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Its always a pleasure to be able to sit down with individuals who’ve “been there, done that”, but anytime I’m able to sit down with someone associated with hockey, this becomes a privilege. Rather than give you Sean’s bio, I’ll just refer you to this link.

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Sean Skahan

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The reason I’m writing about this rendezvous is because of some of the topics we chatted about. Here, in point form, was the jist of our conversation.

• The importance of working hard to create opportunities – Sean isn’t where he is today because he spent 8 hours on the computer and one hour of training clients per day. Sean was in the trenches, interning with one of the best, and jumping on any opportunity awarded to him from his great work. He stated that sometimes these opportunities come in different and unexpected forms (he’s always wanted to work with football), but it was important that he both recognized and pursued them.

• The difference between American and Canadian hockey players - One thing I shed some light on, to which he agreed, was the difference between players north and south of the border. Here, in Canada, hockey schools are a dime a dozen. Our players have a fantastic skill set and our young players spend almost as much time on the ice than they do in school. Unfortunately, this creates a problem. Many, if not most, of our players do not know how to train. In contrast, if you look at American youth, plenty of time and money is devoted to athletic development. In fact, the sporting culture down south is an industry. From full time strength coaches and athletic trainers/therapists in high schools to athletic scholarships in college and university, young American athletes know how to train. One example I provided Sean with was with regards to Olympic lifting. I asked him to compare his Canadian prospects and rookies with his American counter parts. If you’re in professional hockey, ask yourself the same question and I guarantee you’ll come to the same conclusion: Canadians spend too much time on the ice and not enough time developing themselves as athletes.

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Canada - 3 : USA - 2

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• The contribution of track and field – Those of you in the field of strength and conditioning, regardless of sport, should spend some time working with track and field athletes and coaches. Luckily I was fortunate to work closely with the University of Toronto Track Club for a number of years. Some of the lessons I’ve taken away from this opportunity were the importance of a thorough warm up and cool down to training, the creativity utilized by coaches when cueing, and the precise form utilized when training in the weight room. Sean agreed that we can all learn a lot from spending some time working with athletes in this sport.

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For more information about Sean Skahan, please visit seanskahan.com. He also posted an excellent article on Dragon Door and recently released his DVDs on Kettlebell Lifting for Ice Hockey which can be found here.

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For those of you who have yet to read my posts on the previous courses, please take the time to read them below prior to moving forward.

• Dynamic Neuromuscular Stabilization “A”
• Dynamic Neuromuscular Stabilization “B”
• Dynamic Neuromuscular Stabilization “C”

So here are my thoughts.

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www.rehabps.com

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Assessment

Similar to the Selective Functional Movement Assessment, DNS has a series of tests within their system. And over the last several months but also this weekend, I have realized the importance of performing all the tests especially for those who are just starting out.  To me, getting into this habit ensures that clinical intervention is based on reasoning rather than assumption and provides the clinician with a global picture of the patient or athlete’s presentation. Regardless of whether they are performed at the beginning of the initial examination or in conjunction with other testing procedures, doing so may not only act as a filter for one’s current examination protocol, but may also lead to more effective stabilization strategies in rehabilitation.

Ultimately, the key link to the individual’s functional pathology must be found and finding this link will likely guide the practitioner to the most appropriate exercise intervention and, if necessary, the ideal reflex stimulation technique.

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Treatment

One of the most important recommendations I can give is to know the anticipated movements and understand the supporting and stepping pattern framework. Ultimately, the clinician can utilize whichever exercise progressions he or she wants but I cannot stress enough that when doing so, the principles discussed over during the courses must be respected. For those that are curious, I myself largely utilize progressions based on the neurodevelopmental perspective, principles that are common between the Functional Movement System and DNS.

For those of you who viewed my presentation on SCWebinars, you’ll know that I hold a high regard for variability. I was glad to see that Pavel held similar beliefs as well. And using a case example with an elite track and field athlete over the weekend, Pavel spent a great deal of time training a specific pattern (the key link) in a variety of positions. In so doing, variability was achieved and progress was made. The take home message, train the key pattern…in varied positions.

