Getting started with evidence based practice can seem overwhelming. The JOSPT does an excellent job synthesizing and weighting the current evidence for a number of conditions physical therapists treat. Check out the clinical practice guidelines here.
It is often surprising how seemingly basic questions are quite difficult to answer.
A number of months ago, a client of mine informed me that he was considering total hip replacement surgery. This gentleman quite enjoyed playing basketball, football, and softball. He asked if, after proper rehabilitation, he would be able to return to these activities. This seemingly straightforward question proved surprisingly difficulty to answer.
When I first started in PT school (what now seems like centuries ago), “short arc quad” exercises were frequently prescribed for patients with pain around the kneecap. I am surprised at how frequently these exercises are still prescribed. The JOSPT published a great summary of a research article addressing the best evidence in this area. Essentially, to minimize stress on the patellofemoral joint (the joint between the back of the kneecap and the femur), one should perform “short squat” exercises (0-45 degree range) and short knee extension exercises (90-45 degree range).
You can read that summary for yourself HERE.
I put one foot in front of the other, stepping over roots and rocks, my hiking boots leaving little waffle marks in the soft dirt behind me. I am surrounded by trees that reach for the sky, and dive deep into the earth. Plants are emerging from the ground, splashes of vibrant green. And there is a misty fog enveloping it all, a damp hug from the air.
As I have been walking, I have been thinking about connective tissue.
The connective tissue is also called fascia. It surrounds every bone, muscle, organ, and vessel and connects them to every other part. It also creates a surface for those structures to glide and slide on each other. It is integral to the cohesiveness of the body and its movements. Practitioners talk about everything being all connected, and this tissue is the main reason why. It is made up of collagen fibers that give it strength and elastic fibers that give it flexibility.
As I move through the forest, I look around for the thing that interfaces with everything. Is it the fog? Not really. That leaves out everything underground. Is it the earth? Not really, that leaves out everything in the trees. What moves between everything?
The vernal pool to my right has a wooden boardwalk that runs into the middle of the pond. I step onto the planks, making a clunk sound, louder than I expected against the backdrop of birds and wind. Out of the corner of my eye, I see a little frog dive underneath the surface of the water.
I think frogs are pretty cool.
They are happy to swim in the water, they are happy to settle in the mud, they are happy to climb the trees. They can be flashy, orange or blue, characters on the cover of National Geographic, or sedately camouflaged into the green of the algae or the brown of the mud.
They can move between all the levels of the forest, in a sense connecting it all. But as an analogy for connective tissue, they aren’t quite right. But I want to play with the metaphor, it has potential.
I look at the water line of the pond, the interface between the air and water. There is a layer of algae, there are also water bugs dancing on the surface of the water.
Connective tissue responds to the stresses that are placed on it physically and emotionally, the way all tissue does. When there is stress or trauma, the connective tissue goes into a protective spasm, just like a muscle does, it tightens, and it contracts. And sometimes, the structures around the fascia heal, but the fascia forgets to drop its guard. These areas do not move very well. In other words, they become “fascial restrictions”.
I watch as the frog pokes its head above the water again. Ripples move outward to bounce off the surrounding rocks, back to the frog.
Because this system is throughout the body, areas of limited movement impact the entire body, just like the ripples in the water. The frog pokes its head out of the water in the middle of the pond, the ripples can be felt everywhere the water meets the dirt, even three dimensionally if you really think about it, going outward and down, or until it meets another structure that stops the ripple.
If connective tissue does not move in one area, some other area needs to work harder to complete the movement. Some people describe it like a full body nylon stocking, which connects every part to every other part, and moves with whatever movement is being performed. If it were to get a snag, the most common fix is clear nail polish, dab a little on the snag, wait a few seconds for it to dry, and problem solved. Sometimes the polish dries and sticks to the skin underneath it. Sometimes the nylons had to be adjusted to fix the snag, so they are not lying in the most comfortable position when they got stuck. That place of limited movement would be felt all over the rest of the nylons, the resting position would feel awkward, and movements might be altered to adapt to the restricted tissue.
I watch as the water bug skitters past the frog, ripples interfacing, the water amazing me in its ability to support the frog from deep below, and support the bug with the surface tension.
It occurs to me that this is just like I support the collagen and elastic fibers of the connective tissue when I work with a client. I support the elastic fibers and take them to their end range, like the water holding the frog, and then I hold them there, as the collagen fibers dance what they need to dance to get back to mobile tissue, like the water bug. This gentle prolonged stretch of the collagen fibers, while keeping the elastic fibers anchored, allows the tissue to change, and to regain normal tissue mobility. Addressing the fascial restriction takes the stress off the other tissues, so that when the client gets off the table, everything is moving again, and that usually translates into more comfortable movement.
