rehabscience rehabscience

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Dr. Tom Walters  ๐Ÿ‘ฃ Physical Therapist ๐Ÿ“š Kinesiology Professor ๐Ÿ”Ž Dr. of Science Candidate ๐Ÿ‹๐Ÿผโ€โ™‚๏ธ #RehabScience Specialist โ€” โฌ‡๏ธ Learn How to Alleviate Pain & Move Better

๐Ÿ’ฅ๐‘๐จ๐ญ๐š๐ญ๐จ๐ซ ๐‚๐ฎ๐Ÿ๐Ÿ ๐’๐ญ๐ซ๐ž๐ง๐ ๐ญ๐ก๐ž๐ง๐ข๐ง๐ ๐Ÿ’ฅ
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โžก๏ธLove this series from @thebarbellphysio!
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โœ…The Side-lying Trio is my favorite exercise to start with for posterior rotator cuff strengthening. This mechanics drop set is great because it is tolerated well in very irritable shoulders yet still challenging enough to strengthen healthy shoulders.
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๐Ÿ‘€We start with side lying shoulder flexion to 90 degrees. I have the athlete perform reps until a 6/10 RPE (rating of perceived exertion) so that they feel a small muscle burn on the back of the shoulder.
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๐Ÿ“ŒOnce there, we IMMEDIATELY move into side-lying shoulder horizontal abduction working to an 8/10 RPE and then without any rest finish the set with side lying external rotations to failure.
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๐Ÿ’ฅ๐’๐œ๐ข๐š๐ญ๐ข๐œ๐š๐Ÿ’ฅ
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โœ…Sciatica most often describes symptoms that originate from the low back (lumbar spine) and radiate down the back of the leg. In more mild cases, pain, numbness and/or tingling sensations may only travel to the buttock and back of the thigh. As neural irritation increases, pain may then pass the knee and radiate into the calf, shin and foot.
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๐Ÿ“ŒWhen working to improve symptoms associated with sciatica, exercise should have the primary goal of decreasing neural irritation. When neural symptoms improve pain will begin to leave the leg and move closer to the spine. This is referred to as the centralization phenomenon. On the flip side, if symptoms travel farther down the leg (peripheralization), then efforts should be made to identify activities that are worsening oneโ€™s state and modified appropriately.
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๐Ÿ‘€Shown here are several exercises that are often helpful for decreasing neural sensitivity and encouraging centralization.
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1๏ธโƒฃFoam Rolling: rolling the glutes and hip rotators can help to decrease neural sensitivity due to the nerveโ€™s path through this area.
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2๏ธโƒฃKnee to Chest: the single and double knee to chest positions can be very useful when looking to decrease back pain and nerve sensitivity. Hold each position for 20-30 seconds and repeat whenever they are needed.
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3๏ธโƒฃProne Extension: the progression shown here can be very useful for encouraging centralization of neural symptoms. Start with the head on hands, move to elbows and then up to hands. Move to each new position when tolerable. Hold each position for 5-10 seconds and repeat. Symptoms in the leg should get better, if this technique is appropriate.
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4๏ธโƒฃSciatic Mobilization: this nerve mobilization involves using ankle movements to alternate between positions of tension and slack on the sciatic nerve. Try 10-15 ankle movements and then relax.
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Give these a try and let me know if you have any questions.
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Feeling unmotivated or down about an injury? Pick yourself up and get to work on the things that you have control over! Athlete: @big_z_2020
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๐Ÿ’ฅ๐๐ซ๐จ๐ฉ๐ซ๐ข๐จ๐œ๐ž๐ฉ๐ญ๐ข๐จ๐ง๐Ÿ’ฅ
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๐Ÿ“ŒProprioception (or kinesthesia) is the sense though which we perceive the position and movement of our body, including our sense of equilibrium and balance, senses that depend on the notion of force (Jones, 2000).
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โžก๏ธProprioception relies on afferent information from sensory organs throughout our musculoskeletal system, including mechanoreceptors and stretch receptors. This sensory information is then processed and leads to an appropriate motor response.