Whether you choose to utilize DNS-based exercises or your own, it is always important to pay close attention to joint centration. Shirley Sahrmann calls this the path of instantaneous center of rotation. The DNS goal however, is global centration. While DNS will utilize partial patterns to improve the global pattern, the true objective is to respect the power of each joint’s proprioceptive capabilities.

Also respect the punctum fixum. It is never a bad idea to go after the supporting structures prior to the phasic structures. In fact, it’s a great idea. Doing so will establish a better base of support and will give you a better chance to achieve optimal movement patterning. But be picky. As best as possible, try to refrain from cutting the patient some slack. Think about the 3 month supine position (similar to the dead bug) for example. When going after optimal intraabdominal pressure, one common mistake is to let the patient’s feet touch each other. The punctum fixum is the TL junction. Allowing them to touch their feet together will create a false punctum fixum. The direction of muscle pull is important.

I have mentioned this several times before but (borrowing from Gray Cook), you can’t train stabilizing structures with strengthening exercises. So when considering scapular stability and DNS, it will no longer be difficult to understand that the punctum fixum and centration concepts play huge roles in intervention strategies.  All 4’s positions (low kneeling) and side lying positions (RT 2 & 4) are excellent starts.

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Integration

It is important to realize that taking DNS courses doesn’t mean clinicians have to drop everything they have learned in and outside of school. DNS is about the principles not the methods. Use the tools you have, just respect the integrated spinal stabilizing system.

For example, I have found that DNS goes hand in hand with the Selective Functional Movement Assessment. If you’re familiar with the SFMA, you’ll know that its breakouts contain similar assessments to the DNS assessment. The supine neck flexion pattern test and the arm elevation pattern test are two that immediately come to mind. Now if you look at these to tests from the DNS perspective, you’ll know that they are both dependent on optimal intraabdominal pressure. Certainly joint mobility and tissue extensibility dysfunctions may be present, however, often dysfunctional presentations are secondary to faulty stabilization as well. As long as mobility restrictions are cleared, there’s no question DNS principles can easily be integrated into treatment. Just go after the pattern and if the patient can’t get it, that’s where the “magic” comes in.

Just don’t forget to reassess.

Another example can be found with thoracic extension and/or rotation restrictions. If this is your patient’s key link, you now have more tools in your toolbox to build better movement patterns. Remember, every exercise is a test so among others, you have the prone extension test and the bear to work with. And, if they cannot get it on their own or with guidance, (i.e. manual, resisted or verbal-assisted centration) then reflexive locomotion and stimulation may likely be your next tool in line.  Try the 1^st position. Try RT 3.

Those who attended the “A” course need not worry, the Reflex Creep position may serve you just well.

Recently, I’ve been asked for my clinical opinion on ideas for troublesome achlilles tendinopathy and chronic exertional compartment syndrome.  If you know me, you’ll know that my first response would be to look everywhere but the lower leg (save for the foot). You can do so via the SFMA and you can do so via Dr. Liebenson’s Mag 7. But you can also do so via DNS. A simple example? Again, the prone extension test. Faulty uprighting may just be the key link to lower limb posterior chain overload.

Rolling patterns have been quite the buzz for several years though unfortunately, mastering the art often isn’t easy. We’ll know that our patients need to be here in the algorithm but often performance difficulties will lead to frustration. One revelation for me this weekend was that the oblique trunk flexion test may be an excellent breakout for the flexion rolling pattern to shed light on the ability of the chest to stabilize against the oblique muscle chains. One solution for improving rolling patterns then? RT 2.

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I hope this sheds some light to the utility of DNS in practice. For those of you looking for some insight into my thoughts on DNS C, I’ll make sure to provide a little summary sometime later this week.

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Muscle Imbalances Revealed – Upper Body

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Last year, you may have read several of my reviews on Muscle Imbalances Revealed – Lower Body, a dvd package put together by some of the top experts in the fitness industry. Well this year, I’ve had the privilege to contribute to the newest version of this product, Muscle Imbalances Revealed – Upper Body. Together with Rick Kaselj, Tony Gentilcore and Dean Somerset, we have essentially put together everything – well not everything but a whole whack-load of information – you need to know about the core, thoracic spine, shoulder, neck and arm. But for those of you really interested in what I had to say, well you probably won’t be surprised. So let me give you a quick run down:

