I have a keen interest in the role that magic and illusions play in the clinical environment.

Most of us are aware of the role of illusions in pain science. For those that don't, feel free to click on the previous link or read this review of a "pain" seminar I attended to get a better understanding.

What it ultimately comes down to is that all interventions should exploit the nervous system in some form or another. And in many cases, through the use of illusions.

Think about the last patient who stumbled through your door in severe acute pain. Or that individual under extreme stress with chronic pain. What sort of strategies did you use to get them on their way much happier and in less discomfort?

Like I alluded to above, it's not uncommon for me to utilize the power of illusions to care for my patients. Now this is not to say that treatment is all an illusion, but more so that illusions can be used as part of your "treatment" strategy.

Before we move forward, let's watch the following video:

As you can see, magicians utilize various known techniques to exploit neuroscience and influence perception. And for us clinicians, I don't think this should be any different. Here are some examples based on the video:

Misdirection of attention

• The shifting of focus away from pain toward function when it comes to history taking and objective measures. Yes, it is important to understand their complaint and rule out red flags, but by focusing on what they are able to do can be a subtle - yet successful - misdirection of attention away from the pain.

Joint attention and mirror neurons

• The use of "monkey see, monkey do" by having the patient perform the exercise while you simultaneously demonstrate it to transiently interrupt the individuals own mind-body connection.

As you can see, the brain is limited in that it has a one track mind. And when someone is experiencing severe, acute pain or chronic pain, very often that one track = pain. So we need to know how to redirect their attention. Again, not as a stand alone treatment - otherwise we would all be magicians - but as part of our strategies when working in the clinic.

Remember, it's not just what we can do with our hands but also how we interact with our patients! And when it comes to humor, the first individual that comes to mind is Patch Adams.

For more information on what the neuroscience of magic reveals about our everyday deceptions, make sure you check out the book, "Sleights of Mind".

I've mentioned this previously, but one of the main reasons I keep this blog is to keep myself in check. To welcome constructive criticism.

Initially it's purpose was to summarize my notes in a relatively coherent manner so that I can revert back to them for studying purposes. It then became an avenue to share knowledge for the benefit of others (some of you might have noticed that I rarely write info pieces - not because they're not valuable, but more so because everyone else is doing it). Occasionally I'll summarize a research article and often I'll review or summarize a course I attended.  I can't say I'm always proud of it, but if you've been here before, you'll know that some of my posts are rants.

But again, one of the main purposes of this site is for my own benefit. To seek criticism. If I've written something incorrectly or if my thought processes are off the mark, then (hopefully) someone out there will call me on it.

This is important. Not only for myself but for anyone and everyone I work with.

​So for many of you out there, I humbly ask you to seek out criticism. Because as Debbie Millman states in the video below, the most important thing to know, is when we don't know what we don't know.

While this isn't directly related to what Nike is doing, I think the principles are the same. 

This brief post has to do with our little ones and what we may - or may not - be doing with them. Around the same time last year, I posted my thoughts on Bumbo chairs which garnered no shortage of attention. Most of it was positive and understanding of my viewpoint, but there was certainly some confusion. Particularly when it came to developmental milestones.

I'm certainly no expert when it comes to infants and toddlers, and it's no secret that I don't have children. But I have studied and I have observed. Objectively. And I have seen who looks like they're on the right path and who doesn't. And the one's that are, are the one's that are moving.

We humans are creatures of the stimulus-adaptation relationship. When faced with a good stimulus, we'll adapt. But when faced with inappropriate or no stimuli, we'll either shut down or do nothing.

To some it may be difficult to swallow. To me, it's almost common sense.

You keep a kid down in a car seat, high chair or one's arms all day, that'll be it's throne. It's place of comfort. The very place where they will develop very little biomotor abilities!

Children need to move. They need to explore. And there's no better place for them to do that than on the floor with lots of toys. Some will fuss and some won't. But usually the one's that fuss are the same one's who've been artificially supported by devices and contraptions meant to do just that...support.

Remember the phrase "use it or lose it"? Well in children, if you don't use it, you won't even learn it.

Crawling and walking just don't magically happen. They're learned. And they're learned via necessity. Our little ones learn how to do things out of want and need. If they see a toy they want to eat, they will figure out a way to go and get it. Unless we grab it for them of course.

