Wednesday, June 24, 2020

Movement Links Faculty Experiences with Telehealth in the Era of COVID-19

by Jiten B. Bhatt, Francisco De La Cruz, Ernie Linares, and Nicole Lovett

Jiten B. Bhatt

 The onset of a worldwide pandemic has affected the lives of millions of people. Regarding healthcare, countries' systems have been pushed to the brink of collapse as various providers have worked feverishly on the front lines to save the lives of patients stricken with COVID 19. Being a healthcare provider, lots of changes have occurred in medicine; from the utilization of protective equipment, social distancing, and the incorporation of telehealth. In this blog, our faculty will share observations as to how our knowledge of functional movement exam skills has been of benefit during our telehealth sessions.

 In April, Medicare passed emergency measures allowing for the use of telehealth for physical and occupational therapists. Finding myself in a new space, I began the process of navigating a patient exam through telephone or video visits. How did this look for me? The subjective exam was very similar to what I encounter in person. The main difference was what wasn't perceived in a regular face to face session - body language and movement. Here, I felt I lacked being able to see certain mannerisms of how a patient would walk in, sit, or communicate. These non-verbal cues are valuable in gaining clues as to how the patient uses their body, but overall, a check and pass for the telehealth area. 

Concerning the objective exam, this is where my functional movement skills were invaluable. In assessing a shoulder pain patient, I realized I was going to be bypassing some of the critical elements of an exam I usually engage in - end feel, assessing muscle length, and looking at joint mobility. However, in working with my patient, I had enough subjective information to develop a primary hypothesis of subacromial pain syndrome. I had the patient perform some directed quick tests and was able to rule out a possible tear. The patient then performed a ROM exam, and I noted no signs of adhesive capsulitis. As a result, I was able to determine the source of her pain as possibly being subacromial, and the cause being restricted posterior structures length in the cuff or capsule  (through assessment of having scapula fixed at a wall, and having the patient move into horizontal adduction). With a clinical picture coming into better view, I was able to focus on providing some treatment options. 

How about other cases? They all couldn't have gone smoothly. For this, I will agree. I had a patient who had severe chronic back pain and didn't respond as well to the care I provided. To this end, I  asked the patient to come in for a closer look via an in-person visit. Another client with back pain improved rapidly with just 1-2 video visits using my movement skills to determine that he had an extension rotation syndrome. After education on bracing and improving quad and TFL length, the patient's low back symptoms reduced considerably. Overall, the utilization of my movement skills have been incredibly useful during the pandemic and will hopefully improve with more cases and adaptations without the use of my hands.

Francisco Dela Cruz

The sudden health crisis our country has experienced in the past few months has dramatically changed the way we practice as PTs.  
The tools that we had before to evaluate and treat patients in the clinic, such as manual therapy, modalities, tools for kinematics/kinetics analysis, has been sidelined for now.  Now, we are using our visual observation of static and dynamic posture/functional activities,  clinical reasoning/clinical patterns to connect the dots for our patients to provide the best possible treatment.  

My experiences with telehealth have mostly been positive.  My practice in outpatient orthopedics before the COVID pandemic primarily revolved around looking at movement patterns, static/dynamic postures, functional activities, assessing muscle length/strength, and muscle/joint palpation.  Treatments were based on inhibition/facilitation of specific muscles and exercises to improve muscle recruitment and movement patterns/functional activities.  

Fast-forward to the new norm for our healthcare as providers, "Telehealth".   As I reflect on the changes I had to make in the way I practice, I realized it wasn't as drastic as I thought.  I still look at movement patterns, static/dynamic postures, functional activities, and assessing muscle length/strength.  The main change now is no more muscle/joint assessment via palpation.  

I now evaluate muscle length/strength through functional activity. For example, I use sitting knee extension to assess ankle DF ROM, hamstring length, and L/S directional susceptibility to motion.  I will ask the patient to perform a squat to assess ankle DF ROM, knee/hip flexion AROM, quadriceps strength, foot/knee/hip movement pattern, etc.   Correcting movement patterns might require asking patients to look at a mirror for feedback or using their own hands to touch a muscle to facilitate it.  I think, when combined with sound clinical reasoning, I can still provide the best option for treatment, whether it's exercise or management strategies to allow for optimal tissue healing.   

