Too much tactile cueing may not be good

I have spoken of the importance of using tactile cues in order to get a particular muscle contraction or movement to occur.  However, continuing from the previous entry, when dealing with older clients/patients, sometimes too much manual cues may be detrimental.  When you are performing the higher risk exercises mentioned before (standing exercises without support), you are trying to build your patient's self-confidence --- SELF- Confidence.  They must rely on THEMSELVES.  You are there to perform a job, and usually can only work with your patient for a limited time, so you really want them to be safe when you are not there.  Having them walk or perform exercises with your hand on them for security purposes, when they do not really need that much assistance, provides a false sense of security.  When you are not there, they do not feel your support, so their self-confidence may be greatly diminished.  If they do not need it, do not provide it.  I feel the same way about gait belts.  Many therapists use gait belts no matter what.  Usually, a clinic or hospital makes it protocol for liability purposes.  But when the patient is discharged, they will be walking on their own without that gait belt -- without that sense of security.  Use common sense.  If your patient needs the assistance, provide only what they need.  Do not over-assist because you will be under-rehabilitating.  Sometimes you are causing more harm than good by training your patient in an overprotected environment.

Allow Self-Corrections

Many times I will be performing balance training with a patient and he will lose his balance slightly, frequently falling backward.  As I am by his side, I am able to prevent him from falling.  But instead of preventing the fall and completely bringing him to his upright posture, I tell him to "fix it."  As I physically support him, I ask him to maneuver himself back to his stable upright position.  This forces him to use the ankle, hip, core musculature to regain his center of gravity over his base of support.  This is used as an exercise as well as a motor development skill.  If we can get him to regain his balance by synchronizing all the necessary muscles, we are hoping he will incorporate this same technique the next time he feels himself falling backward, thereby correcting it.  So my advice is: Let them make mistakes, be there to protect them and prevent injury, but allow them to attempt corrections on their own.   Let them figure out the solutions and this will enhance their motor planning abilities.

Small Adjustments Produce Big Changes

As a Physical Therapist, I treat many deconditioned patients in their home.  Most of these patients suffer from generalized weakness, balance deficits and difficulty walking.  Initially, depending on the extent of their weakness, I may start them with seated or supine (lying down on their back) exercises.  They then progress to standing exercises, usually holding onto their kitchen sink.  These exercises include heel raises, marching, squats, etc.  We use the sink because it is a stable surface that will not move while the patient holds onto it for balance.  Most of these patients have a fear of falling due to poor balance.  As time goes on, they begin to have less trouble with these standing sink exercises.  However, what is the true functional value of these exercises?  If your patient's goal is to walk without a cane or walker, they are definitiely not going to be walking while holding onto a sink, right?  So how do we get them ready to be independent with their daily activities?

One small adjustment to their position during your sessions will make a big change in their confidence, strength, balance and walking ability.  Have them step back away from the sink, into the middle of their kitchen, with nothing else at arm's reach except for you.  Make sure you remain close to them, but only place your hands on them to prevent a fall.  Now have them perform the same standing exercises that they did when they held onto the sink.  They will seem very cautious, almost fearful.  Progress slowly with this.  Perform only a few reps of each exercise.  This is a confidence building exercise as well as balance and strength building.  They will feel a much greater challenge due to the mental aspect.  The difference here is the risk or fear factor.  They no longer have their security blanket, the kitchen sink.  They must rely on their own abilities (as well as your ability not to let them get injured).  Once they accomplish these tasks over numerous sessions, you will see improvement in confidence, strength, balance and walking ability.  You will see that one minor change can have a very beneficial effect on your patient's progress.  Remember, you are not just training their body, you are also working on their mind.  Take away their "crutch" to get them to the next level.

Functional Training & Observation Skills

We have all heard of Functional Training.  Many of us think of High Intensity Training using Kettlebells, Sandbags, Suspension Training, but it does not stop there.  That may be beneficial for an athlete to maximize his/her performance.  However, what about clients in their 50s, 60s or older, who are looking to improve their quality of life, not their athletic performance?  How do we incorporate Functional Training into their life? 

Just like any of your other clients, find out what their goals are upon the initial evaluation.  For example, presently I have a patient who is recovering from a fractured femur.  She had corrective surgery and during her first session, she stated how happy she would be if she could get down into the bath tub again.  My first goal is to improve her 'quality of life' by helping her return to her prior functional level.  I need to get her to be able to take a bath again.  Initially, if she is having trouble with the basics, such as getting up and down from a chair or is unsteady when walking, I will need to give her a standard strength and balance program (for her legs especially).  I will also need to assess her bathroom, including the size of the tub and the direction of the faucet controls so that I can make the transfer as efficient as possible.