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“Respiratory Control: Linking breathing with rehabilitation & training” 

This was my main presentation where I talked about the following:

• Nailing down your mobility and stability exercises with breathing
• “Money moves” for improved breathing
• The Stability-Motor Control Continuum
• Assessment techniques
• How to integrate breathing into movement

“Understanding Soft Tissue Management: Choosing the right tool”

This shorter presentation essentially discusses:

• The mechanism behind soft tissue injuries
• The 3 Phases of Healing
• Who’s who soft tissue world
• The “integr8r”
• The role of the Instrument Assisted Soft Tissue Mobilization in tissue recovery
• The most effective ways to foam roll the upper body

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But enough about me, what you really need to see is what the other guys had to say in Muscle Imbalances Revealed – Upper Body! Here are short clips from each of “the other guys’” presentations.

“Corrective Exercise Strategies for Athletes (and Meatheads, too)” with Tony Gentilcore

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“Myofascial Training for the Upper Body” with Dean Somerset

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“Unraveling Muscle Imbalances in the Shoulder” with Rick Kaselj

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Now I’m really excited about what we’ve put together. I truly think that regardless of whether you’re a manual & rehabilitation therapist, fitness professional, or just someone who loves to train, that you’ll benefit greatly from this package. In fact, I actually think that your friends and colleagues will benefit as well (so please spread the word)!  And the best part about it? You don’t have to spend your spouse’s hard earned money like I do and fly all over to get your con ed on. In fact, the cost is only $77.

Anyway…

-> -> HERE’S THE LINK <- <-

…and thank you in advance for your continued support!

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Foam Rollers – There are none. Not one. Obviously I use them in practice but watching gymnasts prep for training and competition is making me think that such devices could be used less with proper preparation. Remember Charlie’s thoughts on stretching?

Warm Up – These gymnasts meticulously mobilize each and every joint in their body dynamically. They spend the time starting from distal to proximal, from specific to general, and in all planes and directions. We might be shortchanging our athletes without this attention to detail.

Stretching – There’s no shortage of it here. Warm up here comes first then stretching. Warm up aside, stretching went from static to dynamic and is in general, mini-ballistic.

Focus – Little chatting. Deathly stares. And full concentration. Period.

Crunches – Lots of v-sits, and lumbar flexion warm up exercises as well. I don’t think it’s a green light for all gymnasts, but it would be hard for me to flip on the red for half of them. I see integration of all joint and myofascial segments and load sharing from head to toe. Even see the joint by joint respected (think sternum crunch in a dead bug position). In this case, I think its ok. In the normal population, I’ll still set up a road block. Remember, it was warm up, not training and definitely not volume.

Bands – Plenty of resistance here during the warm up. Band pullaparts, straight arm pulldowns, etc. Great progressions.

Amazing feats of strength, mobility, and stability - Here’s an example of a commonly performed movement seen today. This video is obviously not by the gymnasts themselves as filming them warm up is not only prohibited but creepy. Naturally, the girls were much more precise than this video but he did a great job nonetheless. Note, the girls did multiple continuous reps.

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If you have had the pleasure of attending one of Dr. Liebenson’s seminars, you’ll know first hand that he utilizes a large battery of exercises to rehabilitate a patient with functional pathology. While many of us attendees wished we were looking at the patient through his own lens, often we’ll ask ourselves “how the heck did he know that that exercise was the key link”?

Well in my opinion and aside from his extensive experience, there are two primary reasons why Craig can pull a specific exercise out from the score keeper’s room behind the Green Monster (let alone left field) and instantaneously help a patient improve their dysfunction. The first being the Clinical Audit Process and the second being a continuum of exercise progressions.

In the sport performance world, exercise progressions are to athletic development as I am to continuing education. And frankly, I don’t think the rehab world should be any different. Now I’m not talking about 8 repetitions this week and 10 repetitions next, but more so utilizing a continuum of exercises with similar objectives but with varying difficulties for the purpose of matching the right exercise to the said patient.

For those of you familiar with the FMS, you will know that Gray and Lee have their priorities and progressions. Pavel Kolar and DNS is not different and while I myself have never taken the RKC, I am quite confident that Pavel and his army are no different.