I turn around and step back onto the trail.
Frogs didn’t make a great metaphor for the connective tissue system, but I still think they are pretty cool.
Step by Step
My two kids face each other in the wagon, a soccer ball and two folding camp chairs on their laps. I have food in my backpack, and I pull them down the sidewalk of Route 135. The road is closed off, so there is no traffic.
I look up and see a man in a three wheel racing wheelchair, pedaling with his arms.
“Here come the wheelchair racers!”
In January, I started a study group for manual therapists. That means the time that I was putting into this blog, I transferred into putting together anatomy reviews for the group. Geeky, overly detailed, three dimensional graph kinds of anatomy reviews that barely scratch the surface of how I picture the anatomy in my head and in my hands. I absolutely love putting them together.
Delving into the anatomy deeper, I started thinking about how all the parts fit together, and all the parts that make up all the parts that are fitting together. Body tissues are made of cells and fluids that are dancing around in relationship, those cells and fluids are made up of molecules that are interrelating, those molecules are made up of atoms that are relating back and forth, and the atoms are made up of…….
It was here that I contacted my physics teacher from high school for my crash course on quantum physics. Several emails later…….
Atoms are made of particles that fit into two families. Protons and neutrons that are made of quarks and electrons are in one family. The other family includes photons. Protons and neutrons are connected and the electrons dance around those guys, and that makes an atom. And when two atoms start to relate to each other, they do so by tossing photons back and forth like a medicine ball. But the bottom line, to me, is that even at this teeny tiny level, they are moving around, relating to each other.
Zoom back to the bigger picture of a client on the treatment table, with the anatomy and the emotions and the spirit that goes with being a human on the table.
I really want there to be a direct connection between these small sub-atomic particles and the anatomy that has cells that breath, walk, talk, think and feel. Rationally, it should make sense. I should be able to trace the jumps from subatomic particle, to atom, to molecule, to cell, to fluid, to organ, to system, to person.
I can do that on a physical level.
I can sort of do it on an emotional level.
Emotions are cascades of neurons firing to release hormones. These hormones are molecules. The molecules swim around our bodies and our brain receives them and interprets them. These very concrete molecules have a concrete relationship with the nervous system and the organs. Then the next jump gets murky. Somehow, the brain turns these molecules into an experience of an emotion. Like “anger”. Like “fear”. Like “love”. It’s like magic. Amazing, beautiful, unexplained magic. It’s the unexplained part that has me frustrated right now.
I can almost do it on an energetic level.
In the energetic framework that I use, the Healing from the Core framework created by Suzanne Scurlock-Durana, Suzanne ties those emotions and energy back to the body tissues. If you are in a session and have an emotion or an energy that you want to work with, the first question is always, “Where do you feel that in your body?” And once you have identified it in the body, then you can be present with it, support it, and that support gives it an opportunity to change. So, I keep coming back to the thought that energetics, as well as emotions and spirituality, should have a concrete explanation on how it relates to the physical anatomy. A lot of the last two months, I have been struggling with the belief that if I just think about it enough, in the right way, that I will find the answer. (Suzanne would ask me where I feel that in my body, and I would tell her its right at the base of my skull, where my left temporal bone meets my occiput bone and wraps around to the front of my left neck, just under my jaw. Then she would tell me to ground and fill.)
Todd said the other day, “Humans are complicated structures that exist on many levels with multiple, interrelated complex systems.” And he is right. The “truth” about the way the physical anatomy relates to the energetic and the emotional part of being human is that there probably is a “link” or multiple “links” that connect everything together. Those links may not be linear, rational, or even physically anatomical as we know the anatomy at this point. Those missing links have me thinking in circles, like the computer at the end of the movie War Games playing Tic Tac Toe with itself. Eventually, the computer realizes that there is no winner, and it calls off the nuclear missiles. I am almost ready to admit that there is no “right” answer.
But on the other hand, those missing links are also what make “life” such a mysterious and mind-boggling gift. Like a unicorn.
I am consistently surprised at the speed time seems to pass. October 1st of this year will mark the start of our third year in the new office location. In many ways, it feels like this space has always been our home, yet in others, I cannot believe that much time has passed that quickly.
