[embed]https://www.youtube.com/watch?v=YybcsllEkhk[/embed]

Two common sites for pain and movement problems are the low back and sacroiliac (SI) joints. The SI joints are a common site for sensitivity due to biomechanical overload.

Once we have screened for sensitivities, pain generators and movement dysfunction, the presence of SI joint dysfunction is often found along with poor abdominal sling function. Chiropractic adjustments are great for addressing joint dysfunction, but we must train movement through specific exercise.

[embed]https://www.youtube.com/watch?v=WwIba7PpgXA[/embed]

Keeping with the concept of core stability and hip mobility, the shin box has become a popular drill for improving hip rotation, eccentric loading of the hips, as well as reinforcing ideal intra-abdominal pressure (IAP) and core stability.

Ideally the shin box is performed in a progression of static to dynamic variations. Progressions are dependent upon the ability to achieve ideal external rotation in the lead leg and internal rotation in the trail leg while maintain an upright, braced torso with sufficient IAP.

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In this video we discuss a very relevant truth when it comes to the shoulder - sometimes your shoulder pain is not a shoulder problem.

The inability to properly stabilize the rib cage and pelvis as well as having adequate movement in the thoracic spine can result in problems associated with the shoulder blade or shoulder joint itself. As a general rule, reduced mobility or stability in one area of the body will result in compensations in other areas. These compensations often take the look of reduced movement quality, joint/muscle stiffness, or poor movement control.

To correct the problem you must first identify the true cause.

This video demonstrates an exercise progression that can help improve core and scapular stability as they relate to shoulder motion. The plank variation utilizes single elbow support on one arm and a slider with a reach on the opposite arm all while being performed from support on either the knees or toes.

Some tips and pointers to keep in mind during the set-up and execution of this exercise:

• Choose a support position (knees or toes) that enable you to maintain proper posture and support without compensation during the exercise.
• Brace the core with proper intrabdominal pressure (IAP), maintain a neutral spine and pelvis
• Shoulders, rib cage, and hips shoulder remain parallel to each other. Think about maintaining a 'table top' position from shoulders to hips.
• Keep the chin tucked and maintain a neutral head and neck position.
• The only movement that occurs is from the hand/shoulder on the slider. Perform a reach straight ahead and return to the starting position with hand next to the shoulder.
• Perform 2-3 sets of 5-8 reps per arm and switch sides. Be sure to give yourself adequate rest between sets and allow for enough recovery.

GP recently interviewed Ben Gallagher DPT, FMSC. If you happened to figure out that Dr. Ben is related to us, you are correct. Ben is a physical therapist at Somerset (PA) Hospital Rehabilitation and Wellness Center. As brothers, we share some very similar concepts in the treatment of patients. But, we also share contrasting viewpoints, which makes it fun to learn from each other and gain a better understanding of the professional roles we serve in providing improved quality of patient care.

Now, let's get to the questions.

GP: Please introduce yourself and give our readers some information on your professional, educational, and athletic background (as well as what you have had to overcome since birth in order to participate in athletics).
BG: My name is Ben Gallagher, brother to Sean and Ryan. I live in Somerset, PA with my wife and daughter. I am a physical therapist and have been working at Somerset Hospital Rehabilitation and Wellness Center for over two years. I graduated from Indiana University of Pennsylvania (IUP) with a degree in Exercise Science in 2008. Then went on to Saint Francis (PA) University to get my Doctorate in Physical Therapy, graduating in 2012. Since graduating I have become FMS (Functional Movement Screen) certified, focusing my continuing education on movement analysis and manual therapies thus far.

Athletically, I grew up playing most sports, mainly focusing on basketball until the 8th grade when I got into ice-hockey as a goaltender, then that became my passion. I played through high school and into college at IUP. As for what I had to "overcome," that would be referencing my heart condition. I was born with Tetrology of Fallot, a congenital disorder that required surgery as a young child and again in 2008, and another in about 15-20 years. The condition restricted me from some sports and it is not advised I lift max weights, placing a limitation of how I could physically train for sport. However, prior to my 2008 surgery, in which my heart was over 3x normal size, I had no issues or symptoms. The doctors attributed my training to why I could function so well with such a crappy heart. Training was a mainstay, and still is.

GP: The thought process in your evaluation and management of patients is not widely instructed in physical therapy programs. What were the biggest influences in your professional development in not only the care that you provide, but also why you sought out additional resources beyond what you learned in school?
BG: The purpose of physical therapy school is to: 1) make sure you pass the licensure exam, and 2) make sure you don't seriously hurt anyone. As for producing quality clinicians? No. School just teaches you the basics, and most practicing therapists provide you just that, the basics, which is what you could find on a Google search. So, as for what helped my professional development, honestly the biggest thing was I just thought differently. I saw things differently and I attribute that to my athletic background and training history. For example, as a PT student I would tell my class-mates, "I'm gonna have my grandmas deadlifting." My classmates would gasp, as if that was the most absurd thing they ever heard. But my thinking was, "If someone needs to build strength, why am I gonna have them lie down and lift their leg? When I want to build strength, I train the squat and deadlift, so how couldn't the same application benefit my patients?" Now let me clarify, not all movements are appropriate for all people, at all times. That's why programs need to be individualized, not cookie-cutter.

