Shoulder Post-Rehab

Recently Anthony Renna interviewed me about our collaboration on a recent client of his.  At the time, she was several months post-surgical left rotator cuff repair.  I don’t know if there were any special factors or unique characteristics of her surgery.  She was discharged from physical therapy and cleared from her physician to return to Anthony with no restrictions.  No restrictions as in, this client had a list of exercises to read to the physician who as I understand it, okay’d every one.

The specifics to this case are all in the interview which can be found at StrengthCoachPodcast.com, Episode 62.

My Photo

So as Anthony and I discussed my impressions after I saw this client, I described how I felt that she was in need of some manual therapy and how I viewed progressing her to the exercises she wanted to do.  Often we speak of progression in terms of exercise continuums such as split squat to RFE split squat

Below are the variables that can apply to all types of progressions, but the unique biomechanics of the shoulder joint lends to the non-provocative to provocative positioning that may not exist with other joints.

The choices below are hardly all-inclusive, and there is no reason that you must clear dynamic of a lesser provocative position before going to static on the next position.   For instance, I am very comfortable getting to the 1/4 Get-Up

Static to Dynamic
Slow to Fast
Unloaded to Loaded
Sagittal to Frontal to Rotational
Non-Provocative to Provocative

Non-Provocative Static (Arm @ side)
Deadlift variations
Farmer’s Walk
Gripping

Non-Provactive Dynamic
Dips
Low Rows

Middle-Provocative Static (Arm 80-120 degrees)
Rolling Shoulders (Supine T-Spine Rotation w/Hip Flexion)
KB Armbars
Plank variations
EQI
KB Swings
KB Clean Walks
Inverted Row Pack
Body Pull

Middle-Provocative Dynamic
Bench Press variations
Inverted Rows
Chest-Supported Rows
TWYL
Push-Up Rows (Renegade Rows)
KB Cleans

Provocative Static (Arm overhead)
Turkish Getup
Overhead KB Walk
Pull-Up or OH Pack

Provocative Transitional
KB Snatches
Olympic lifting variations
–Dynamic through Provocative range followed by Static deceleration

Provocative Dynamic
Pull-Up variations
OH Pressing
–Narrow grip before wide grip Pull-Ups before Push Pressing before Strict Pressing

Med Ball Progressions
Short Amplitude to Large Amplitude
–Limiting range through overhead position or across body
OH Slam to OH Granny Toss to Soccer Throw
Low Rotational Throw to Middle/Upper Rotational Throw to Shot Put
Chop to Lift
Kneeling to Standing to Stepping to Footwork

Review of Asessement and Treatment of Muscle Imbalances

Over the last several years that I have subscribed to the thoughts of Dr. Vladimir Janda, there has been a dearth of formal resources describing the principles and methods.  Since his passing in 2002, we have relied on the few of his written works, some translated, and interpretations of the students he has mentored.

Many folks have located a 15-page article on the Internet from Phil Page and Clare Frank titled The Janda Approach to Chronic Musculoskeletal Pain.  This article has 3+ pages of citations and provides enough breadth to understand the basic premises of Janda’s message.

The Janda Approach

I think this article is best at describing and illustrating the Upper and Lower Crossed Syndromes and the tonic and phasic muscles of the body.  It enumerates the basics, but it did not open the window into a full or contemporary approach to a full training program.

Also for some time, the Janda Compendiums 1 and 2, as collections of Janda’s writings. have been available.  Some of the articles in the Compendiums have less applicability than others, but again, the window was not open very far.  I will say this with much confidence though, that the value was much like “Teach a man to Fish.”  Understanding the message and then crafting your own approach based on the methods is something that I have found incredibly fruitful.

It is somewhat of a knock on our continuing education society where great books or courses that don’t force feed tons of ready-to-use exercises or techniques are looked upon as not as satisfying as those that lay out the How To for developing your own stuff.