Now here is where the task observation comes into play.  In order for her to transfer safely into the tub I need to break the entire task down into its individual parts, and focus on each part prior to attempting the entire task.  First, she needs to be able to approach the tub, and lift each leg high enough to get into the tub.  Then she needs to be able to transfer into a lunge, then tall kneeling, side-sitting, and sitting with legs stretched in front of her.  To get out of the tub she will need to roll over into quadruped (on hands and knees), into tall kneeling, lunging, standing and finally lift each leg high enough to get out of the tub safely. 

Who would have thought it took so much work to get in and out of the bath tub?  Each session, I work on these individual components, and will eventually take her into her bathroom in order to practice the entire task. 

Your goal is to be observant of the task at hand.  Learn your client's strengths and weaknesses and customize the task to their abilities.  Break down the activity that your client is trying to relearn into its component parts, which will be easier for your client to initially learn and master.   Then, for proper carryover, you need to have your client perform as many of the individual components in proper order as soon as possible, so that it makes sense to your client why she is performing all these exercises/activities.  

Repetition of the task will establish motor patterns in the brain. And before you know it, your goal will be accomplished.   Remember, if you must break the task down into component parts, the trick is to 'bring it all together' as soon as safely possible for actual learning and retention to occur.

The Value of Tactile Cues on Your Client

When training a client, you may want them to contract a particular muscle/area of their body during an exercise.  In the fitness and rehabilitation industry, we realize very quickly that every person we work with has a different level of body awareness.  Some clients demonstrate great control, while others make you wonder how they survived walking from their car into your clinic.  Tactile cues, or in this case, "tapping" a muscle is very beneficial in getting your client to do the exercise the way you want them to.  Just remember how quickly you corrected your own posture upon feeling someone tap your lower back, telling you to "straighten up."  If a client is having difficulty "firing" the exact muscle that you are asking him to, tap the area of concern to provide manual/tactile cues, along with providing verbal cues.  The more information your client receives into their CNS (central nervous system), the better they will perform a given task.  This works especially well with stubborn muscles following injury, such as the Vastus Medialis (VMO).  This is the "tear-drop" shaped muscle on the inner aspect of your knee.  Following any knee injury or surgery, inflammation is expected.  Very little swelling causes the VMO to 'shut down.'  With the VMO "off," the lateral thigh muscle (Vastus Lateralis) pulls the patella laterally during a quad contraction.  During a quad contraction, the patella should track superiorly.  This does not happen when the VMO is not firing properly and therefore you can expect more problematic knee issues in the future.  When having your client perform a basic quad set, if the VMO does not appear to contract, have them tap it with each contraction. 

You can also use this technique to assist with lower trapezius recruitment during shoulder/scapula exercises in order to maintain stability of the scapula.  If you are observing an incorrect exercise movement, tap the muscles that should be activated during that exercise and see how quickly your client corrects his/her form.  This should help your clients progress quickly through the intial stages of rehab or post rehab fitness.

The Kettlebell Swing: The Shotgun Exercise

KettleBell Swing:

Everyday benefits

By: Nicholas Parmigiano MSPT, BSHS, CKTP, ACE-CPT, FMS, Crossfit Kettlebell Instructor

         The Kettlebell Swing is a fundamental exercise of what is one of the most popular exercise techniques of today – Kettlebell Training.  Used for fitness by most, I have been successful gearing this ancient art of training into Physical Therapy and Rehabilitation treatments for my patients with great results.  I call it the ‘Shotgun Technique’ because you can get the most “bang for your buck” by incorporating it into your program.  I have listed below just a few of the many benefits of this excellent exercise.

Lumbar Muscle Endurance:

         Many therapists and trainers feel that their clients are suffering from lower back pain due to strength deficits in their core and lumbar paraspinals.  They focus their sessions on seated trunk extensions using gym equipment or Roman Chair hyperextensions without realizing that these exercises actually create more compression and shearing force on the spine, which inevitably leads to herniated discs!  Most of my patients complain of lower back pain upon performing the lifting and repeated trunk extension movements required by their occupation.  They also experience symptoms in static positions, such as leaning over the sink to shave or to wash dishes.  This is not due to a strength deficit, but rather a muscular endurance deficit.  With proper form, the kettlebell swing will rapidly improve lumbar muscle endurance.  