Now, of course, there are challenges that I have also faced.    The two main obstacles are technology and giving instructions.  The clarity of the video visit is essential to optimize the analysis of visual information from the patient's movement.    The instructions have to be concise, and you might have to keep switching between internal vs external cueing to get the right movement pattern and muscle recruitment.   Overall, using the different movement science concepts of looking at movement patterns, static/dynamic postures, assessing muscle length/strength, facilitation of muscles has made a challenging transition to telehealth not as daunting.

Ernest Linares

Having a background in movement science has most definitely prepared me for the challenge of performing telemedicine.  I feel confident in what I can observe and functionally test; will give me the information necessary to create the best intervention or movement strategy for my patients. On reflection, the most important skill/tool that has helped me is knowing what "normal" movement looks like. The great part about that knowing normal is that I can then ask myself "So do you like what you see?" and then ask the patient "Can you fix it?" or "make it not hurt?" and observe what they do. For myself, this observation gives lots of information about the patients' body awareness which is paramount when one is trying to incorporate interventional movement strategies in a virtual environment. It helps me understand which verbal and visual cues my patient may need; in the absence of tactile cues. It has been a challenge to cover all facets of the patient encounter but at the same time a good form of stimulation to think differently and utilize our movement analysis skills to help link the movement to the possible impairment. I see it as a great opportunity to practice a most valuable skill. Keep practicing!

Nicole Lovett

At Kaiser Permanente, telehealth has become more popular in recent years. Our organization has used video visits through this pandemic as an option for a patient to receive evaluation and treatment for musculoskeletal pain. So far, I have found video visits to be quite useful. With my movement specialist background, I have to rely on my observation and movement analysis skills versus my hands-on skills. The new environment has challenged me to work on my external cueing. Overall, I have had a good experience and will continue to offer video visits to my patients as another option.

Jiten (“Jay”), Francisco, Ernest (“Ernie”), and Nicole, are Movement Links Instructors and hold various clinical specialist and senior roles in the department of physical therapy at Kaiser Permanente Medical Center in Southern California. They each will lead upcoming course series as we transition out of the tight restrictions of COVID-19. Follow along with us!

Wednesday, May 20, 2020

Proprioception: The Sixth Sense

By: Nicole Lovett, DPT, OCS


Imagine walking across a room and without warning, the lights go out, and suddenly,  you fall down.  Or you reach into your pocket to grab a quarter and when you look down to see, your hand is empty.   What would life be like if you had to look down at your feet every time you took a step?  Luckily for most of us, this is not the case; we have the ability to sense where we are and where other things are as part of our 6th sense.  But in rare cases, there is the absence of proprioception, which can occur when a fetus is just developing.  The absence of proprioception occurs when a mutated gene makes the Piezo2 receptor non-functioning. The Piezo2 receptor is an important receptor that integrates mechanical and thermal cues in vertebra mechanoreceptors. (1)  Without it, an individual has no proprioception.  Separate from genetic factors, proprioception can be affected when someone suffers an ankle sprain, an ACL tear, an Achilles rupture, a lumbar muscle strain, or in someone who is afflicted with a neurological disorder.

What is Proprioception?

Proprioception, also called kinesthesia, is the body’s ability to sense its location, movements, and actions in space.   Proprioceptors are specialized nerves that facilitate neurological and physiological responses.    The proprioceptors are sensory and can be found in the inner ear, muscles, skin, joints, tendons, and other tissues.  This is how the brain receives information about the body’s position and to perform certain tasks like, catch a ball, reach for a glass out of the cupboard, or walk in the dark.

How do you test for Proprioception?

There are a variety of ways to test for proprioception. Some tests include:
-     Romberg Test
-     Field Sobriety Test
-     Thumb Finding Test
-     Sequential Finger Touching, or Distal Proprioception Test

Also, the Single-Leg Stance Balance Test with eyes closed would be appropriate to assess proprioception. (2)  These particular tests determine a patient’s ability to sense, move, and act or react. It is a safety-related issue that includes balance and awareness to determine treatment plans that will prevent potential injuries during day-to-day activities.

Single limb stance
 Simply stated, the single-leg stance balance tests for proprioception. With the patient’s eyes closed for 30 seconds, the individual must maintain his or her position for the duration.

Normative data
Age (years)         Eyes closed
20-49                  24-29 sec
50-59                  21 sec
60-69                  10 sec
70-79                  4 sec

How do you train Proprioception?

