More On Your Nerves

In part one of this series I highlighted the connection between the Nervous System and the Immune System.   Previously viewed as two separate entities, these can now confidently be viewed as one interconnected system.  However it is this exact relationship that influences the physical capacity of our nerves and driving the neural symptoms often experienced in the arms and legs.  In part two, we will discuss neurodynamic testing as a tool to evaluate these physical capacities and how they may be restricting our movement patterns.

It may be surprising, but our neural structures are the most resilient human tissue we have.  Think about how adaptive they must be in real time. Every step we take, door we open, or Saturday night dance move we bust is only achievable because our nerves are able to efficiently adapt.  If our nerves did not glide, lengthen, and shift none of this would be possible without eliciting neural tension. A happy nerve demands, blood flow, space, and movement to function optimally and the restoration of these is fundamental to treatment.  

But how do you know which is needed?  Insert neurodynamic testing.

To be effective with neurodynamic testing there has to be an understanding of the science between normal neural mechanics and neural physiology.   In other words, neurodynamics assess and treat the physical health of the nervous system. When pathology exists in either the mechanics or physiology of a nerve it can disrupt the conductivity of the nerve making the communication between the nerves, brain, and muscles inefficient.  This can be difficult to treat effectively, if not identified correctly. However the use of neurodynamic testing intentionally positions and loads a nerve to help communicate where the dysfunction is stemming from.  This testing thereby identifies the capacity of a nerve to slide, glide, angulate, strain or compress efficiently.  

* Fun fact:  A peripheral nerve can lengthen approximately 12-20% to accommodate normal movement, while the spinal cord can elongate nearly an inch!  So, those tight hamstrings may not be due to muscle tightness, if you have symptoms into the legs, it could be a restriction within the nervous system.

Neurodynamic tests are thus designed to bias neural elements more so than the surrounding interfaces. This intentional loading of a specific nerve root, trunk, and localized region of the spinal canal, and/or sympathetic nervous system allows us to grasp a deeper understanding of where the symptoms are being generated from to treat the cause rather than the symptom.   

Here is a video from David Butler to help further explain how our nerves move!  Check it out.

Stay Well, Stay Strong

Keaton

Practical Stress Management: Part 2

If there is one aspect of life that is often undervalued and under-appreciated it is sleep.  Our ability to sleep is essential to allow a full resolution of pain and restoration of our movement.  Our ability to sleep can be correlated to how our nervous system is being activated. We have 2 parts of our nervous system:  sympathetic and parasympathetic. You see, when we are experiencing pain our nervous system becomes sensitized and preferential to the sympathetic nervous system.  Now when this is the case you will see a rise in heart rate, blood pressure, respiration rate, and even anxiety. Sound familiar on those sleepless nights? You can loosely think of this activation of the sympathetic nervous system as if you drank a large cup of coffee or an energy drink right before bed.  Most people would not choose to partake in such behavior because they would be up all night. This is the exact case for many of those who have had or are currently in a pain-cycle however it isn’t perceived as such. People who are experiencing sleep disturbances or find it difficult to become comfortable at night, please realize that the solution is on the other side of the nervous system:  parasympathetic. There are numerous things we can control or change in the activities leading up to bed as well as with the sleep environment that will allow the parasympathetic nervous system to be tapped into.

According to the National Sleep Foundation, sleep hygiene is considered to be a variety of different practices and habits that are necessary to have good nighttime sleep quality and full daytime alertness.  Sounds great, but what does this have to do with resolving pain and improving movement? Well, consider sleep as the foundation of your health and stress management. By purposefully improving sleep hygiene you are taking a step in regaining control of your life.  Here’s how to do it:

1. Be regular and consistent with the time you get up.  

That’s right when you get up opposed to when you go to sleep.  The reason is that this will allow you to improve your sleep efficiency, the ratio of time in bed asleep opposed to in bed and awake.  The first couple of days may be rough and you may feel fatigue during the day, but this should be reflected on the back end of the day because you will feel tired sooner and be able to determine your ideal bedtime.  I guess you can say we are trying to reverse engineer your bed time.