So why isn't your kid crawling or walking? It's simple. They haven't been asked to. At least not from the get go and likely not enough (an hour a day on the floor vs eight hours sitting doesn't cut it). Asking a child who's been artificially supported for the first 8-12 months of their life to locomote is like asking a rock to come over and sit beside you. Of course they'll fuss and no question it'll look like their rear end is duct taped to the ground. That is, if they haven't already face planted five or six times.

It's hard, I know. Well, I don't. Because I don't have any children.

But what I do know is this. If you always do something for them, they'll never learn how to do it themselves.

A common phrase often used as a metaphor to "suck it up", "rub some dirt on it" has recently been considered a no-no in the medical world.

I understand the need for caution as well as the potential ramifications and liability of neglect, but I think in some cases, telling someone to rest, take it easy, or not do ____, might actually be iatrogenic.

Take for example the athlete who comes to the training room on a daily basis complaining of this niggle and that owie. Or the weekend warrior - who's "injury" correlates very little with pain that's reportedly getting worse as the days go by. Coincidentally, this same warrior has been receiving "treatment" by the therapist down the street for the last 8 months.
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What I'm trying to get at is that sometimes we simply need to provide reassurance that they're actually going to be okay. I'm not literally suggesting that we tell our patients and athletes to "rub some dirt on it", but what I am advocating for is the ability to decipher whether or not one's clinical presentation is actually a reflection of their lack of confidence.  Because pain itself is a societal construct:

And believe me, you don't always have to put your hands on someone to provide a therapeutic intervention.

I'm here at Frans Bosch's course in Arizona and as I was having (what was supposed to be) a brief text conversation with one of our coaches back home in Canada, I realized that my rambling is simply "putting thoughts down on paper".

So since this the purpose of this blog is to virtually - but literally - put thoughts down on paper leading to my own personal development, I figured I would share the conversation. 
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Coach:
"How's the course?"

Me:
"Course is good. Deep."

"I love courses that teach dynamic - somewhat abstract - thinking, rather than traditional or typical protocols. Even if you don't think some parts are applicable, I still like feeling mentally drained by the end of the day."

"Really trying to wrap my head around long tendons, passive tissues, elastic properties, etc. I.e. in comparison to high energy cost of muscle contraction...also what/how to identify, then how to address."

"But on somewhat of a tangent, thinking about how the body compensates and the role of "tight muscles". Is it the body's way of creating passive stiffness? I.e. "turning muscle into tendon" since the tendon itself can't sufficiently transmit forces passively in the first place?"

"Sorry for the rambling, just needed to get my mind wandering thoughts down on "paper"".

Coach:
"Keep typing"

"I'm interested"

Me:
"Lol. No that's it. Just while he (Bosch) was talking about "the passive", that's what was going through my mind."

"Which then goes back to "feeling loose" (a separate earlier conversation the coach and I had). It doesn't always mean increased performance. BUT that said, a muscle that's more loose - "slack" as Frans would call it - can adapt to variable situations (i.e. distance events) more easily."

"I remember when working with the Jamaicans at Penn. Their connective tissues were thick and stiff. I think that's (possibly) one reason why they can sprint. That it's not just the fast twitch ratio, but also the ability to transmit high forces rapidly."

"Their feet were also stiff and flat. And according to Bosch, the foot's purpose is to "recoil" energy. If they had high arches, when the foot dynamically goes into (over/prolonged) pronation, the energy would leak."

Coach:
"Do you think once you "clean up" movement to a near optimal level, you can focus on improving muscle tension?"

"What I'm really asking is: do they need to happen in that order or can you work on it simultaneously?"

"Or does that require trackside therapy?"

Me:
"That's actually what I was going to answer with. I think it can and should be done simultaneously."

"Going stepwise won't lead to progress (I don't think). I think you would always be "chasing". (Versus) doing it simultaneously would allow
 you to address what's necessary but also lead to improvements (at the same time)."

Coach:
"I have so many thoughts on this."

"What is the balance then within a microcycle and how do you balance workouts with therapy?"

Me:
"I think therapy is twofold, but not necessarily mutually exclusive. 1 - for mechanical efficiency and 2 - performance enhancement."

"The first being a range from fine tuning to injury prevention to mechanical performance enhancement."

"The second being more neurophysiological and autonervous system/readiness based."

"So from a microcycle standpoint, the first would be governed by what you and I see with out eyes."

"The second would be governed by the athletes' subjective (i.e. health & wellness / fatigue questionnaire), their readiness and fatigue level (mood, etc), tapping quality, ground contact times, monitoring scores, etc."
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This conversation is still transpiring but now onto a different subject but I figured I'd stop here.