Once the assessment is complete and altered proprioception is detected, training is essential. When a soft tissue injury occurs, receptor activity is lost. With a loss of receptor activity, proprioception is affected. This is why that during the rehabilitation process, it is imperative to restore receptor activity.   This is done through proprioceptive training in order to re-activate the receptors in the soft tissues. To challenge the receptors one can vary the surface they are standing on or vary the speed of the task or multi-task.  Furthermore, there are three key areas of proprioception input, the cervical spine, pelvic girdle and the sole of the foot.  When training proprioception, pay close attention to alignment in these areas to better improve your outcomes. Improving proprioception will improve a patient’s motor skills, balance, and muscle strength.   Below are three exercises to focus on the three key areas: the sole of the foot, the pelvic girdle and the cervical spine.

Cone pickups on the grass to challenge the lower
extremity and sole of the foot

Deep cervical flexor swiss ball isometrics to challenge the cervical spine

Swiss ball marching to challenge the pelvic girdle

Nicole Lovett is a physical therapist working at Kaiser Permanente. She is a movement science fellowship graduate, Movement Links certified clinician and instructor, and has taught movement concepts in the Loma Linda Residency.

1. Chesler AT, Szczot M, Bharucha-Goebel D, et al. The role of PIEZO2in human mechanosensation. N Engl J Med. 2016;375:1355-1364. DOI:10.1056/NEJMoa1602812.

2. Bohannon RW, Larkin PA, Cook AC, et al. Decrease in timed balance test scores with aging. Physical Therapy. 1984;(64)7:1067-1070.

Wednesday, April 15, 2020

F.M.P. (Yah you know me)

By David, Kurihara, DPT, OCS, SCS, FAAOMPT

One of the more challenging things we do as a clinicians involves our clinical reasoning and how it guides the prioritization of treatment.  In other words, making sense of the information we gather in our examination and implementing an effective and logical intervention plan. 

To this day, I still have cases where I fall off the track or get lost in the plethora of information.  When that happens, the picture becomes muddled and the case complexity automatically doubles. 

To keep me on the right path, I like to use a very useful tool adapted by Phil Page and Clare Frank called the Functional Management Progression (FMP).  I have it in my head constantly and it guides me in terms of progressing and prioritizing appropriate interventions. The pyramid is broken down into four main categories. 

1) Normalization of dysfunctional structures (base of pyramid)
2) Correction of muscle/movement balance (mid-bottom pyramid)
3) Increasing proprioception and facilitate subcortical pathways (mid-top pyramid)
4) Improving endurance in coordinated movement (top of pyramid)

*within each category are specific impairments

Functional Management Progression - adapted from Phil Page and Clare Frank

This is a powerful tool and there are many ways to utilize it.  For most cases, my personal preference is to use it like a ‘ladder’.  I will try to climb the pyramid all the way to the top where ‘skill/functional activity’ is sitting (which is usually the goal).   As I climb each level, I’ll try to address any impairment the patient might have within that specific level.  I usually won’t advance levels until the impairment at the current level is resolved.

This is especially helpful when you have what I like to call “impairment overload”.  It’s when you gather so much data in the subjective/objective exam that you don’t know what to do with it or where to start.  The easy way out is to have a “shotgun” approach to blindly treat every impairment.  That approach may sometimes produce results, however, there is no “progress control” and the reasoning of what helped or not is lacking.  It’s always nice to have a system in place. 



13 year-old female with chief complaints of:

1) Right lateral hip clicking/pain with every step x 4 years. Insidious onset.
2) Left anterior- posterior hip pain (“locking/weird feeling”) x 4 years. Insidious onset.  Has episodes every 1-2 months until 1 month ago got 3 episodes in a span of 2 weeks.  Symptoms occur with putting on pants, getting in/out of car, turning while feet planted.  Pain lasts 3 days. Plays judo and golf regularly for years.

1) Posture: BL pes planus (functional), BL genu valgus, BL femoral IR (worse on left)
2) Gait: excessive femoral IR worse on right (with clicking laterally in left hip)
3) PROM: hyperflexible all joints (especially hips)
 4) Wobbly/incoordinated SL squat on left > right
 5) Golf swing: over-rotation with shoulder, trunk and hips
5) MMT: 3/5 (inhibited--poor initiation) BL glute max, ER and medius


13 year-old female with BL hip pain secondary to multidirectional excessive mobility driven from inherent joint laxity and poor phasic muscle stability.

Day 1

It would have been fair (and obvious to most) to start strengthening her hips due to the glaring strength deficit.  However, using the FMP, I started on the bottom of the pyramid and opted to normalize her faulty posture and pain deficits (as much as possible). 