So in the rehab realm, how do we choose the most appropriate exercise for our patients? Well recently, Dr. Liebenson released his new 3-DVD set that answers just that. But as always, we must first start with a functional evaluation. Because without this, as Dr. Liebenson says, “any training flexibility, stability, or performance training is no more than dumb luck”. For more on functional evaluations, I highly suggest you attend one of his seminars, as well as that of the SFMA and Stuart McGill.

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So with these dvds, it is important to understand that it is the principles upon which corresponding exercises are chosen. Remember, it’s not about the tools but the principles behind them.

Core Stability Training

• For those of you in the rehab world, you probably already use several of these exercises already. Some of you may use them as your “core” exercises and others may simply use them to troubleshoot a specific patient. What some people fail to realize, however, is that Dr. Liebenson has been around since the invention of such exercises. Take McGill’s “big 3″ for example. Did you know that Stu and Craig have worked closely together for many years? To me, if I’m using specific exercises for my patients, I want to make sure that they are being performed correctly. And with this particular dvd (as well as the other two), Dr. Liebenson does an excellent job instructing each exercise and providing the most effective cues during their performance.

Overall, these dvds set themselves apart from many others not only because of the creator behind the discs, but also because of their professional quality. Utilizing custom-created images as well as “live” dialogues, Dr. Liebenson takes the time to explain with detail the purpose behind each exercise series. Certainly many more exercises will be invented but like I said, the principles behind the process are what’s most important. And it is these principles that will stick around in our industry for many years to come.

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For those of you who haven’t read their thoughts, here are the links:

• Corrective Exercise: Muscle Imbalances Revealed (Upper) – Eric Cressey
• Muscle Imbalances Revealed Upper Body Review – Mike Reinold

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Oozing with both practical and nerd-ical content, this dvd set is very comprehensive but also very user friendly. Grounded in scientific information, Eric and Mike presented various concepts ranging from the epidemiology and etiology of shoulder injuries to injury prevention and performance enhancement.

Here are some highlights from Optimal Shoulder Performance:

The importance of assessing Total Range of Motion

• Both Eric and Mike go into great detail to explain the importance of  the continual assessment shoulder total range of motion. Using the example of Glenohumeral Internal Rotation Deficit (GIRD) vs Instability, Eric and Mike explain why stretching the posterior capsule and cuff may not always be the best idea. In fact, they explain that doing so may even be pathological. So while the sleeper stretch has become a mainstay in many training centers, these two gentlemen provide their reasons why you probably shouldn’t be prescribing such exercise.

Dynamic Stability Progressions

• Supine to standing, stable to unstable, open to closed, Mike does an excellent job of introducing his exercise progressions for eliciting and achieving dynamic rotator cuff stability through rhythmic stabilization. I, myself, use his progressions quite frequently and really think this is a great way to “activate” the cuff prior to functional therapeutic exercise. In fact, I believe Eric may even use these progressions prior to training as well. The only downside with this type of exercise is that while gains can readily be made in clinical settings, there really wasn’t a similar exercise (that I knew of) to send the patient home with…until now. After several months of using this technique, especially early in the progression, I realized that bottoms up kettlebell work was a great way to repeat the objective at home. So here are two exercises that I now often sent my patients home with. The screwdriver and the armbar.

I believe Dr. Snell also uploaded this exercise on MyRehabExercise.com

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Note: For the complete exercise progression continuum for training dynamic cuff stability through rhythmic stabilization, I would highly suggest Mike’s Treatment of the Shoulder Joint Complex: Principles of Dynamic Stabilization DVD. You can pick it up at AdvancedCEU.com which, unsurprisingly, is an affiliate link to fund my “continuing education for life” endeavors.

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Impingement

• Going back to assessments, Eric and Mike use the differentiation between internal and external impingement ESPECIALLY as they relate to specific demographics to illustrate the importance of comprehensive assessments prior to training. Knowing your athlete history and choosing the most appropriate assessment recipe is can be a difficult thing to master but a trainable skill to practice nonetheless. It is often stated that if you’re not “assessing, you’re guessing” but how easy is it for us clinicians to simply assume and treat? Shooting for perfection 100% of the time will make us better practitioners and assessing will help us get there.