2. Don’t oversleep.  

Many people live by the idea that they can go on little to no sleep during the week and make up for it on the weekend.  This is not the case. You cannot make up for your accumulated weekly sleep debt by sleeping in on the weekends or days off.  What you are actually doing is setting yourself up for increased grogginess and fatigue throughout the day, which in turn could increase tension and amplify your aches and pains.  

3. Create a positive psychological association with the bedroom.  

The purpose of a bedroom is two-fold:  sleep and sex. If you currently reading, watching television, drinking a cup of tea, etc. before bed, work to try to move these activities to somewhere outside of the bedroom and prior to being ready for sleep.  To perform these activities it requires an increase in alertness and attention, which are both associated with wakefulness and thus an increase in sympathetic activity.

4. Substance avoidance:   alcohol, nicotine, or caffeine.  

Alcohol is often regarded as the ideal nightcap beverage given that it is a depressant.  This is true that it is a depressant, but what is often missed is that alcohol causes us to fall asleep faster than we normally would thus miss out on a portion of our REM (radpid eye movement) cycle.  This is important because disruption of the REM cycle can alter the entire sleep-wake cycle and associated hormonal releases that help you both function and recover when injured.

With regards to nicotine and caffeine, they are both stimulants and will make it difficult to fall asleep.  Now if your thinking I drink a cup of coffee before bed every night and don’t have any changes in my ability to sleep.  I am here to tell you that this is likely due to you already being sympathetically driven and in need of a shift into more parasympathetic activity.  Take the caffeine away and see if you notice a difference.

5. Can’t sleep, GET UP.  

If you lay in bed unable to sleep for more than 20-30 minutes get up and perform some form of relaxation:  meditation, breathing exercises, etc. Once you feel tired again return to your bedroom and go to sleep. The goal here is to keep the positive association with your sleeping environment.  

6. Get rid of all your thoughts and worries.  

A lot of people ponder their to do list for the next day or revisit a stressful part of work day that happened this only achieves a rise in heart rate and blood pressure.  Take the 3-5 minutes before going to bed to let it all out in a journal so you can clear your mind before you sleep.

7. Create a sleeping environment.

Try to implement 1 or more of these sleep environment changes to optimizes your quality of sleep once you fall asleep.  

I hope these help you understand and appreciate the role of sleep in our ability to not only manage stress in our lives, but how it can facilitate an improvement in function.  In the next post we will visit the ever controversial topic of nutrition.

Stay Well, Stay Strong, 
Keaton

References:

1. Chouchou, F. and Desseilles, M. (2017). Heart rate variability: a tool to explore the sleeping brain?.

2. H. Craig Heller, P.  (2017.) https://www.thegreatcourses.com/.

3. Hartman, B.  (2017). All Gain, No Pain.

4. sleepfoundation.org.  (2017).  Sleep Hygiene.  [online] Available at:  https://sleepfoundation.org/sleep-topics/sleep-hygiene [Accessed 21 Oct. 2017].

Practical Stress Management: Part 1

Recently we have highlighted the impact that stress can have on our breathing pattern as well as our movement, but how do we effectively manage stress?  This is the first in a 4 part series emphasizing specific behaviors that can optimize stress management. In this post we will discuss the importance of establishing a morning ritual to help set up a day for success.  This will be followed by sleep optimization, nutritional support, and concluded with the benefits of consistent exercise.

Let’s jump into learning the importance of a morning ritual.  This will be the easiest of the four pillars to implement into life immediately.  

What is a morning ritual?