Our first winter at this office was marked by more snow that we have seen in a while. Unfortunately, many Integrative clients found themselves getting acquainted with our then-new office space because they had injured themselves moving snow, or slipping on ice that never seemed to fade. I thought that, not knowing what this winter will bring, that I would review what I discussed with many of you that particular winter: how to minimize injury when dealing with snow.
Look closely at our Christmas tree.
I’m not sure if you can tell from the photo, but there are an awful lot of gold beads on the lower half of the tree, and the lower part of the tree has the ornaments in clumps with big areas without decoration. The really expensive ornaments and the ones we can not replace, those are on the tippy top of the tree. And if you look really closely, you might see that the felt reindeer ornaments all are “tagged” in pairs with matching balls. If you sort of squint, there are some nutcracker ornaments dangling off the end of a strand of gold beads, hovering just above the train engine on the rug.
You may or may not have guessed, but this year I had help decorating our tree. I had a very enthusiastic and creative five and a half year old helper. From where the decorations are placed, you can get a sense of how tall he is this season.
He insisted on putting the beads on himself. I am not usually one for gold, but we got a box of decorations that my mother in law was getting rid of, and he thought they were great, so I went with it and let him go to town.
When I was little my mom made the felt reindeer, and I always had to have them in order the same way the rainbow is organized. This year, I let Ryan put them on. Then he started hanging glass balls on the reindeer hangers. I asked him what he was doing. He replied, “I am tagging the reindeer. See, there are girl reindeer and boy reindeer, and the tags match, and that is how they will know that they belong together.” I chuckled at the elaborateness of his story.
Then he found the little nutcracker ornaments, and started hanging them off the end of a bead string, and he said,” Look Mommy, the nutcrackers are climbing the mountain.” By now, I was trying not to laugh out loud. He couldn’t hang an ornament without creating a back story of who the ornament was, what the ornament was doing, and where it was going. His stories were interesting, elaborate and unexpected. (I told this story to a friend of mine, and she laughed and said, “You do that too, you don’t just do something, there is always a story that goes with it.” Really? Do I really do that? You don’t have to answer.)
But I found myself struggling to let him find his own way of decorating the tree. I desperately wanted to reorganize the beads over the entire tree, fill in the holes where there were no ornaments, and, as it was starting to get late, I wanted to speed him up a bit so we could finish and get him to just put an ornament on and not get so caught up in all the stories he was telling about each one.
I am not always good about “process” when it comes to myself or my own family. I want things done now, and I can be a bit of a perfectionist. It seems a lot of my personal learning is about appreciating the “process” and all the moments that lead up to the goal. I think it’s something a lot of people struggle with, especially when they are dealing with a part of their body that is no longer working as it did.
We are all in a continual process where one minute flows into the next, one movement flows into the next, and where injury flows into wellness. The process of our bodies striving towards wellness, physically, emotionally, and spiritually, is so fluid and circular and never ending. One injury is not a separate and distinct entity from everything else in your life, past, present or future. It is all connected.
It’s hard to be patient when a body is in pain. I know first hand, I am no different from any one else in that regard. But I also know that the process of recovering also brings many good lessons with it. Struggling through a healing process gives me insights into dysfunction that I would not have learned any other way, and almost always those lessons come back around to help me help others. It may be a day, a month, or a year, but eventually, I run into someone else with similar symptoms, and I am able to help guide them through their process precisely because of the process I had to go through. Such a funny thing is this web of life.
Dr. Upledger (the osteopath that advanced CranioSacral Therapy) always jokes that when you finally have it all figured out, and the “process” is complete, then you have about 6 minutes left to live.
It seems I am stuck with “process”, as the alternative doesn’t sound that much fun.
So I tried to support Ryan’s process the way that I support the process of my clients, with openness and without an agenda. I kept my mouth shut about where to put the ornaments. I kept myself from repositioning the bead strings. I left the “tags” on the reindeer, and the nutcrackers “climbing”. In other words, I refrained from “fixing” his portion of the tree. I enjoyed the stories, and tried to appreciate the moments we were spending together instead of rushing to finish.
He is so proud of himself, proud of his contribution, and proud of his independence. I would have completely negated that if I had gone back to fix the tree. I would have been putting my agenda of how a tree is “supposed” to look onto my son. And I would have missed all his creativity, humor, and all the little moments that went along with our spending time together.
I am proud of myself too, for letting our tree be a “process” tree this year. I am making progress in my process.
Oh, Christmas Tree, Oh, Christmas Tree, how lovely are thy branches…….
We recently reorganized our basement.