There has been no shortage of discussion and coverage over Asafa's trainer, naturally. If you're unfamiliar with why he and Tyson Gay have caused quite a stir on both twitter and blogs alike, simply click on the link above to get a bit of an overview.

Aside from the obvious, what really has been running around in my mind is the topic of unlicensed professionals performing therapy.

In the track world this is not uncommon. Stu MacMillan has talked about this topic at length and I have my own personal opinions. But let me tell you this, I have both seen and know of coaches who do a great job in not only enhancing biomechanical performance through various means but also in preventing injuries. And I have seen coaches who have absolutely no business putting their hands on their athletes.

So why the need for coaches doing manual therapy anyway? Are we as clinicians lacking the necessary skill set to work with this demographic? Sure we may be trained in the gold standard of soft tissue therapy and know the latest in fascial research. And sure our websites may list the dozens of courses we've taken. But why then, do coaches feel the need to take it into their own hands (pun intended) and do the work themselves?

In my opinion, we (clinicians) need to stop pointing fingers, worrying about who's licensed and who's not, and start looking in the mirror. Because sure they may not be certified, but frankly, many of us aren't qualified.

Rehabilitation isn't just strengthen this and release that. Perhaps in the really early stages of injury it may be reasonable and effective to treat within the confines of a clinic. But in the later stages of rehab, let alone a healthy athlete, if the therapist isn't "trackside" then I don't know how precise they can be.

And this is why I still have some difficulty in comprehending core medical teams during major competitions. How do you know your athlete's personality and what they look like in action - not to mention competition -  when you're confined to a polyclinic or the therapy tent?

Injury prevention additionally isn't just strengthen this muscle and activate that. And table tests and "functional testing" in the clinic aren't always what they seem once the spikes are on. We need to understand what variables, specific to that individual IN their sport, may predispose them to specific injuries. Biomechanically, we need to know how far they deviate from the ideal model and systemically, we need to know when they're deviating from homeostasis.

And I don't think we can be 100% precise without being present.

Finally, performance enhancement is well, a different beast all together. There are far too many variables involved in this realm and unless a dynamic, almost daily, communicative relationship is present amongst the athlete, coach(es), scientist/support staff, and therapist is present, then I don't think it can truly be performance enhancement.

So what's the answer? Time? Education? Financial compensation?

If the latter, then I strongly think we (again, the clinicians) need to revisit the certification vs qualification question.

Because in general, overconfidence and entitlement are the first two words that come to mind.

We first need to start paying our dues and earn the trust of the coaches. And maybe then the issue of whether a person is certified becomes a non-issue altogether.

Shouldn't junior level athletes still look smooth and be relatively injury free?

Not to be naive but if they're roughly the ages of 16-21, they can't possibly have been put through volumes of training and environmental stresses that say a 29 year old has been put through.

Because why then, do so many of them look like "ticking time bombs"? Kinesiology tape is rampant in this demographic and although the caliber of available coaching may vary, some of these athletes look more like post-surgical veterans than they do 18 year olds.

With respect to the kinesiology tape, I have no issues of its application...when appropriate of course. I'm simply disappointed to see the magnitude of its use in this age group. Naturally I'm not aware of the circumstances behind each athlete's case but seeing so many athletes using it this at elite level championships concerns me. It simply makes me wonder what could be improved in diagnostics and therapy. Even in their development. Now perhaps I have absolutely no right to comment and generalize, but I do wonder.

And with the way they look, sure they are still developing and may not have access to the top coaches (like most), but some of these young athletes look like surgery waiting to happen. They're young. They, theoretically, should still be moving relatively well. But they're not. Is it the volume?

Just a little summary of some of the posts I've shared on Facebook this past week and my rationale for doing so...

The Carpenter

• "The carpenter is defined more by his skill set & knowledge than tools and tool box”
• The above quote was given by Kyle Ridgeway in a recent twitter discussion and is a simple reminder that regardless of the quantity and type or tools we possess in our toolbox, it's the timing and precision of choice of their usage that matters most. For many, such tools considered are often named techniques but to me said tools also include - but are not limited to - education, reassurance, humor and keeping my mouth shut. And to truly know when to use what, I think this is where deliberate practice comes in.