First, I believe that we have to define, ritual.  A ritual, typically associated with religious beliefs, can be viewed secularly as an order of actions arising from convention or habit to support a goal.(1)  It is likely that most, if not all, of us already have some form of a ritual each morning. But is it setting a foundation for success? The key component of a ritual should be the freedom of thought.(1)  We should not have to think about what our next action will be. This is wasted energy and will ultimately lead to fatigue during the day. The brain is only about 2% of our bodyweight, yet it consumes an astounding 25% of our glucose energy supply.(2,3)  In other words, if we reduce decision-making fatigue we can reduce the onset of early morning stress.

Why have a morning ritual?

By reducing morning stress we in turn allow our actions to become more goal oriented whether in regards to movement health, career health, or family health.  I have noticed since implementing my own morning ritual I have been able to restore what I call my daily-margin. If we think about the margin in a book or on a piece of paper, we recognize there is only a finite amount of space.  Now apply this to a day where in today’s society we are jam packed from sunrise to sunset with checklists for our checklists. Ever heard there isn’t enough time in the day? There is no margin. The words we are writing on our piece of paper is our daily stress.  We can only accumulate so much each day before we are maxed out and start developing health complications. Obviously, this is not an ideal situation. When stressed we are less adaptable when faced with stressors that actually matter. Implementation of a morning ritual can be our first offensive tactic to reduce stress at the front end of the day and allow us to tolerate stress in a better way.(4)  

What is my morning ritual?

1. 4:05AM  Wake up and drink a bottle of water
2. 4:10AM Make a cup of Neuro Coffee (best coffee available, no joke! Check it out.)
3. 4:15-4:45AM Read daily bible scripture and meditate on the day’s teachings.
4. 4:45-5:00AM Daily Movement Hygiene
5. 5:05AM Make wife coffee and leave for gym
6. 5:15-6:30AM Workout
7. 6:30-7:00AM Eat, shower, and get to work

What is your morning ritual?

Stay Well, Stay Strong,
Keaton

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References:  

1. Hartman, Bill, ALL GAIN, NO PAIN: The Over-40 Man's Comeback Guide to Rebuild Your Body After Pain, Injury, or Physical Therapy.  William Hartman. 2017.

2. Kuzawa CW, Chugani HT, Grossman LI, et al. Metabolic costs and evolutionary implications of human brain development. Proc Natl Acad Sci USA. 2014;111(36):13010-5.

3. Esch T, Stefano GB. The neurobiology of stress management. Neuro Endocrinol Lett. 2010;31(1):19-39.

4. Swenson R. Margin, Restoring Emotional, Physical, Financial, and Time Reserves to Overloaded Lives. Tyndale House; 2014.

Getting A Handle On Our Ribs

We have recently wrote about the respiratory system: from the upper respiratory airway down to the primary respiratory muscle, the diaphragm.  But what about the protective rib cage? Our ribs play a critical role in not only respiration, but in movement, too.

Let's get a better handle on our ribs.

Rib facts:

1. There are 7 sets of true ribs, ribs 1-7
2. There are 5 sets of false ribs, ribs 8-12
3. Rib sets 11-12 are considered floating ribs
4. Ribs move when we breath
5. The true ribs are dominated by a pump handle action
6. The false ribs are dominated by a bucket handle action

Understanding Fact #1

The first 7 sets of ribs directly attach to the sternum anteriorly and to the thoracic spine posteriorly.  This forms a singular unit that is stable and rigid. While this helps to protect the heart and lungs, its' position and motion will dictate the function and orientation of the scapula as well as influence apical lung expansion.

Understanding Fact #2

Rib sets 8-10 are considered false ribs.  These ribs have a posterior attachment to the thoracic spine, but anteriorly they only connect to the sternum through costal cartilage.  This makes them more mobile than the true ribs and allows them to be influenced by our abdominals. Our abdominals help the ribs facilitate the respiratory function of the diaphragm.  This is reflected in the infrasternal angle (ISA). A normal ISA is about 90 degrees, if wider, greater than 100 degrees, it indicates poor abdominal opposition and a diaphragm posturally orientated.  If less than 90 degrees, there is likely an abdominal imbalance driving a similar diaphragm orientation.

