Teaching New Techniques

Teaching New Techniques

 

When working with a client, as they progress from the basics to more complex activities, a close eye on their technique and motor skills is extremely important in order to maximize their "gains" while avoiding injury.  There are three stages of motor skill development.  The first stage, called the Cognitive Stage, provides constant external coaching by you, the instructor.  You introduce the new technique and then provide the visual, verbal and manual cues to your client in order for them to perform the activity properly.  You may have to place your hands on your client to correclty move them or cue them on stability at this time.  Body Awareness and proprioception are touched on here, but they are not the main focus yet. 

The second stage is the Motor Stage.  During this phase, your client is performing the technique efficiently and consistently.  They know when they make a mistake and can adjust appropriately.  Body Awareness for the skill and proprioceptive feedback become the prevalent form of feedback.  This is when I begin to reduce the use of mirrors and visual/manual feedback.  I stand back and only assist to prevent injury.  This is the "practicing stage."  To move onto the next stage, your client must practice the activity frequently. 

The third stage is the Automatic Stage.  Here, your client is able to perform the activity properly, efficiently and with minimal assistance by you.  Know which stage your client is in, because giving too much feedback can be just as bad as too little feedback.



Fitness Center Machines

Fitness Center Machines

 

 

People of all ages purchase memberships to their local gyms in order to gain strength and improve function.  However, is the fitness center training equipment optimal to gain strength and function?  While functional movement requires stability, balance and control at multiple joints simultaneously, most of the gym machines restrict motion to one joint and provide an external, "artificial" stability throughout the movement.  

The Smith Machine stabilizes the body so that you do not have to control the descent/ascent in any other direction but up and down.  Forward and Backward sway is limited and controlled by the machine.  This minimizes proprioceptive integration when training

 

The Smith Machine for Bench Press helps develop the chest.  However the shoulder stabilizers are not working optimally during this movement because the stability is provided by the machine. So you gain pectoral strength without foundational stability

Same as the Bench Press, the machine takes over for the shoulder and scapula stabilizers as you are only moving the weight up and down.  You are not responsible for lateral or anterior/posterior control of the weight

The Leg Extension Machine helps develop the Quadriceps Muscles.  However there is little  carryover into functional tasks such as getting up from a chair.  And if you do not line your knee joint up with the machine's axis of rotation, you are just asking for a knee injury.

 

 To improve function and athleticism, your goal is to mimic the required activity as closely as possible.  Avoid single joint movements in which the stability is provided by an external machine.  You want to maximize proprioception and body awareness by controlling your own balance, movement and stability at multiple joints.

Training the Obliques

Training the Obliques

 

Here's a training substitution that you can make if you are recovering from a back injury.  Everyone knows that in order to protect your back you must train the core.  So you do sit ups, back extensions, seat torso twists, etc... However, many of the gym exercises that we once thought were beneficial for our core and lower back, may actually cause more spinal problems.  For example, when training obliques, many people will be seen on the Resisted Torso Rotation Machine. 

 

 

Unfortunately, repeated twisting causes deterioration of the annulus portion of the spinal disc.  Adding resistance to the rotational movement of the spine can be even more detrimental.  

 

  

Substitute the Seated Torso Twist with the Side Plank to train the Obliques.  It will train the core, and spare the spine.  Hold each repetition for 5-7sec and alternate sides for 8-10 reps each

LEVEL ONE: After each 5-7sec rep, do not drop your hips straight down to the floor.  Instead, push your butt back by hinging at your hips.  This will avoid excessive lateral flexion of the spine and will minimize overall strain on the back

 

LEVEL TWO

 

Check out www.lowbackpainvideos.com for more Lower Back Rehab Exercises

Is Your Patient Truly Independent?

Is Your Patient Truly Independent?

 

As a Physical Therapist, I have noticed that most Assisted Living Facilities, Nursing Homes, Hospital, Rehab Centers, Outpatient Clinics as well as Home Care Agencies make gait belt use on patients mandatory.  Gait belts are used around a patient's waist to provide the therapist with a sturdy grip just in case the patient loses their balance. 

Even if your patient is highly functioning with minimal loss of balance while walking, most of these settings require use of the gait belt for liability reasons.  This is understandable.  However, when the goal of therapy is to discharge your patient to living independently in their home, using the gait belt every visit may not be most beneficial for your patient.  I totally agree with using the gait belt on a patient who is just beginning therapy and is extremely weak or has balance deficits.  This is for your safety as well as their safety.  However, I also feel that frequent use gives your patient a sense of security and comfort and gives you the therapist a sense of control.  This "security blanket" may help boost your patient's confidence, because in the back of their mind they know you will be there to grab the belt if they stumble.  Once they are discharged, they will no longer be walking around the community or their home with this "security blanket."  If they never practiced functional activities in therapy without the gait belt, how can we expect them to feel comfortable performing these activities without the gait belt after being discharged.  As therapists, we are not only working on improving strength, balance, gait and transfers.  We are also trying to improve confidence by reducing the fear of falling before we discharge.  If we intend to discharge to independent status, I feel there should be a transition during our sessions and prior to discharge to eliminate gait belt use.  I am not for or against using a gait belt.  I feel that there are times it is overutilized and can actually be detrimental to a patient's progress.