Several months ago, the authors of The Janda Approach, Clare Frank and Phil Page, teamed with another PT, Robert Lardner who I have also spent time with, in writing Assessment and Treatment of Muscle Imbalance: The Janda Approach.

It has been a few months now since I have finished the book, and below are some of the thoughts that have moved me during reading as well as added to my practice and thoughts.

1.  Parts I-III
Assessment and Treatment is made up of 4 sections of 15 chapters.  Looking back at the book, I felt like it was 2 parts: Theory and Application.  The Theory was the first 3 sections and 11 chapters.  These chapters are the gold of this book.  The final 4 chapters are also of tremendous use, but I had much more affinity to the information that allowed me to try to fit into my own “stuff.”

I mentioned before as it related to what has been out there attributed to Janda, and quite honestly, I’ve heard the same complaints about the FMS and SFMA courses, there is a lack of satisfaction with learning resources that don’t spoonfeed ready made exercises and techniques.

I look at it like this (and you may hear this again somewhere…………..), there are a lot of courses where people think they are great because they just get the house.  The house is the end tool.  I think it’s a very weak learner that just wants as much as possible even if they promise to use it on Monday.  This whole notion that a good course is chock full of stuff that you can bring back to the clinic after a weekend of exposure is really sensational and not terribly practical.  Don’t you want to practice and understand things more than a ride home?

The house to this book is Part III, Chapters 9-11.

Not this House..............

The better courses give you the blueprints as to how they come to build their type of house.  This is more to the likes of evaluation of a situation to decide which tools to use.  This is Part II, Chapters 5-8.  Most of the techniques in these sections are things I use in my “Janda Screen,” which is what I do to prove or disprove the -Crossed Syndromes, as well as the Breakouts in the SFMA.

What I think is the most moving of this book and what I think separates some of the very best education modules is that you get the house, the blueprints, but also how to make your own blueprints.  This is the science long before the theory and way before the application.  Part I, Chapters 1-4.

I really like the idea of getting the house, the blueprints to this particular house, but also how to make your own blueprints in case you want to build your own house one day.

Try figuring out these blueprints.


2.  Need to Reconsider Unstable Surfaces
For some time, I among others, have been very vocal against the use of unstable surfaces.  I’m not sure this part is going to ultimately change in terms of why I don’t have use for unstable surfaces in terms of strength and balance training.

There is certainly no reason to believe there is an increased strengthening affect in using unstable surfaces.  I think they have some use in deload weeks where the Airex pad demands a lighter load.  But we are not getting more balance or strength in a big lift like a RFE Split Squat.

In  terms of balance, I am firmly of the belief that if you can’t balance on a stable surface, making it harder isn’t going to all of a sudden yield brilliant balance.  You need to breakout the balance dysfunction first and then decide if indeed some proprioceptive input is the fix.  It is very frustrating to watch PTs and trainers have folks try to float all over on the bright little unstable surface product du jour.

Look at me. Look at me.

The notion that doing typical exercises on an unstable surface yields more “core” is really quite unfortunate.  It just doesn’t work that way.

However, what I need a lot more exposure to is what Janda called Sensori-Motor Training.  Using flat surfaced on wobble or rocker boards progressing to sandals with a wobble-bottom appear to have excellent affect in facilitating the short foot and lower quarter stability.

When I look at SMT, I don’t see the same foolishness that prevails in big box gyms.  I see flat surfaces that allow a natural contact with the foot.  I think this qualitative position of the foot allows for the closed chain to begin with stability.

I suspect that the further I go with the Prague School and taking Clare’s Janda course will allow the proper use of unstable surfaces in certain phases of training.

3.  Phil Page Parts

I’ve never met Phil Page as I have with the other authors of this book.  But I found it to be quite humorous to probably be able to pick off the parts of the book that were his domain.

Whenever there were suggestions of using anything Theraband or some other choices that didn’t seem to be very contemporary, I suspect these were his parts.  These sections I think really drew away from the overall quality of the book and sent a mixed message of isolated and impairment-based movements in a world of movement-based training and rehab.