Understanding Fact #3

Rib sets 11-12 are also false ribs, but classified as our floating ribs.  These ribs attach posteriorly to the thoracic spine, but do not have an anterior attachment.  These ribs do not serve a significant role in the respiratory process, but are critical for protection of vital organs like the kidneys and the adrenal glands.

Understanding Fact #4-6

Facts 4-6 are all about normal rib mechanics during respiration.  As we breathe the ribs have to move in such a way to optimize thorax expansion.  All ribs upon inhalation will externally rotate and elevate, anteriorly, and internally rotate and depress, posteriorly.  The opposite occurs during exhalation. However this is only part of the story for optimal thorax expansion. The rest of the story is found at the thoracic spine.

The orientation of the costovertebral joints are different for the upper and lower ribs.  As a result the defining motions within these ribs also differs. The movement of true ribs can be best seen from a lateral view and resembles the motion of a pump handle.  Whereas the false ribs have more of a bucket handle motion and can be seen posteriorly. These normal mechanics both work to best increase the thorax dimensions during inhalation and decrease it with exhalation. This in turn creates a pressurized system that will drive bidirectional airflow.

But how does this influence our movement?

Our movement is dependent upon how we manage this pressure system.  You see, as the arms and legs move, they will change the shape of the thorax and alter the airflow as well as the pressure within it.  As the thorax shape changes so does the orientation of our pelvic innominates and scapulae. So if we have poor rib mechanics or don't manage our thorax pressure well we will begin to compensate and restrict our movement patterns.  Thus it becomes increasingly important to be good pressure managers to avoid these compensatory movement strategies.

The ribs have become vastly under appreciated in our movement health.  They can and do influence multiple body parts as well as systems making them an ideal starting point for almost every injury type.  Hopefully you can appreciate this and now have a better handle on why our ribs matter in the restoration of our movement health.

Stay Well, Stay Strong

Keaton

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References:

1. Hartman, Bill, ALL GAIN, NO PAIN: The Over-40 Man's Comeback Guide to Rebuild Your Body After Pain, Injury, or Physical Therapy.  William Hartman. 2017.
2. Lee DG. Biomechanics of the thorax - research evidence and clinical expertise. J Man Manip Ther. 2015;23(3):128-38.
3. Neumann DA. Kinesiology of the Musculoskeletal System, Foundations for Rehabilitation. Mosby; 2010.

Understanding the Airway Part 3: The Diaphragm

In Parts 1 and 2, we discussed the relationship between the airway and stress on the body and how the upper airway plays into that. In this article, we will discuss the prime mover of the respiratory system, the diaphragm. The diaphragm muscle is especially important, not just because it keeps us alive but also because we use it roughly 25,000 times per day. It then becomes important to know how it functions, and this requires an understanding of anatomy.  Here’s a few important facts about the anatomy of the diaphragm:

1. The right half of the diaphragm (hemi-diaphragm) is larger, thicker and stronger than the left.

2. The crura (“legs”) of the diaphragm attach to the bodies and disks of the 1st, 2nd, and 3rd lumbar vertebrae on the right and the 1st and 2nd on the left.

3. The medial ligaments of the diaphragm cross over the psoas, a muscle which has a hip flexor function.

4. The position of the right hemi-diaphragm over the liver assists in keeping the right side in its resting domed shape whereas the position of the left hemi-diaphragm under the pericardium assists in keeping the left side in its flattened descended active state.  

5. The arcuate ligaments of the diaphragm on the lumbar spine can act to “tighten” the back into an arched and loaded position.

6. During inhalation, the diaphragm descends into a “flattened” shape and during exhalation the diaphragm forms into a domed shape allowing airflow.  