The Subconscious

• While deliberate practice is far from the be all end all as Hambrick and colleagues recently noted, I do think mastery of carpentry comes from the daily passionate grind. As Maria Popova states, "when you work regularly, inspiration strikes regularly", and it is my opinion that one off exposures countlessly laid on top of each other builds experience and subsequently wisdom and creativity. Kotler put together a nice post to attempt to explain the how, especially in terms of the subconscious. Over time, I myself am starting to realize that my lightbulbs often turn on at the most unexpected moments and I'm not sure what's going on but more and more it seems that I can sense the dialogue between the conscious and the subconscious. 

The Human

• Going back to the carpenter, I think too often we forget about the human element and interaction of the "intervention". Sometimes we simply need to do as little as necessary or even nothing at all. And as Spence suggests, nothing with style. Patch Adams has been a strong advocate for this and maybe we just have to think like him a little more.​

Full disclosure: I stole this analogy from EliteTrack.

Anyway...I used to play whack a mole.

When I first entered chiro college 10+ years ago, I immediately became certified in ART. Didn't know how to take a history, didn't know how to do a physical. But that's okay, I was certified! The traps, the erectors, the adductors...I used to play whack a mole.

Then I learned how to assess patients. Orthopaedic testing was the you-know-what. Empty can, full can, Lachman's, Kemps. Find the positive tests, give the high and mighty diagnosis. Treat the MRI...I used to play whack a mole.

I also learned how to manipulate. Oh you want your SIs adjusted? Go ahead and lay on your side...BANG...I used to play whack a mole.

Lame rehab? That too. Weak glute medius? Clam shells...No core? Planks...Tight pecs? Doorway pec stretch...I used to play whack a mole.

Oh, and I learned how to read radiology as well. Hey look, he's got stenosis! Here are your flexion-based stretches. Ooh, looks like you're developing a stress reaction, you should take a month or two off. Yup, I was right, you have a type 23 SLAP lesion. We need to get you to a surgeon...stat!...I used to play whack a mole.

I no longer play whack a mole.

But maybe I do.

​Only time will tell.
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I've been doing a little bit of self-reflection lately, reflecting specifically on how I attack while I work in the athletic setting. Doing this has made me realize a few things. That 1) It's not easy to look at yourself from another person's viewpoint and 2) Sometimes this process is a good way to keep you in check.

Out of all of this, what I've come up with is a guiding framework of how I do what I do. Some may do things differently, while others might take a similar approach. But what matters most is that this framework is what works for me...at least for now.

Starting with a technical model

• Particularly in skill-based sports, it's always important to analyze before I attack. I think it's also important to first keep my mouth shut and let the sensory (the input) do it's job before the motor (the output).  Doing so generally minimizes the possibility of preconceived biases from clouding my judgement or plan of action. Often I'll have a technical model (to borrow from track) rolling in the back of my head that I think needs to be achieved and although athletes vary morphologically, this silhouette - if you will - let's me know how close or far off we are from the end goal. It also acts as a blueprint for the necessary interventions so that I don't over do it.

Sticking with basic principles

• With the amount of information (and fluff) floating around these days, it can be quite easy to get carried away with the fancy stuff. And in my opinion, I really don't think there is any need to be fancy. Sure unconventional interventions may be warranted, but so long as they're necessary, they don't fall under "fancy". In my mind, this is the art of what we do and the basic principles will guide you there. Ask any Yoda and they'll tell you that basic principles win all the time.

Thinking motor learning

• More often than not, the deviation from the intended technical model is secondary to an error in performance. And if performance of a task is the goal, then performance should be the goal. Now the term "performance" can hold various meanings but if you think about it, it's dynamic and it's active, rather than static. And with this comes control which is preceded by learning. So in most interventions, I try to think motor learning because it needs to stick. I have no problem with doing manual therapy in fact I think it's often necessary, but by thinking "motor learning", very rarely do I end with manual therapy alone. Unless it's planned restoration of course.

Knowing regressions and progressions

• Thinking on the fly is a skill that often puts rookies in awe but to me it's all about regressions and progressions. By keeping the intended technical model and basic principles in mind, and understanding the individual's presentation in front of us, understanding regressions and progressions truly shouldn't be too difficult.

​Not being a slave to my methods

• By adhering to all that was stated above, I think it would be quite difficult for one to be a slave to their methods. If we put the individual in front of us first and us second, then there should absolutely no way that our judgement will be clouded by personal biases in methods. Only when the dynamic thought process is halted will slavery prevail.

Hope this helps. If not, here's another example by Patrick Ward and a complementary one by Mike Reinold.