4. PRRT
PRRT stands for Primal Reflex Release Technique.  Assessment and Treatment does not go over PRRT, but it was very excited to be reminded of this technique.

ThePRRT.com

I don’t remember what brought me to be exposed to this several months ago, but its inclusion along with Voijta’s Reflex Stimulation and Developmental Kinesiology ideas was an excellent reminder.

From the little I know about this approach, it is every bit as magic as Reflex Stimulation and DNS, and it is without a doubt on my To Do List in 2011.  They have a Home Study course that I may try sooner than later.

5.  WBV
Whole-Body Vibration was briefly mentioned, and I think it’s mechanism has an immediate role in tapping into the Sensori-Motor System and reflexive core.

What was troublesome was the unfortunate poor dissemination of information regarding WBV itself.  It wasn’t even the whole vertical vs. rotational thing, but more just what was an incomplete description.  Maybe it was just supposed to be a mention or teaser like PRRT was, but certainly this is a topic I feel confident in and wanted to see more, especially since I think it has a useful role in this whole approach.

I think the book below is the best independent resource for learning WBV.

7.  Movement-Based Approach
Assessment and Treatment of Muscle Imbalance: The Janda Approach is a must read in my opinion.  For fitness folks, there is not much of a need to go beyond certain chapters.  This is the identical case for Shirley Sahrmann’s book where the 1st 6 chapters are the theory and foundation for the system: The Blueprints.

For the medical professional, along with Liebenson’s, Lewit’s and Sahrmann’s texts and Gray Cook’s Movement, this book is the framework we need to keep everything we hold on to from an impairment- and kinesiology-based approach while putting it into a Movement-based approach.

The bottom line is that whoever the “guru” you prefer, the Movement-Based approach is a link between biomechanics, neurology, and pediatrics, and blending these approaches, as I see it, is the premiere and most contemporary methodology that we have available at this time.

And Janda started this stuff back in 1964.  How’s that for contemporary?

Draw-In vs. Brace

This post was inspired by some of the things I added to a Facebook thread from Bret Contreras discussing Megan Fox’s butt.  It was from last Thursday if you want to track it down.

Bret's Book

At some point, the comments diverted from a glute-based topic to the core, where someone suggested drawing-in the navel would improve the perforamance of the hip thrust/glute bridge, etc.

Also in my DVD, which is probably still on timeline to be out by the end of the summer, someone asked where I stood on the Draw-In vs. Bracing.

So here is the answer.  But first I have to change the question.  Draw-In vs. Bracing as in one or the other isn’t the way I look at the topic.  The reason is that I don’t use the draw-in at all……….as in ever.

So we can start there.  There is no doubting the EMG and Diagnostic Ultrasound evidence that the draw-in elicits a greater TvA response.  And there is also no questioning the importance of a TvA response as a component of the inner core.

But please consider the following………..
1.  TvA came to prominence from the work of the Queensland folks in proving that the TvA had a delayed onset of response in folks with back pain.  That’s it.  The study said no more and no less.  Despite all these attempts to “activate” TvA, in fact, the TvA is never OFF.  It always activates whether you draw-in or not, it just activates later in the presence of pain.  More recent evidence suggests that even after a bout of nociception is resolved, the previous neuromuscular strategies may still be present.  This is called a High Threshold (Pain) Strategy.

Now particularly for a performance or fitness based training program, there is absolutely no reason to consider the Draw-In.  This was never the message from Hodges, Jull, Richardson, etc.  A long time ago, I remember reading a Q&A interview with maybe it was Richardson who was almost laughing at the fitness worlds taking the TvA stuff on a tangent.

So if you are not in pain or potentially coming off of a back pain injury, you don’t even have a reason to think about these things.  And there are still better options like segmental rolling that can ensure TvA firing as per similarly impressive EMG studies.