A few things that we can learn about function of the diaphragm based off of these facts is that the diaphragm is a muscle with a stronger pull on the right.  This means as we breathe 25,000 times per day we may be cranking the spine to the right. The diaphragm is also an important muscle in regards to posture. If the abdominals, especially the internal obliques and transverse abdominus, become weak, the diaphragm may stay descended on both sides into a “flat” and shortened state resulting in potentially tight backs and hip flexors.  When this occurs the diaphragm will assume a more postural stabilizing role rather than its desired respiratory role. We may also notice rib flares, especially on the left due to the position and asymmetry of the diaphragm. This shortened state of the diaphragm makes it weaker as a respiratory muscle because it lacks a normal length tension relationship. Because of this we may end up using accessory muscles of the back and shoulders to inhale which may result in tight shoulders and necks.  Though this doesn’t sound like it should be a problem because you’re just breathing, but you’re doing it 25,000 times per day!

This strongly relates to stress.  The resulting decrease in intra-abdominal pressure results in a “hyper-inflated” state.  This can lower the CO2 in the body which increases the “fight or flight” response resulting in an increased breath rate at rest.  This can also restrict blood flow to the cerebral cortex of the brain, impair gastrointestinal blood flow, promote fatigue and weakness, increase sympathetic adrenal activity, increase anxiety, as well as make you more sensitive to light and sounds.  Like we discussed in Part 2 these are all strongly associated with mouth-breathing.

Now that we’ve seen what inefficient breathing looks like at rest, let’s look at optimal mechanical function of the diaphragm and how a physical therapist can help you out in this regard.  

Optimal mechanical function and power of the diaphragm occurs when the diaphragm is able to go in and out of its resting domed shape and flattened active state on both sides and even be able to alternate in the appropriate conditions.  The diaphragm is mechanically coupled with the abdominals and the rib cage and these all depend on each other for optimal function. This relationship is referred to as the “zone of apposition.” Abdominal disuse can result in flared ribs and a loss of a zone of apposition.  This may appear as “belly breathing.” There’s nothing wrong with belly breathing however if this is the preferred way of respiration, the result can be an elevated stress response and the development of pain syndromes. A physical therapist can help you to restore a zone of apposition by helping you to normalizing resting abdominal tone thereby increasing intra-abdominal pressure and allowing the diaphragm to rest in its domed shape.  In this shape, the diaphragm will function with the abdominal musclature in a piston-like movement allow us to avoid overextending and tightening up the lower back. In turn, this will end up relaxing accessory breathing muscles throughout the body: back, shoulders, and neck. Hence, how you breathe matters, especially since we do it 25,000 times per day!

As always, take care, and breathe easy!

Dave

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References

1. Postural Respiration: An Integrated Approach to Treatment of Patterned Thoraco-Abdominal Pathomechanics. 2000-2016.

2. Boynton B, Barnas G, Dadmun J, Fredberg J: Mechanical coupling of the rib cage, abdomen, and diaphragm through their area of apposition. J Appl Physiol 70:3,1991.

3. Cassart M, Pettiaux N, Gevenois PA, Paiva M, Estenne M. Effect of chronic hyperinflation on diaphragm length and surface area. Am J Respir Crit Care Med. 156:504-508, 1997.

4. Estenne M, Derom E, DeTroyer A. Neck and abdominal muscle activity in patients with severe thoracic scoliosis. Am J Respir Crit Care Med. 1998 Aug;158 (2):452-457.

5. Goldman M, Mead J: Mechanical interaction between the diaphragm and the rib cage. J Appl Physiol 35:2,1973.9.Hodges P, Gandevia S, Richardson C: Contractions of specific abdominal muscles in postural tasks are affected by respiratory maneuvers. J Appl Physiol 83:3, 1997.10.

6. Hruska RJ: Influences of dysfunctional respiratory mechanics on orofacial pain. Dent Clin North Am 41:2,1997.

Understanding The NeuroImmune System

The nervous system is truly the most incredible and adaptable biological system ever created.  The nervous system is an intelligent design composed for bidirectional biological communication to ensure survival.  I was fortunate enough to attend a course, Mobilization of the Neuroimmune System, this weekend to enhance my understanding of how to best recognize and approach a comprised nervous system.

