Stimuli -> Handling an Item/ Cognitive Challenge

     My clinic has a Biodex Sit2Stand™ Trainer, a piece of equipment that facilitates lower extremity strengthening. The machine replicates a functional sit-to-stand, but supplies assistance, making the task easier for lower level patients. Check it out here.


     The presentation continues with a discussion about a new theoretical model for treatment progressions.  The following information is pulled from an article found in Physical Therapy in Sport, the reference can be found below. This model can be used to attain any goal or perform any activity that involves combining multiple skills in order to execute.  

     The X-axis represents time, and the Y-axis represents the level of difficulty. Each grouping, moving along the Y-axis, is a combination of skills. At skill (1), the patient has the most control by using intrinsic factors, such as what they feel or see. The therapist can provide external control by way of providing feedback or cues. This element, skill (1), remains consistent throughout.  You can progress within this skill level by increasing hold time or repetitions. Skill (2) is the addition of an extrinsic component, which is a change in stimulus or environment, and skill (3) is the addition of another advancement. Skill (2) can be removed and replaced with skill (3) to ensure proper form and mechanics before combining all three skills, as seen in the fourth column.

     Now if that was confusing, I hope these two examples will help you understand how to apply this progression model.

Spinal Stabilization/ Core Strengthening

(1)   Abdominal activation

(2)  Extremity movements

(3)  Sitting on a Theraball

(4)  Perturbations

            Standing Balance

(1)    Postural control and abdominal activation

(2)   Unstable surface – foam pad

(3)  Upper extremity manipulation / Perturbations

 

     Using the model, you want to ensure the patient obtains stability and core control on a stable surface before progressing. Following completion of skill (1), the patient can then be placed on an unstable surface. Next you would put the patient onto a firm surface and introduce perturbations. Once skill (2) and (3) are mastered independently with skill (1), you can place the patient on an unstable surface with perturbations. The next example is adjusted the same, with the addition of a 4th skill.

     To determine whether an activity is too difficult and requires a downgrade, the therapist needs to look for various compensations. Including the following examples:

Spinal Stabilization:

Arching the Back

Bearing Down/ Global Activation

Holding Breath

Loss of Abdominal Contraction

Balance:

Increased Postural Sway

UE Support

Excessive Hip/Ankle Strategy

Disorientation

 

     The bottom line is that an activity cannot be performed correctly unless it is built upon a strong foundation. The body cannot function as a whole without correct activation and use of its’ parts.

- Patrick Berner, SPT

 

References:

Blanchard S, Glasgow P. Masterclass: A theoretical model to describe progressions and regressions for exercise rehabilitation. Physical Therapy In Sport [serial online]. August 1, 2014;15:131-135. Available from: ScienceDirect, Ipswich, MA. Accessed October 10, 2015.

#5 Icing an Injury - Watch the Clock

     This post will be rather short, but I thank you for reading. Check out my other clinical internship posts so far and those on my main blog page. Over the past few weeks, I have come across numerous patients that required the use of ice for reduction of pain and swelling. Ice has been shown to decrease the inflammatory response and presence of edema by causing vasoconstriction and reducing blood flow to the treatment area. However, the idea of "more is better" does not apply here, nor does it for many other things. 
     

     Icing should be limited to 15-20 minutes and no more. With an increased icing time, the body has a Hunting Response, where vasodilation and an increase in blood flow will begin to occur. Think of it has a self-preservation mechanism, where the body wants to re-establish blood flow and nutrients to that tissue. This response will negate the effects of icing and more than likely increase swelling of the tissues being treated. Also, keep in mind the possibility of frostbite with prolonged icing. 

     While icing, you should experience a cycle of sensations. Starting with coldness and progressing to burning, aching, and numbness, taking roughly 5 minutes to reach the numbness stage. Ensure you know the contraindications to this modality prior to use, including Raynaud's, Buerger's, severe cardiovascular or respiratory disorder, tissue with a history of frostbite, and tissue with decreased circulation, such as in peripheral vascular disease and arterial insufficiency. 

- Patrick Berner, SPT

#4 Imaging is Not a Guarantee

     Hello again. I am a bit behind on my weekly updates, but I am going to try my best to catch back up. I performed a patient evaluation today that reminded me of another evaluation I completed a couple weeks. I had been waiting to post about the older case because I wanted to provide some evidence-based research to back it up, but I will end up just posting that on my main blog page soon. Both of these cases involved the patient providing imaging results during their evaluation.

Case #1 –Bulging Disc vs. Hip Tendon Pathology
     The patient came in with complaints of hip pain, which came on gradually to his/her recollection. During the history taking, he/she immediately inquired about whether or not we had his/her imaging results. I politely acknowledged that we did receive them, but we would discuss the results later on. The patient was convinced, due to the imaging results, that his/her pain was being caused by the bulging disc in his/her lumbar spine. The patient did not present with a symptomatic bulging disc, and I say this because not all bulging discs cause pain or symptoms (this is the research evidence I was referring to). The patient  presented with evidence indicating the presence of a hip flexor tendon pathology, where a contraction and palpation of those muscles elicited pain.