We had three big shelving units in the little alcove at the bottom of the stairs, storing our holiday decorations, random dishes, luggage and random crap that had accumulated there. Our scuba diving dry suits were hanging in another corner of the main area with the rest of the gear in assorted bins on the floor. The air hockey table kept the air handler company, and our work out equipment was gathered in another. Dave, my husband has a workshop for woodworking and assorted house projects in the other end. And I can’t forget that my son Ryan had unpacked the train that is supposed to go around a Christmas tree and set it up amongst the work out gear, stacking all the free weights in the center as a “camp fire”.
There is a lot going on in our basement. Storage, exercise, play, wood working.
My husband was getting annoyed that there was always a huge pile of stuff (I have changed the wording here somewhat) in the area at the bottom of the stairs. He was feeling that the area for storage was too small for what we needed, so that stuff ended up on the floor and not always put away promptly. He had an idea that if we changed the storage to be more linear against the back wall, we could reorganize it to put the stuff we used most where we could get at it, we would have enough room to get boxes down and back up, and it would not longer be the first thing you see when you come down the stairs.
So we spent an afternoon taking everything off the shelves, moving the shelving units, throwing away trash, recycling what we could, and reorganizing so that everything had a place. We decided that we need to put a wall up to separate the sawdust from the rest of the basement (a project for a later date), and we moved the dry suits in front of where the wall will be, and moved the rest of the gear onto the shelving unit we freed up by throwing away stuff. The mini home gym is now the first thing you see when you come down the stairs, and the main area of the basement is open floor space and everything just functions, looks and feels better.
An instructor I had years ago used to say that he thought of a client’s body like a house, that all the different parts of the body were like different rooms. And when he would put his hands on the client, he connected with their tissues as if he was a guest walking into their house. Respectfully taking a look around, he would say, to find the areas that were not moving, and then helping them to move, the same way a nice neighbor comes over to help move furniture or help to fix a leaky pipe.
As I walk into our basement now, I think of that instructor, and how reorganizing our basement is a lot like physical therapy.
Fascial restrictions, dysfunctional joint mechanics, poor postural habits, lymphatic congestion, are all things that stack up in our bodies that impair functional movement. Just like the crap that accumulates in a basement. It’s the stuff we don’t want to deal with, or only partially deal with, like an achy joint for example, that we ignore, promising to “deal with it later”, until it’s so painful that we physically can not move anymore, and “later” becomes “now”. Then we finally decide it’s time to “deal with it”.
And just like my instructor, I see myself as a guest in the client’s house when I connect with their tissues. A guest who cleans. Systematically going through every room, helping the body organize, flush, and cleanse, until the tissues are moving smoothly again. Then I graciously say “thank you for having me, goodbye,” and I exit the house.
I find it really interesting that, now, every time I go down there, I have a brief moment of disorientation. I expect the old messy disorganized space and it takes a moment to register the new location of everything. I have clients say similar things to me. “I didn’t think I could move that way anymore,” or, “right in the middle of what I was doing, I realized it didn’t hurt anymore,” that sort of thing. It takes the brain longer to catch up, to unlearn the old ways and old movement patterns and old expectations. I could talk about neuromuscular junctions and nerve pathways and limiting beliefs and all that stuff, but really it comes down to basements and attics. The brain is in the attic and sometimes if you are in the attic you can’t really hear what’s going on in the rest of the house, so it takes a little longer to get the message if someone is having a conversation in the basement.
I have been surprised at how cleaning our basement seems to have impacted the workings in the rest of the house. I needed some paperwork, and was able to find it right away. I wanted to exercise again. My husband went to the basement for a tool, and was not annoyed when he came out of the basement. Things that are subtle, but those things really make a big difference in decreasing our overall frustration levels, and increase our enjoyment of life. Just like my clients when they no longer have pain with certain movements or limited movements. The scales are tipped towards enjoying life rather than suffering through it.
And isn’t that what living is all about?
Six months have past since I have found the time to pen an entry here. What have I been doing? Well, six or seven months ago, it became apparent to me that Integrative Therapeutics was going to have to find a new home. Our old space was no longer working for us on a number of levels. Most importantly, it was constraining my ability to take the practice in the direction I wanted to take it.
This was no small undertaking. Integrative Therapeutics had just celebrated its 10 year anniversary, and we were in the space originally designed and built for the company. We had developed strong relationships with the Longfellow club on many levels, and (perhaps most dauntingly) we had 10 years worth of stuff crammed into every conceivable nook of the office. Most importantly, though, I had to consider the impact of moving on the well established (and hard won) practices of each member of the Integrative team.