Body Mechanics 

         Learning the proper technique of the Kettlebell Swing usually includes the following instruction: “keep your weight on your heels - Hinge at your hips, not your lower back - Sit back as if you are lowering yourself into a chair - Drive with your hips.” Following these instructions will protect your spine from any injury, which can occur from even the simplest functional task such as transferring out of a chair from a sitting to standing position.

Psoas Flexibility

         The psoas muscle is a hip flexor.  Tightness of this muscle is related to lower back problems. The explosiveness of the Kettlebell Swing applies a repetitive dynamic stretch to the psoas muscle, maintaining its flexibility, thereby minimizing it as a cause for lower back pain.

Lower Extremity Strength and Endurance

         Anyone who has performed over 2 minutes of non-stop Kettlebell Swings will understand this.  Once you become coordinated with the technique, the movement pattern will improve and you will be able to swing a heavier weight for a longer period of time.  Your legs, as a result, will gain strength and muscular endurance.

Scapula Stability

         To begin ‘The Swing,’ grab the kettlebell handle with one or both hands and stand up tall, holding the kettlebell at groin level.  In this position, your shoulders will ‘want’ to roll forward.  It is your job to pull your shoulder blades back (scapula retraction).  You can then proceed to perform multiple repetitions of the Swing.  Upon each repetition, your shoulder blades will again ‘want’ to roll forward - again, maintain retraction.  Holding your shoulders back isometrically strengthens the middle trapezius and rhomboid muscles.  Strengthening these muscles will assist you in maintaining proper posture.

         The possible rehabilitative and functional benefits you can derive from Kettlebell Training is endless, limited only by your experience and imagination.  Confucius once said, “Every journey begins with the first step.”  He failed to mention that you first need to be on the right path.  Therefore, seek a Certified Kettlebell Instructor who will guide your early experiences and walk you through the exercises, demonstrating proper form.  Then, you’ll be on your journey to strength and recovery.

Popular Causes of Knee Pain

Knee pain is a very popular issue for Personal Trainers and Physical Therapists.  Although the pain is localized to your client/patient's knee, you must observe the peripheral joints as possible causes.  One of the first joints you need to assess is the ankle/foot.  Many times, your client may be flat-footed on one or both sides.  Pronation or "flat-footed" many times creates a "down and in" movement of that entire lower extremity.  "Down and In" refers to an internal rotation motion of that leg.  This internal rotation leads to a shortening/tightening of the Ilio-Tibial Band/Tensor Fascia Latae (ITB/TFL).  This then leads to more internal rotation and "down and in" and it becomes a viscious cycle. 

Tightness of the ITB/TFL may create an increase in lateral pull of the patella or knee cap.  Instead of the patella tracking superiorly upon knee extensor contraction (quadriceps), it tracks supero-laterally.  In time, this may cause knee pain.  Most of my "knee clients" are taught how to perform proper calf (gastrocnemius/soleus) stretches to help minimize the "down and in."  They are also educated on ITB/TFL stretches if I observe the patella tracking laterally.  Unfortunately, these stretches alone will not correct the "down and in" motion.  You must ensure proper carry over by immediately practicing the activity in which the "comparable sign" (your client's chief complaint) was observed.  During the practice, make sure that the "down and in" motion is minimized.  For example, many times this motion will be obvious during step downs.  Instead of the knee tracking over mid to lateral foot, the foot arch drops (pronates) and the knee track medially over or past the big toe.  This step-down (using the affected leg to lower the body) may create your client's symptoms of knee pain.  Teach the stretches, and have your client perform the step down during that same session, making sure the knee tracks properly over the foot.  Many times, if you correct the movement pattern, the involved muscles will begin to work properly and efficiently.  Oh yeah, and don't forget to check the VMO contraction which assists with medial pull of the patella during contraction.  The VMO is the tear drop shaped muscle on the inside aspect of your thigh just medial and superior to the knee cap.  This muscle helps minimize lateral patella migration.  So, stretch the calves and ITB/TFL and strengthen the VMO.  Then perform the required activity and make corrections.  Remember "Perfect practice makes perfect!"

On a side note, for those trainers with clients who want to train barefoot, keep the above information in mind.  Training barefoot may have its benefits.  However, if your client demonstrates any of the pronation and "down and in" movement patterns with shoes on, their form will very likely worsen without foot/ankle support (training barefoot).  If they are unable to correct this inefficient pattern when barefoot, you may want to scrap barefoot training for now.  This is especially true if they already require orthotics in their footwear to reduce pronation.  Make sure the benefits outweigh the risks of barefoot training.