Bottom line here is that regardless of whatever ultrasound studies are showing you, the TvA is never not turning on or weak.  It’s the timing of it that qualifies the efficiency.  The only time TvA is not on is when you’re dead.  And I got that line from Marc Comerford, and it shows he is actually worth something.

You're not the most important muscle in the world, Mr. TvA.

2.  This isn’t a defense of the brace as much as a knock on the draw-in.

Plain and simple.  Try to push the back of a parked car as if there were a billion dollars underneath.  Can you keep the draw-in?

The stability required to access the strength for moving loads can not come from a draw-in.  And the argument for the draw-in to make sure TvA is on is debunked from the above.  No matter what you try and do, the TvA is on, and you are going to wind up bracing when you attempt to move bigger loads.

I’m sure somebody is going to say they can pull like 135 with their stomach sucked in or this or that.  I’m talking about when you need your core the most when you’re performing a maximal effort expression of strength or speed, you can not accomplish the task with a draw-in.  The body will not allow it.  And it doesn’t allow it because it’s wrong.

Ready to take over the world.

3.  While it is a very rudimentary thought in the world of strength athletics, I will acquiesce that it is not in the common teachings of rehab and training that creating intra-abdominal pressure through a “fattened” abdomen is a sign of an effective core.

The EMG studies that gave birth to this whole TvA fallacy also support that diaphragmatic breathing not only yields signal in the TvA but also the multifidus, pelvic floor, and diaphragm.  And unlike the action of the draw-in, diaphragmatic breathing has been shown to be associated with back pain negatively when you can’t breath that way and positively when you can.

So if you don’t believe in the breath, you are probably behind the curve, but the teachings are out there.  But if you do believe in the diaphragmatic breath, one of the objective criterion is costal depression and creating a tensioned hoop surrounding the navel.  You should not only get fat in the gut, but also be able to push your fingers away from the abdominal flanks as you inspire.

Try doing that with a draw-in.  It’s one or the other.

Do you want TvA alone, or do you want TvA, diaphragm, multifidus, and pevlic floor, and the functionality of the deep neck flexors?

This isn’t much of a discussion for me.  There is no use for the draw-in because as you draw-in, you change the fixed point (punctum fixum) of the diaphragm resulting in not even a mechanical disadvantage, but almost a mechanical impossiblity for it to contract and depress the ribs.

Take a look at some well trained athletes and see if you can appreciate what I mean when I say fat abs.  Think Chuck Lidell.  He looks like he has a little belly, but he has abs on top of it.  By hook or by crook, his belly is likely a function of abdominal tone from diaphragmatic breathing along with outer core tone from whatever his other choices are.

Fat Abs

Ask any strength athlete about getting a belly full of air and pushing out against the belt before a lift.  That is the strong core, not the draw-in.

So now that I’ve changed the question from Draw-In vs. Push-Out, where does bracing fit in?

I don’t think you should need to brace unless the load of the movement demands it.  Now that is going to be different for everybody.

The problem for folks in pain is that bracing can eliminate or control the pain, but it takes work to do that.  That is not a bad thing, but it is not the most efficient motor program in my opinion.  Bracing hard in the presence of pain assumes a dysfunctional inner core.  We learned that above from the TvA research which also applies to all 5 of the inner core muscles.  They are all associated with back pain.

It’s not that the inner core is more important as a muscle group than the outer core.  It’s the inner core is more important in the sequence of the motor control than the outer core.

For the same load, if the inner core is reflexively appropriate, you won’t need to brace as hard or as often for a given load.

Certainly you will have to brace when you progress, but part of progression can be demonstrating integrity via breathing.  For instance, you may need to brace hard to hold the plank for 30 seconds.  Eventually that plank will not require such an intense brace, and you will know this because you will be able to demonstrate diaphragmatic breaths during those same 30 seconds when you harness your inner and outer core.  Then you move on.

So all in all…………………
Always get fat when you breath, never Draw-In, and Brace if you must.