So for me, I thought, why do I want to further inundate myself with PT knowledge that is elementary and narrow-minded. I sought out other means to fill that thirst for a fuller, better understanding of how the body functions. FMS, which is for any health or fitness professional, is just one of many means to that end that I am pursuing.

Plus, I have to add this: In reference to the grandmas deadlifting story, there was a research article published shortly after in regards to the most effective exercises to strengthen the hips. The study basically ridiculed all traditional PT exercises and found the most effective was a single-leg deadlift. How 'bout them apples?

GP: You are extremely involved with your patient’s care, preferring to perform a lot of manual therapy and oversee the exercise process. This is not common of the majority of physical therapists. Can you speak to why you find this so valuable in the outcomes your patients are able to achieve?
BG: I don't even know where to begin with this issue. I get fired up about the lack of quality care there is in this field.  Most therapists treat with a shot-gun approach, meaning they're not sure what is really going on or how to treat so they will throw a ton of stuff at you hoping something sticks and works. But the best in rehab are like snipers. They isolate what the exact issue is and address it appropriately. And how can you do that if you are not present and in the mix with your patient's rehab process?

GP: As a physical therapist, you see tremendous value in what chiropractic care has to offer. Could you please give your thoughts on what makes chiropractic and physical therapy so complementary?
BG: Following off the above question, when you are involved with your patient's care, you may find that some issue(s) may be out of your scope and there may be better, more skilled hands that are able to provide effective care. How can one means of healthcare be the most effective? What is most effective is what the patient needs. How can chiropractic care be so bad, which is the view of many therapists, when chiropractors help so many? And how can therapists think we are the kings of rehab and exercise when many therapists stick you on a machine and walk away? I have referred patients to chiropractors and massage therapists. But, I do so instructing them on what they need to share with those professionals, because just going blindly to another professional does not always mean you will get quality care. Chiropractor, massage therapist, physical therapist, strength coach….I don't care what your title is; if you're good, you're good.

GP: Posture, stability, and mobility are intensely debated topics at conferences and continuing education seminars. Could you expand on your philosophy when it comes to the dynamic role between posture, stability, and mobility, what athletes and coaches should understand about these topics, and what should be left to physical medicine providers such as physical therapists and chiropractors?
BG: The first thing that athletes and coaches should understand about posture, stability and mobility is that you likely don't fully understand these concepts. Most lay people honestly don't understand how posture impacts how their body feels and the role it has in movement. Someone with good posture likely can't explain why they have good posture or how they achieved it. But, that is why we, as professionals, are here.

The stability-mobility debate is like a left-wing versus right-wing debate. My philosophy is it's a spectrum. No one physical issue is 100% in either direction, but I do believe stability is the issue the majority of the time. And if mobility is an issue, and is addressed, such as stretching or mobilizing, it should complimented by stabilization training to ensure you have control of the new motion you have just obtained.

GP: You have developed a reputation in your area as a “go-to-therapist” for athletes being referred from orthopedic surgeons because of your eye for assessing movement and your ability to successfully return athletes to competition. Besides the FMS, what other assessments do you find valuable in dealing with athletes and their competition needs?
BG: For those who don't know, the FMS is a tool used to assess a person's quality of movement using seven standardized movements. If you move poorly, you are then going to compensate, compensation leads to altered or poor biomechanics, which leads to injury. So the whole purpose of the FMS is to make sure you move well. The job of the clinician is to not only identify poor movement, but to also figure out why you are not moving well. Therefore, what other assessments do I find valuable for athletes? I want to see them go through their athletic movements: swing a golf club or hockey stick, throw a ball, jump, land, cut, sprint, run, etc.

To be able to do this effectively you must first be able to analyze the movement correctly. Is the movement efficient? If it is not, then you must be able to figure out why it is not and be able to address the problem effectively. All this said, what is really needed is knowledge of athletic movement, a good clinical eye, and the knowledge of how to fix whatever issues are present.

That’s a Wrap
Ben, thank you for taking the time to answer our questions. Your knowledge and insight is truly appreciated. We hope this was informative for our readers as well. For those in the Somerset, PA area, be sure to check out Ben at the Somerset Hospital Rehabilitation and Wellness Center for tremendous results when it comes to returning from injury or understanding how to move better for your exercise or sport-related goals.

More related reading:

https://gallagherperformance.com/posture-and-movement-linking-training-and-therapy/

https://gallagherperformance.com/prevent-re-injury-integrated-training-rehabilitation/

Mobility is sexy and it sells.