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๐Ÿ”ŽFollowing injury to a joint, proprioception can be negatively altered potentially increasing oneโ€™s risk of suffering another injury at some future point. The ankle joint is one of the most common areas where this situation is thought to play out, in large part due to the high incidence of ankle sprains.
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โœ…Shown in the following videos is a simple progression you might use for training Ankle proprioception. When you can perform a given exercise position three times and hold for 30 seconds without losing your balance, then move to the next level of difficulty. When you can do all of them, perform them again with your eyes closed as a means of further challenging your joint receptors.
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This type of training should help improve your sense of where your body is in space and help to reduce your risk of injury.
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#RehabScience

๐Ÿ’ฅ๐๐ฎ๐š๐ ๐ƒ๐ข๐ฌ๐ฌ๐ž๐œ๐ญ๐ข๐จ๐ง๐Ÿ’ฅ
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Ever wonder what your quads look like when the skin, fat and fascia are dissected away? Here is a great image that shows this very thing.
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In this image, we can see three of the quadricep muscles; vastus medialis, vastus lateralis and rectus femoris (not labeled). We cannot see vastus intermedius as it lies deep to these muscles.
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How many of you have had the chance to dissect a cadaver? I have had the opportunity to do this three separate times and have learned so much from each experience.
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๐Ÿ’ฅ๐‡๐ข๐ฉ ๐…๐ฅ๐ž๐ฑ๐จ๐ซ ๐‘๐ž๐ก๐š๐›๐Ÿ’ฅ
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๐Ÿ“ŒPsoas is a truly interesting muscle that is thought to be associated with a number of musculoskeletal conditions that most often result in low back and pelvic region pain.
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๐Ÿ‘€Anatomically, psoas major is the deepest core muscle and the only muscle that attaches the trunk to the lower limb. Pretty cool! It runs from the vertebrae and discs of the low back (T12-L5) down to the lesser trochanter on the inside of the femur. This unique configuration allows psoas to possess the dual role of spinal stabilizer and hip flexor.
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โœ…All of this to say, if you are experiencing pain in the low back, sacroiliac joint region or hip, it is worth your time to determine whether or not addressing your hip flexors may help. This can be most easily accomplished by adding a bit of stretching and/or strengthening and then examining whether or not your symptoms improve.
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1๏ธโƒฃHip Flexor Stretch: Place the leg you would like to stretch down. Before moving from this position, make sure to squeeze your abs and glutes to place the pelvis in a position of posterior tilt, which help take any slack out of the hip flexors. Lunge forward slightly without arching the low back. For increased stretch reach up with the same side arm and lean your trunk away from the leg being stretched.
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2๏ธโƒฃHip Flexor March: Place a mini-band around your feet and flex the affected hip as far as possible. Feel free to hold onto something, if you need to, as this is not necessarily meant to be a balance training exercise. Perform 3 sets of 12-15 reps.
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#RehabScience

๐Ÿ’ฅ๐‰๐จ๐ข๐ง๐ญ ๐๐จ๐ฌ๐ข๐ญ๐ข๐จ๐ง ๐’๐ž๐ง๐ฌ๐ž๐Ÿ’ฅ
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Joint position sense describes a common measure of proprioception in which an individual is asked to replicate a particular joint position without the help of vision. This video does a great job of showing how someone could train proprioception on their own following a shoulder injury or surgery. The same process can also be applied to other peripheral joints.
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To perform this drill, move your unaffected limb first and then try to replicate the position with your affected limb.
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๐ŸŽฅVideo credit: @drjarodhalldpt
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๐Ÿ’ฅ๐‹๐ข๐ ๐š๐ฆ๐ž๐ง๐ญ ๐‡๐ž๐š๐ฅ๐ข๐ง๐ ๐Ÿ’ฅ
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๐Ÿ‘€We often talk of various ligament injuries, especially tears of the anterior cruciate ligament (ACL) of the knee. In this MRI image, we can see how a torn ACL appears as compared to a healed ACL.