Weekend Takeaways:

1. The immune system heavily influences the nervous system
2. Neurodynamic tests assess the physical capacity of the nervous system
3. Active treatment is more than just moving it also includes breathing and learning.
4. The type of biological container implicated matters for treatment approach
5. "Rehab exercises" are not as much about strength as they are about homuncular clarity

In this post I want to explore the first take away to help illustrate briefly how the nervous system and immune system are related.  

The Immune System Heavily Influences The Nervous System:

We got the weekend started by diving deep into the neurobiology of the nervous system and its relationship with the immune system.  Traditionally these two systems have been viewed as separate entities, but that view is now stale, especially when pain enters the picture.  It would now be appropriate to view the nervous system as a neuroimmune organ. Have you ever wondered why you get a whole body ache when you are sick?  Or why your musculoskeletal pain worsens when sick? What about why your pain increases with a weather change? Each of these are due to an elevated neuroimmune system response based on past experiences.  The immune system is a system that knows who you are and will intervene whenever you are not yourself. The immune system is very efficient as there are nearly ten times the amount of immune cells than there are neurons (nerve cells). This is a beautiful and efficient design for protection.

Unfortunately the initial response of the nervous system tends to be inflammation and a painful experience because they are most effective at altering behavior and reducing an imposed threat.  But why does this occur with something as simple as a weather change or going on a walk? Well, the human brain never forgets. It has an amazing capacity to remember and store memories within the hippocampus.  When memories are stored so are the emotions and the environmental context of the time. So when an event or environment is encountered the body will recall memories, the associated emotions, as well as the environmental context to predict an appropriate outcome.  If there was a harmful experience in the past you may trigger an immune response. How? Interestingly enough, your emotions are derived from the amygdala and memories, the hippocampus, both of which are immune system mediators. This means that your past experiences can trigger immune responses and dictate how the nervous system responds.

How the nervous system responds is dependent upon the pathobiological mechanism, or how the brain processes the incoming information.  There are two types of mechanisms: pain and tissue. The pain mechanism tends to be related to central processing and viewed as a top-down process.  When this occurs there has become alterations in the central nervous system causing the brain to become too protective with its’ predications. There has become a belief there is more danger than there is in reality.  Danger will evoke F.E.A.R (false evidence appearing real). Remember your emotions can trigger an immune response even if unnecessary. This in turn begins to make your nerves more sensitive and more irritable for the future.  

Tip:

Often you can determine if there is a central processing issue by placing a hot pack on a painful region.  If you think about it from a physiological perspective this should increase inflammation and make you feel WORSE!  So if heat feels good be thankful because the tissue you think is damaged is likely not as bad as you think!

The tissue mechanism is related to peripheral processing, or a bottom-up process.  This is the typical process during an acute injury and follows the predictable stages of healing.  When a tissue is injured inflammation is sent locally to start the healing process. This inflammation triggers the neuron to fire a signal to the brain. If pain is the output, inflammation will be sustained to allow the tissue to heal.  Remember inflammation is a protector. So when inflammation persists it will reduce the firing threshold of the neurons, making it easier for them to be triggered. This prevents you from further tissue damage, but makes you more likely to experience pain with normally non-painful activities.  Interestingly though this is not just an acute scenario. Once you have healed completely, your body will leave some resident immune cells in the previously injured area just in case. This is why your body can remember your pain so well and allow a “relapse” to occur. Remember the brain never forgets and always predicts.

Tip:

We do not have pain receptors!  We have nociceptors that send a signal to the brain where it is decided whether or not pain is the appropriate response.  This is why tissue damage and pain rarely correlate!

That being said, deciphering if it is a pain or tissue mechanism is not as simple as placing a hot pack and seeing what happens.  Central and peripheral processes occur simultaneously, but which is the dominant player is the critical aspect. In part 2 of this series I will review how the use of Neurodynamic testing can help to illuminate the physical capacity of the nervous system and guide this clinical reasoning process.