 

I have also noticed that during many sessions of gait training with patients, some therapists have the habit of walking with their patient while lightly placing their hand on the patient's shoulder, hip or lower back.  With gait training, this is considered Contact Guard Assist.  If you are providing this, your patient is not independent and you can not document that they are independent.  This is another "security blanket" that we provide to our patients and ourselves for comfort and security.  However, it is counterproductive if the goal is independence.  Once they are at home alone, how confident, safe and secure will they feel walking without that manual support?  It is establishing a false confidence.  If the intention is to discharge our patient to independent status, we need to stand back a bit to allow them to accomplish their goal.  But common sense should never be ignored.  If it is obvious that your patient can not walk yet without your manual assist, then provide only what is necessary to prevent injury.  Do not overutilize or underutilize these protective measures, because either extreme may cause problems for your patient in the future.            

Leg Press and Lower Back Rehab

Leg Press and Lower Back Rehab

When working with patients recovering from lower back injuries, particularly bulging or herniated discs, I mentioned in previous posts that my goal is to improve function while minimizing irritation to the lower back.  For people rehabilitating from bulging or herniated discs, I avoid spinal flexion activities, as this may cause further disc protrusion.  I do not usually use the leg press machine, as in my opinion there are more functional lower extremity activities that I would rather spend time performing.  However, if for whatever reason you are using the leg press with your "lower back client," you can minimize the strain placed on the lower back by performing single leg presses rather than bilateral presses.  Here, the non-working leg remains on the floor during the press. 

Image 1

Image 2

In image 1, you can see that at the deepest part of the motion, where the knees are up against the chest, the lower back is extremely flexed.  This may lead to further posterior "disc creep."  In image 2, keeping the non-working leg on the floor helps to maintain a more neutral pelvis and lumbar spine, decreasing disc protrusion.  This places much less stress on the spine and intervertebral discs.

Benefits Of The Single Leg Deadlift

Benefits Of The Single Leg Deadlift

 

When performing the Single Leg Deadlift, in order to maximize the benefits you must perform the technique with proper form, especially upon fatigue.  I have used this exercise to train ankle and knee stability, hip stability and strength, balance, trunk rotational stability, grip and scapula control (to name a few). 

To begin the technique, place the kettlebell on the inside of the stance leg so that as you flex forward you can reach the handle with the opposite side's arm

While lowering your trunk down towards the kettlebell, you do not want to allow your trunk to rotate.  Keep your shoulders and hips 'square' with the floor.  The image directly above is incorrect, while the image below is correct

You want to maintain a straight line from your shoulder to your hip, knee and ankle.  This will help you with the hip hinge technique which protects your lower back

Lower your trunk while maintaining scapula retraction.  Keep your ears in line with your shoulders.  You lower your trunk until your hand reaches the kettlebell handle. 

 

Do Not allow your scapulae to protract or your trunk to rotate towards the kettlebell in order to "lengthen your arm" for you to more easily reach the handle.  You will need to work hard at this especially upon fatigue

Grip the handle, contract your glutes and scap retractors and return to stance

 

Finish the repetition in tall standing with glutes squeezed. Do not rush into the next repetition by not locking out in tall standing first

Stabilizing the Lumbar Spine During Common Low Back Exercises

Stabilizing the Lumbar Spine During Common Low Back Exercises

 

During a recent treatment of a patient recovering from lower back strain, she began the Straight Leg Raise exercise for hip strength and spinal stability.  The patient had been previously educated on core recruitment during activities.  However, during the Straight Leg Raise, she complained of difficulty controlling her lower back from moving.  She stated "It feels like my lower back is moving and unstable."  Even after providing manual cues to engage the core, she still had difficulty maintaining spinal stability.  That's when we incorporated shoulder isometrics during the Straight Leg Raise.  Here's what I had her do:

Initial performance without shoulder isometric

Straight Leg Raise with shoulder isometric

 

Having one knee flexed while raising the other leg helps to prevent flattening the lower back into the floor - This maintains more of a neutral spine position.  Prior to lifting the leg, press your hands into the medicine balls.  You will feel your trunk muscles 'engage.'  Follow this with the Straight Leg Raise.  This will help maintain spinal stability, and many times decreases lower back pain.  For a full rehab protocol on lower back pain, check out www.lowbackpainvideos.com