Get your foam rollers. Get your PVC pipe. Get your stretch bands. Let’s get mobile!

Between mobility screens, mobility workouts, mobility tools, and mobility DVDs, there are plenty of opinions and products available for purchase.  The experts are convincing you of how crucial mobility is for health and performance, while doing their best to convince you to purchase their product.

Enough with it.

While some elements of mobility have merit, many of the approaches to mobility (warm-ups, DVDs, seminars, evaluation systems) are very general and cookie-cutter. A lot of it is unoriginal thought simply repackage and over-priced. Many of these products are not impressive. They are systematic programs that are easy to apply. It’s the classic, “If you see X, then perform Y” approach, providing correctives for movement errors and superficially removing a degree of critical thinking. No wonder the products are so appealing. Someone else has done the thinking for you, so just follow the instructions in the manual and you too can be an expert.

Mobility and movement so easy that seemingly anyone can be an expert?
What troubles me is the trend towards ‘simplifying’ movement, when movement is quite the opposite. Movement is complex. It should be recognized that once you add variables such as load or speed or vector/direction, movement changes. Most screens do not account for these variables and I wish more ‘experts’ understood this clearly.

One individual who has a unique, and truly expert, understanding of the complexity of movement is Stuart McGill. McGill is a spine biomechanics professor from the University of Waterloo. He has authored over 300 scientific publications that address the issues of lumbar spine function, low back injury mechanisms, investigation of the mechanisms involved in rehabilitation programs, injury avoidance strategies, and high-performance training of the back. He serves as a consultant to many medical management groups, elite sports teams and athletes, governments, corporations and legal firms. On top of all those responsibilities, he is often referred the most challenging back pain cases from around the world.

Professor McGill sees two patients per week, spending 3 hours with each patient. His evaluation is of paramount importance in relation to the success he has in treating his clients and athletes. The time he spends on evaluation is often significantly more than many providers spend with a patient on their first visit. As a chiropractor, I know doctors that see 15-40 patients a day and don’t have the time to spend on lengthy assessments. Quick and easy ‘systems’ or ‘assessments’ are exactly what many professionals in the fields of rehabilitation and fitness need.

But does ‘quick and easy’ ensure a thorough exam? Does it ensure all variables have been accounted for? Unfortunately, this is what many have to deal with, so 'quick and easy' is certainly better than no assessment at all. But keep it mind there is a huge limitation to operating in that fashion. This is exactly why my brother and I tailored the operation of GP to allow for the necessary amount of time for our assessments.

At GP, we do not perform general assessments. Every single assessment is personalized to the individual, modified to meet their objectives. What we perform during an assessment “depends” on the presentation in front of us. We understand that movement and the action of musculature is not always obvious. Muscle action will change depending on the movement task, having an effect throughout the entire body. Regarding the ability to recognize the muscular demands of movement, Professor McGill has said, “This is the transition point between a trainer and master trainer.” I’m sure he would say that this also separates a therapist and master therapist.

You will not find our approach in convenient DVD and PDF format, leading you step-by-step through our evaluation and corrective process. Why? The approach we take at GP is very difficult to teach and has taken years to develop through mentorship, experience and self-learning. Whereas, most movement screening systems have the advantage of being easy to teach.

Being ‘easy to teach’ is good for business. But is it the best service for our clients and athletes? Certification courses are designed to churn out new coaches or new trainers at a mind-numbing pace. You would be foolish to assume everyone walking away with a certification functions with ‘expert’ understanding. But that’s what they want you to believe since most attempt to position themselves as experts.

Moving beyond the initial assessment, continual re-assessment is a staple of the process at GP. Our approach focuses on continually assessing and fine-tuning the program as necessary. This is why mobility, like any ‘movement fix’, must be applied appropriately with a solid understanding as to why it's being applied.

Just because someone has a tight hip, doesn’t mean you should blindly advocate foam rolling and performing goblet squats.

Can’t maintain your arms overhead during an overhead squat?

Oh, that is totally caused by tight lats. You need some foam rolling on the lats and then band stretch the daylight out of those bad boys.

Heels come off the ground during the squat? Tight calves and limited dorsiflexion, right?

Let’s foam roll those calves and mobilize those ankles.

This thinking is widespread and too simplistic. In my opinion, it’s no different in application than simply telling someone to stretch because they are tight. Do you think it's superior or different because you applied a foam roller? Sure it may get results a percentage of the time, but often there are deeper underlying issues being missed. Let’s consider the following quotes:

“Soft tissue injuries result from excessive tension, so excessive tension in the rehabilitation setting is counterproductive…stretching of…chronically tight tissue is counterproductive. It may give an initial sensation of relief because the muscle spindles have been deadened, but this practice…weakens the tissue further because of the weakened proprioceptive response.” – Boo Schexnayder

“Stop trying to stretch and mobilize, let tissues settle and regain their proprioceptive abilities so they tell the truth.” – Stuart McGill