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๐Ÿ“ŒIt is well known that ligament healing time frames are quite a bit longer than other, better vascularized tissues in the body. As such, surgeons and rehabilitation practitioners are careful to introduce movements slowly as a means to allow for ligament remodeling and reconditioning of the neuromuscular stabilizers of the joint. Many sources estimate that ligament remodeling can go on for many months and even up to a year or more. Furthermore, many individuals will no longer experience pain due to this longer period of healing, which may increase their risk of re-injury as they are more likely to participate in more aggressive activities when symptoms have resolved.
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โžก๏ธHere is an example from monkey subjects (see reference below) that depicts how long ACL reconditioning can take after only a few weeks of immobilization:
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๐Ÿ“ŠFollowing 8๏ธโƒฃ WEEKS of immobilization, it was found that the ACL in monkeys failed at 61% of maximum load.
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๐Ÿ“ŠAfter 5๏ธโƒฃ MONTHS of reconditioning, the ligament failed at 79% of maximum capacity.
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๐Ÿ“ŠAt 1๏ธโƒฃ YEAR, the ligament failed at 91% of maximum capacity.
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โœ…So, the take home message here is to keep in mind the slower healing rate associated with ligaments and make sure to include a rehabilitation program that adequately reconditions the neuromuscular system including motor control and muscle performance (power, strength and endurance) in order to protect the healing tissue.
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๐Ÿ“šNoyes FR. Functional properties of knee ligaments and alterations induced by immobilization: a correlative biomechanical and histological study in primates. Clin Orthop Relat Res. 1977.
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๐Ÿ’ฅ๐๐ž๐ฎ๐ซ๐จ๐ฆ๐ฎ๐ฌ๐œ๐ฎ๐ฅ๐š๐ซ ๐‚๐จ๐ง๐ญ๐ซ๐จ๐ฅ๐Ÿ’ฅ
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๐Ÿ‘€Here is a great follow-up post to my ACL neuromuscular training post from yesterday from ACL specialist and physio @mickhughes.physio.
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๐Ÿ“ŒEveryone wants to be STRONGER, run FASTER and jump HIGHER. But, how many people want to learn how to absorb forces better or land safely? Not many I can imagine...
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โžก๏ธHere's one of my ACLR patients going through a landing drill on her reconstructed side prior to getting into her plyometric and strength program. 2x 6-10 QUALITY reps each side.
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โœ…Take home message: There's no point having a Ferrari without any brakes! Learn to "brake before you accelerate".
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๐Ÿ’ฅ๐€๐‚๐‹ ๐ˆ๐ง๐ฃ๐ฎ๐ซ๐ฒ ๐Œ๐ž๐œ๐ก๐š๐ง๐ข๐œ๐ฌ๐Ÿ’ฅ
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Research has commonly pointed towards four motor behavior patterns that are associated with ACL injury. These patterns can largely be offset when a neuromuscular training program that focuses on lower quarter control is implemented. Learning how to land from a jump (as shown in these videos), in a way that is not characterized by any of the four patterns outlined below, is a great place to start.
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1๏ธโƒฃ Inward collapse of the knee or dynamic valgus (ligament dominance) places extra stress on the passive structures of the knee and is associated with poor control of the hip joint and, less so, the foot.
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2๏ธโƒฃ Limited knee flexion (quadriceps dominance) is commonly seen in individuals who have suffered ACL injuries. A strong contraction by the quadriceps translates to a stiffer landing and increased anterior shear stress on the ACL.
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3๏ธโƒฃ Asymmetrical weight bearing (leg dominance) is seen in activities that are normally characterized by equal loading of each leg. When this happens, the loaded leg is put under greater stress, including the ACL.
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4๏ธโƒฃ Lateral trunk flexion (trunk dominance) relates to an individual's inability to precisely control their trunk in three-dimensional space through coordinated trunk muscle action. Several studies have demonstrated that trunk proprioception and control serve as predictors of future risk of knee ligament injury.