Practical Labs

• In the lab portions of the dvds, while Eric and Mike don’t dump the exercise tool box and give you all their exercises, they do spend plenty of time teaching proper form and optimal cueing strategies. I think this approach is far more important and effective than demonstrating hundreds of exercises. Because in each exercise, the principles stay the same – perfect form and proper joint positioning. That said, for those of you who are seeking an exercise database, they’re at your fingertips on each of their respective youtube channels. In fact, Mike has come out with some great exercises as of late so be sure to check out his page.

Finally, there were countless pearls embedded deep in the Optimal Shoulder Performance ocean. One specific pearl I liked was the fact that during rhythmic stabilizations, Mike almost wants the athlete fail on some of the reps. This is showing him that the exercise is difficult enough for the athlete to force an adaptation. Because like the clinical audit process, only with a significant but controllable challenge will a new pattern emerge.

All in all, I really enjoyed Optimal Shoulder Performance. It has provided me with excellent principles for effectively managing not only my 74 year old cuff patients but also my varsity swimmers. So if you work with overhead athletes, make sure you check it out.

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Why you might be the reason your child may be inactive – Tralee Pearce

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Lindsay is now a chiropractic student and by the end of this weekend, will be an ART practitioner.

Anyway. She introduced me to a tool originating from Italy that I, myself, need to look into further. It may fit in and it may not. But I need to research it.

Because we first have Movement.

Functional Movement Screen

Y Balance Test

Got it? Good.

Now what about Performance?

Well she introduced me to the Optogait and the Optojump. And I think it might fit in. It might not. But then again it might. I just need to look into it further.

What do you think?

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Advances in Functional Training
Michael Boyle
Santa Cruz, California
On Target Publications, 2010
315 pages

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Authored by one of North America’s pioneers of strength and conditioning, Advances in Functional Training is a book written primarily for coaches, trainers, and athletes. With an obvious emphasis on function, one would be hard pressed to withhold this text from the rehabilitation professional as well, since many of the concepts discussed look at applied movement as it pertains to sport.

Advances in Functional Training is divided into eleven sections:

1. Advances in Functional Training (the introduction)
2. Mobility and Flexibility
3. Injuries
4. The Core
5. The Hips
6. Cardiovascular Training
7. Developing Athleticism
8. Equipment Choices
9. Exercise Choices The Basics and Single-Leg Training
10. Program Design
11. Sample Progressions

While many of the above chapters pertain specifically to strength training and athletic development, there is certainly no shortage of crossover to the field of sport medicine. Touching on specific topics such as core stability and sports hernias, among others, Boyle provides the reader with sound strategies for training around injuries. In fact, his “sports hernia” section really opened my eyes to effective rehabilitation and I’ve been treating hockey players for quite some time. Regardless, many of the training principles incorporated in this text can easily be applied in the rehab setting, even those principles surrounding periodization.

Now many of you in the field of sport medicine may be quick to ignore this text simply because of its title, but I can assure you that many of its concepts are relevant to your everyday practice.  For those of you unaware, prior to full time strength training, Boyle previously worked an athletic trainer so he certainly understands the nature of injuries sustained in sport. Now I, myself, am a big believer of training heavy in rehabilitation but for those of you comfortable with yellow resistance bands and heat packs, you’re more than welcome to forego this text. And for those of you interested in taking your rehabilitation skills to the next level, I highly suggest you get your hands on a copy. Think about it, how fun would it be to differentiate yourselves with the next clinic by using kettlebells, the TRX and valslides/slideboards in your practice? You really don’t need much to rehab your patients effectively and efficiently and you certainly do not need a large budget for useless exercise machines that take up enormous amounts of space. If you are doubtful, just ask my interns.

But you do have a great opportunity to change the way your current rehabilitation programs are being implemented and Advances in Functional Training is but one important resource to help you do so. Better yet, get yourself a membership to

And for those of you that really need convincing, here are a few exercises from Boyle’s youtube page that I commonly use in my clinic.

