The Process, Not the Tools

What a powerful statement in the context of patient management. With the vast array of treatment techniques and tools flooding the market these days, it is quite easy to get caught up in feeling the need to get certified in this and credentialed in that. Here are a few to illustrate my point.
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Tools:

• Acupuncture
• Active Release Techniques (ART)
• Intramuscular Stimulation (IMS)
• Craniosacral Therapy
• Graston Technique
• Kinesio Taping
• Z-Health
• McKenzie Method
• Sound Assisted Soft Tissue Mobilization
• ASTYM
• Mulligan Mobilization with Movement
• Muscle Activation Technique
• Active Isolated Stretching
• Muscle Energy Technique
• SpiderTech Taping
• and the list goes on...

Several years ago, I had the privilege of attending my first Modern Spine Care workshop by Dr. Craig Liebenson in Seattle, WA. The workshop was hosted by Drs. Jim Kurtz (Seattle Seahawks and Sounders) and Ming Ming Su-Brown of NW Sports Rehab. What an awesome facility!

"Modern Spine Care" however, was not about the tools...it was about the process. Integrating theoretical principles and practical applications from such pioneers as McGill, Janda, Lewitt, McKenzie, Kolar, Butler, Brugger, Cook, Gary Gray, Travell, Moseley, etc.. (seriously, he had them all), Dr. Liebenson provided us with a comprehensive, clinical reasoning framework upon which we should be managing our patients. Here are some of the principles that flipped my switch this weekend.

​The Clinical Audit Process:

This was the meat and potatoes of the weekend. So rather than providing you with my interpretation of such a valuable clinical reasoning and management process, I simply ask you to read the original document from DC Online. Just click here.
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Microbreaks
The importance of microbreaks during rehabilitation and normal activities of daily living was strongly emphasized. Stuart McGill explains the importance of microbreaks in maximizing the margin of safety of our tissues in both of his texts (Low Back Disorders and Ultimate Back Fitness and Performance - both of which can be obtained from my Educational Resources page above) and Dr. Liebenson was very diligent in not only stressing the importance of such breaks but also implementing them within his workshop (we had to perform a toe touch and squat every 20 minutes). Two simple exercises to perform during these microbreaks to combat a sitting posture, for example, are reaching up to the air and the Brugger relief position (click here for a simple handout to provide your patients).


The Importance of Self Care
Since one of the most vital concepts in effective pain management is the utilization of graded-exposure to feared stimuli, the importance of implementing and facilitating self-care exercises cannot be understated. This may not seem new to most of you but here are some ways one can maximize its effectiveness:

• Since the presence of pain perpetuates abnormal motor control, utilize exercises that are spine sparing and non-painful. As Gray Cook states in the Selective Functional Movement Assessment, attack the most dysfunctional, non-painful pattern first. Dr. Liebenson states, "our job is to build up capacity in the safest way possible."
• While strengthening may be the end goal, it should not be the means. "Stability should precede strength".
• Self care exercises should be challenging enough for compliance but not so much that our margin of safety becomes exceeded. The goal is to "close the gap between functional capacity deficits (the painful dysfunctions) and activity goals (the painful activities)".
• As mentioned above in the clinical audit process, it is of utmost importance that painful movements be reassessed post-exercise and that the specific exercise prescribed is successful in both restoring function and reducing pain. This specific exercise, the "hardest thing the patient can do well", should therefore be the self care exercise prescribed since only then can we enhance central nervous system pathway myelination and promote novel motor engrams. "Send them home with an exercise that reboots the system" since "when they realize that their expectation to an activity isn't painful, that is when neuromuscular reeducation occurs".
• Two of the most important things to work on regardless of the presenting problem are: 1) Verticalization of posture and 2) Restoration of normal respiration.
• On specific tools and techniques: "Don't fall in love with the technique, fall in love with the goal".​

Functional Capacity Testing
Since the goal of patient care is to close the gap between one's functional capacity deficits and their activity goals, Dr. Liebenson workshopped us through an excellent model for quantitative functional capacity evaluation. What was most interesting was that rather than reinventing the wheel, Dr. Liebenson simply combines those tests that already have normative data to compare to:

• Side Plank Endurance
• Forward Plank Endurance
• Trunk Flexor Endurance - V Sit
• Back Extensor Endurance - Sorensen
• One Leg Standing Balance
• Cervico-Cranial Flexion Incoordination

Random Thoughts from the Weekend

1. "Most people are not damaged, they're dysfunctional"
2. "The hurt that your patients feel becomes the feeling that they're hurt" - on chronic pain
3. "You can only find the key link if you have a huge net" - be comprehensive!
4. "Every exercise is a test" - this is the clinical audit process
5. "We don't want to see if they can obey the cues, we want to see what their habit is" - on asking them to demonstrate exercises/movements
6. "The slouched posture is the number one source of pollution for someone unable to perform a squat"
7. "One of the most effective ways to mobilize the T4 region into extension (and simultaneously myelinate the CNS) is via the squat. This is the true meaning of Functional Active Release Techniques." - vs a segmental approach to exercise
8. "McKenzie (technique) has nothing to do with extension, it has everything to do with reassessment"
9. "One of the best anti-lumbar flexion exercises is the squat"
10. "Athletes get injured because of a lack of stability, not a lack of strength"