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If you are an athlete between the ages of 10-25 and participate in a sport where ACL injuries commonly occur, please consider implementing a neuromuscular training program. For a comprehensive, research-based program, see the link in my story.
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๐Ÿ“šMandelbaum BR, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005.
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๐Ÿ“šHewett TE, et al. Understanding and preventing acl injuries: current biomechanical and epidemiologic considerations. N Am J Sports Phys Ther. 2010.
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๐Ÿ’ฅ๐’๐œ๐š๐ฉ๐ฎ๐ฅ๐จ๐ญ๐ก๐จ๐ซ๐š๐œ๐ข๐œ ๐‚๐จ๐ง๐ญ๐ซ๐จ๐ฅ๐Ÿ’ฅ
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๐Ÿ“ŒThe scapulothoracic joint involves an articulation between the scapula (shoulder blade) and the rib cage. Interestingly, this โ€˜jointโ€™ is not actually a true joint as it does not possess many of the typical structures associated with our other freely moveable joints including a joint capsule and synovial fluid. In fact, our scapulothoracic joint is controlled largely by the surrounding musculature, except for the AC joint where the acromion process of the scapula attaches to the collarbone.
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๐Ÿ‘€Clinically, the scapulothoracic joint is interesting because the vast majority of people barely know it exists and even less people have any idea of how to control its movement. With so many movements possible including elevation, depression, upward and downward rotation, protraction and retraction and anterior/posterior tipping, there is much to see when it comes to this unique region of the body.
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โžก๏ธThis video was originally brought to my attention by @fitnesspainfree and is excellent for demonstrating the various movements of the scapulothoracic joint as this individual (@bimflip) clearly demonstrates superior awareness and motor control.
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โœ…Here is note from @shift_movementscience on when you might incorporate this type of training. - "Hanging scap circles and the progression to small butterfly progressions are one of the best forms of eccentric training for the shoulder. Often times, athletes jump right to full dynamic pull ups or kipping pull ups, but lack the underlying strength/control in their rotator cuff and scap muscles. These drills help build resilience in the shoulder in proper technique to enhance performance and reduce the risk of traction based shoulder injuries during hanging skills"
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๐Ÿ’ฅ๐‘๐จ๐ญ๐š๐ญ๐จ๐ซ ๐‚๐ฎ๐Ÿ๐Ÿ ๐‘๐ž๐ก๐š๐›๐Ÿ’ฅ
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โœ…The four rotator cuff muscles act to stabilize and rotate the shoulder joint and can be susceptible to tendinopathy and tears. Of the four muscles, supraspinatus is most commonly injured and will most typically produce pain at the lateral shoulder that can refer down the lateral arm.
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๐Ÿ“ŒPain in this region is most commonly referred to as โ€˜shoulder impingementโ€™ or โ€˜subacromial pain syndromeโ€™ and is often thought to involve structures that lie in the subacromial space including the tendon of supraspinatus, the biceps brachii long head tendon and the subacromial bursa.
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๐Ÿ‘€If you have pain at the lateral aspect of the shoulder when lifting or reaching overhead, you may be experiencing subacromial pain syndrome. The good news is that progressively loading these muscles and tendons helps to reduce pain and improve function.
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โžก๏ธGive these exercises a try as they have been shown to specifically target supraspinatus and infraspinatus. As always, make sure to consult a rehabilitation provider if your symptoms worsen or do not improve.
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1๏ธโƒฃProne Y
2๏ธโƒฃSide-lying External Rotation
3๏ธโƒฃProne 90/90 External Rotation
4๏ธโƒฃFull Can
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๐Ÿ“šAbdulla SY, et al. Is exercise effective for the management of subacromial impingement syndrome and other soft tissue injuries of the shoulder? Man Ther. 2015.
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๐Ÿ“šGebremariam L, et al. Subacromial impingement syndrome--effectiveness of physiotherapy and manual therapy. Br J Sports Med. 2014.
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