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Here’s the post:

Elite Performance via Early Specialization

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Authors: T. Noakes

Journal: British Journal of Sports Medicine

Date: November 2011

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Summary:

• Here’s a recent article published in BJSM and shared to me by my graduate co-supervisor, Joe Baker. Rather than being a randomized control trial, this is a highly opinionated and perhaps controversial paper expressing his feelings towards the American College of Sports Medicine outlining the significance of the omission of his previous findings on exercise-associated hyponatremia (EAH) during prolonged exercise. Specifically, based on research that does not include his previous studies in 1985 and 1991, it was promoted by the ACSM that athletes should consume, during exercise, as much fluid as tolerable. On the contrary, it was proposed by Noakes and colleagues that exercise-associated hyponatremia “appears to be (related to) voluntary hyperhydration with hypotonic solutions combined with moderate sweat sodium chloride losses“. As an aside, it is not uncommon to witness typical EAH symptoms of vomiting, nausea, dizziness, altered mental status in less skilled (aka “slower”) endurance athletes. While the principle argument for this paper was to suggest that very low levels of postexercisue serum sodium concentrations in athletes suffereing from EAH result from body weight gain secondary to fluid retention irrespective of volitional electrolyte (i.e. sodium) consumption, the main “takeaway” from this paper was that his research may be largely ignored due to commercial influence. What Noakes does suggest however, is that increasing sodium ingestion with increasing duration of exercise may not provide any biologically significant effect to countering EAH. So should we really still be drinking our Gatosauce or should we be paying more specific attention to our water consumption levels if we’re less gifted and toward the “back of the pack”.

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Noakes, T. (2011) Changes in body mass alone explain almost all of the variance in the serum sodium concentrations during prolonged exercise. Has commercial influence impeded scientific endeavour? British Journal of Sports Medicine.

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For those of you interested in another summary of this paper, please take a look at Alex Hutchinson’s blog.

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“We’re having a injury-ridden season this year, and we’ve been trying to determine why. We do see very common trends among the men, and we believe it’s the guys’ lack of scapular stability and endurance in the stabilizer muscles, and general thoracic cage stability…We see a lot of mid-back injury and especially rib injuries, and very commonly rib stress-fractures.

Now, these guys have the best Strength and Conditioning team around, however the medical team feels that they’re…not getting enough stability and shoulder blade mobility exercises (they basically need to improve the stability of the scap to work in a large range of motion).

Anyway, I was wondering what you thought were the best couple of exercises for scap stability and serratus anterior activation. Now these guys are elite athletes, they’re amazing machines actually, so they can probably do some advanced stuff, but I think we need some activation exercise, and then followed by integrating this into some advanced functional movements!”

Admittedly, I have never worked with a rower in my life. However, having examined some of the current literature (Vinther et al, Warden et al) it seems as though the exact causal mechanism for such injury is not clear cut. That said, first things first.

Stress Fractures = Bone Resporption > Bone Repair

(at sites of microfractures secondary to repetitive loading)

While certainly stress fractures may be associated with abnormal (low) levels of bone mineral density and its associated factors, several causal mechanisms have been proposed to describe its etiology. Namely:

• Sheer forces resulting from co-contraction of the serratus anterior and external oblique
• Increased co-contraction levels of the serratus anterior and lower trapezius
• Poor eccentric control of shoulder flexion
• Faulty motor patterning (timing) between the lower body and the upper body
• Inadequate knee-extension strength to elbow-flexion strength ratios

From a training and periodization standpoint, it is quite easy for those on the outside to immediately suggest that such athletes are “doing too much too soon”. However, seeing that such fractures are quite common regardless of the level of athlete, we cannot simply point the finger at loading parameters. Anything and everything from biomechanics and motor control to poor nutrition to improper rest is fair game. Certainly a thorough assessment must take precedence but with respect to the above question posed, here are some recommendations for simultaneously improving scapular mobility and stability.

Scapular Mobility:

(I really like this video)

Assisted Push Pull / Twister (sorry, I couldn’t find a video on youtube)

Scapular Stability/Eccentric Shoulder Flexion:

With respect to motor patterning between the lower and upper of the body, I would consider utilizing such exercises as deadlift and jump squat variations, however, I will leave this for another post. Hopefully some of the above strategies will prove useful when incorporated into the overall training programs of these athletes. Certainly several of the exercises above are anterior chain dominant however, these athletes are exceptionally strong posteriorly and so ensuring balance between the two seems prudent. They are by no means definitive, but when indicated for the right individual, I think they can be helpful. What are your suggestions?

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