Stay Well, Stay Strong

Keaton

The Sportsman: A Journey Together

Sports are the most captivating scenes in America.  We can all identify the iconic sportsmen of our childhood and we all know what it means when we hear, “I wanna be like-Mike”.  However, most of us fall short and recognize these sportsman as the lucky few who were blessed with God-given talent that reached super-stardom, effortlessly.  This is not true though, the journey of a sportsman is anything but effortless.  No journey is effortless.  And no journey occurs in isolation.    

In reflection of the sportsman journey, I see the journey of a patient.  The sportsman is usually part of a team who cohesively works together to achieve a common goal:  winning.  A team struggles as well as finds success as a singular unit.  Similarly a patient is part of the rehabilitation team striving to succeed at restoring functional capacity.  However there are often roadblocks that slow this process.  Identification of how the sports team and rehab team constructs are similar can allow us to begin to see where our roadblocks may be developing and how we can overcome them.

So here’s the breakdown:  coaches = physical therapists, players = patients, opposition = movement/behavioral dysfunction, and the officials = our pain.  Recognizing that not only are we a part of a team, but we carry a specific role is powerful.

Let’s dive into each of these to learn how to overcome our roadblocks.  

Distinguishment between the opposition and the official is essential.  Far too often we hang our hat on “It’s my pain’s fault.”  Why?  It’s always easier to blame someone or something else.  Just like in basketball, it is easier to say “the refs cost us the game.”  However we know this is not the case.  The officials are present to ensure we play be the rules and to alert us if we do anything wrong just like our pain does.  To not get the whistle blown on us again we have to change our behavior.  However, this can be incredibly difficult, but it’s not just you, even elite athletes have ordinary habits they struggle to overcome.  A recent sport psychology article identified three primary drivers of behavioral change in elite athletes:  credibility, reliability, and intimacy.  However the interesting part is that these three primary drivers are not about the elite athlete, but rather their coach.     

This is no different in physical therapy.  A patient and physical therapist must not only trust one another, but they have to trust the process.  This starts with effective communication from the physical therapist.  An explanation of a patient’s condition or procedure allows the credibility of the physical therapist to be highlighted.  Providing knowledge and resources alike ensures a person they are in good hands.  The outcome is often improved compliance in their behavioral modifications.  Knowledge can be the liberator needed by a patient to break them free of a movement dysfunction.

However sometimes more than one explanation is needed to help break a chronic movement/behavioral pattern.  Being a reliable and consistent resource is also critical.  Often a person leaves a session feeling good about their exercise program as well as her behavior changes, but return ill-confident in their performance.  Utilizing repeated exposures and reassuring a person can go along way.  And just because a person struggles doesn’t mean they are doing something wrong and need “more change”.  It is quite the contrary, at the point of struggle is the start of learning, so consistency in their performance becomes essential.  The physical therapist should highlight this notion and coach each person through their exercises as they learn how to regain control of their movement patterns.  

That being said though sometimes frustration sets in and hinders performance.  Early recognition of this by the physical therapist is important.  This reflects the intimacy of the relationship between a patient and physical therapist.  Being able to pick up on differences in mood, verbal language, and/or body language can mitigate the frustration roadblock and allow for a consistent restoration of their movement and resolution of symptoms.  

In the end, a physical therapist is in the coaches seat.  Their influence drives and guides the success of the players.  The role of the coach is to maintain focus on overcoming the opposition and not the officials.  To do so hangs on the three primary drivers of behavioral change:  credibility, reliability, and intimacy.  

Stay Well,

Keaton

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References:  

1. Butler DS, Moseley GL, Sunyata. Explain Pain 2nd Edn. Noigroup Publications; 2013.

2. Halson SL, Lastella M. Amazing Athletes With Ordinary Habits: Why Is Changing Behavior So Difficult?. Int J Sports Physiol Perform. 2017;12(10):1273-1274.