Case #2 – Osteoarthritis vs. Shoulder Tendon Pathology
     The patient came in with complaints of shoulder pain, which started after a day of heavy lifting where he/she moved into a new home. During the history taking, he/she referred to the imaging performed on the painful shoulder that revealed osteoarthritis. Once again, this patient was confident that the pain was being caused by what the imaging results stated. However, imaging results were again not the cause of his/her pain. The patient presented with evidence that indicated the presence of a rotator cuff tendon pathology, specifically the supraspinatus and teres minor, as well as a long head of the biceps tendon pathology.

         Source Link

       Source Link

     The general public has become reliant on imaging and believes that the results will have all the answers. The fact of the matter is that this is just not true. Yes, imaging gives us more information into what can be causing dysfunction, but the results should not be all we look at to confirm a diagnosis. As movement experts, we primarily rely on what the body tells us and what our patients tell us during their movements in order to diagnosis a musculoskeletal condition.


- Patrick Berner, SPT

#3 We All Have Impairments

     This week I have a brief summary of an examination that did not lead to reproduction of symptoms. As neuromusculoskeletal experts, physical therapists look to reproduce a patient’s primary complaints of pain, as one of the many things that we do. Physical therapists examine bodily movement, along with gathering a subjective history, to gain an understanding of how a particular motion may elicit symptoms.  As a quick example, if someone was to have an Achilles tendon pathology, the patient would typically report pain with walking, ascending stairs, and coming up from a squat, which could then be reproduced in the clinic.

     My patient reported low back pain with a gradual onset and no recollection of a cause. The patient did not present with any red flags or signs that indicated the pain to be outside of our scope of practice. During my examination, his/her symptoms of pain could not be brought on; however, the history did include that pain increased with prolonged sitting or standing. Movements involving the thoracic spine, lumbar spine, and hip could not reproduce his/her back pain, not even mobility testing. However, the patient did reveal significant lumbar paraspinal muscular tightness during palpation, within the area of his pain, which correlated with his/her sway back posture in standing. With a sway back posture, lumbar extensor muscles can be constantly turned on and shortened, think of it as irritating those muscles. My clinical instructor and I hypothesized this to be the cause of his pain, along with weak spinal stabilization musculature.

     However, this was not all we found. This patient also presented with significantly tight hamstrings, weak hip musculature, forward head and rounded shoulders posture, and poor standing balance. These are impairments that could easily lead to decreased mobility and function. He/she did not expect these results from the examination, nor would anyone else expect to have these. The truth is that many of us could have impairments and not even know it until having been examined by a physical therapist. Though you are not having pain from these, some may affect you in the long run. 

- Patrick Berner, SPT

#2 Osteoporosis - In The Dark About It

     This blog's topic is on osteoporosis, a condition that requires a lot of lifestyle modifications, but a lot can also be done to prevent it. Osteoporosis is one of many conditions, in my opinion, that requires the collaboration of a physical therapist and a registered dietitian for successful management. I will provide some links to the National Osteoporosis Foundation website, where you can get a lot of information on prevention, living with the condition, and who is at risk. 

Prevention of Osteoporosis

How to Safely Move and Exercise


     I had two encounters over this past week involving osteoporosis; the first was in a support group  for individuals living with osteoporosis. The meeting began with a physical therapist and myself demonstrating the proper way to safely sit and stand from a chair. We emphasized the importance of avoiding lumbar flexion, due to the risk of spinal compression fractures for those with osteoporosis. The meeting was then led by a medical doctor, whose caseload includes numerous osteoporotic patients. The majority of the meeting was focused on medications and getting enough Calcium in their diet, but an individual asked about performing sit-ups. The medical doctor gave no warning to performing this activity and gave a "those are fine to do" response. 

  Compression Fracture of the Spine    Image Source

Compression Fracture of the Spine

Image Source


     The second encounter was a patient evaluation, involving an individual with osteoporosis that was seeking a preventative program. The patient wanted to focus on building strength and avoiding bone breaks and falls. Following a brief history and examination, because this patient had no injuries or complaints, my clinical instructor and I moved onto educational information. The patient was shocked when told about the importance of avoiding particular movements, such as bending forward. The patient indicated never being told the precautions and modifications necessary when living with osteoporosis. 

     The bottom line is that the general public and even other medical professionals do not know how this condition affects a person's life, especially their movements. Maintaining strength, both of bones and muscles, performing safe movements, and eating an adequate diet are all crucial to living with osteoporosis and preventing the condition.

- Patrick Berner, SPT

Introduction to Internship Blogs / #1 Function Turned Contracture

     Hey everyone, while on my clinical internships for my Doctor of Physical Therapy, I thought it would be interesting to share some thoughts that arise from patient encounters. I will not be providing any detailed information about any of my patients in agreement with HIPPA. I will attempt to be very brief and straight to the point for all of these mini postings, and occasionally throw in some research evidence when necessary. Enjoy!


#1 Function Turned Contracture  


     A patient came in with a history of an abnormal movement pattern, in this instance toe walking. Due to this learned behavior, this patient displayed significant contractures in the ankles bilaterally. A contracture is the shortening or hardening of soft tissue, such as muscle or tendon. During his/her development, this abnormality was never addressed, primarily due to an oversight by another medical professional. Formation of contractures over time had led to deformities and rigidity of the joints and significantly decreased function. The lesson of this encounter is that if a movement does not look "normal" or similar to a majority of those around, the individual or their caregiver should seek the help of a movement expert, a physical therapist.

- Patrick Berner, SPT

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