Posture re-ed: Neutral legs in standing (tripod foot position), sitting (no crossing legs), sleeping on side (pillow)

Postural Re-Education in standing, sitting, sleeping

Gait re-ed: Verbal cueing for reducing right femoral IR during gait resolved her right hip clicking

Gait Re-Education out of excess Femoral IR

Day 2

Patient experienced no clicking in the right hip with “mindful” hip position and no symptoms in left hip with putting on pants, twisting in closed chain or getting in/out of car.  Patient was “mindful” about centration of joints with sleeping, sitting, standing and walking and often catches herself in bad positions, but quickly re-corrects.

*** Addressing the static postural deficits proved to be helpful as she was standing, sitting and sleeping in poor positions and creating a ‘stretch weakness’ within her muscles and de-centration of joint position.  If that was not corrected, strengthening exercises may not have been as successful.

Furthermore, her words of being more “mindful” was a huge positive in that it told me that she was understanding the building blocks of motor control/awareness, which is a nice prerequisite for creating muscle balance.

Continuing to climb up the pyramid, there was no need to address her joint mobility or muscle length as she was hypermobile and flexible.  Those levels were skipped and we advanced to motor function/proprioception activities (with an overlapping of ‘muscle performance’).  I wanted to dial-up her “phasic” motor chain to increase stability in her joints.

Illustration of clinical reasoning using the FMP for Day 2

Brügger band squat, sidestep and leg opening, SL with TB

Top line: Brügger band squat// Bottom left: Brügger band sidestepping// Bottom middle: Brügger leg opening// Bottom right: Single leg stance with TB

*** The faster I can get a patient off the table, the better.  It would have been fine to start her in open chain exercises but it was a clinical decision I made to get her in closed chain immediately.  I felt that her motor awareness was excellent and the exercises we put her in could facilitate the right muscles even better than in open chain.

Day 3

Still no symptoms with all aggravating factors and able to return to full Judo and Golf without problems.  She liked the exercises as it helped her feel “good” in her legs.

We now arrived at the top of the pyramid and addressed the functional activities and skills she’d been doing regularly (judo/golf).  I could tell she felt a difference in her body with the exercises so I decided to advance her to a more functionally difficult regimen (specifically, dynamic single leg stability and closed chain hip rotation control to mimic judo and golf mechanics)

Illustration of clinical reasoning using the FMP for Day 3

SL squat with TB, SL airplanes

Left: Single leg Squat with TB// Right: Single Leg Airplanes

***.  We also tightened up her golf swing with leg and trunk positional cues to not over rotate (skill).

Again, you can utilize the pyramid to your liking based on your patient case or preferred way of thinking.  It’s probably better if you do, that way you know you’re thinking criticallyJ

David Kurihara is a board-certified specialist in Ortho­pedic Physical Therapy (OCS) and Sports Physical Therapy (SCS) and a fellow in the American Academy of Orthopedic Manual Physical Therapy (FAAOMPT).
He completed the Southern California Kaiser Permanente Orthopedic Residency Program in 2005, Manual Therapy Fellowship in 2006, Sports Residency in 2007 and Movement Science Fellowship in 2009.
David served on the clinical faculty for Kaiser Orthopedic Residency (2010-15), and Sports Fellowship (2008-15) and has been instructing various continuing education and residency classes since 2009. He currently resides in Honolulu and is part of Queen's Medical Center Sports Medicine team.

Friday, March 13, 2020

Evidence Based Therapeutic Exercise for Cervical Spine Disorders

Summary of key points from seminar by Dr Deborah Falla, BPhty(Hons), PhD.
University of Birmingham

Common forward head position with shortened sternocleidomastoid (SCM)- Source: 

Neck Pain
-       Relatively common complaint.
-       Affects 70% of individuals at some time in their lives
-       Annual Prevalence of neck pain 30-50%         
-       Tends to be persistent and recurrent disorder
-       85% of people can expect some degree of ongoing pain for many years after their first episode.
-       Most concerning is the recurrence.  Recurrences are partially attributed to ongoing dysfunction of the neuromuscular system (motor control) Carroll et al, Spine, 2008
-       When pain & Injury occur, the strategies used by the CNS to control movement and/or posture can be substantially compromised.

Clinical Implication:  Not only treat & reduce pain, but to prevent further episodes.

Common findings with neck pain
1.   Reduced force output and maintenance of force output.
2.   Reduced Deep neck flexor (DNF) activity (longus colli and capitus that is responsible for cranio-cervical (CC) flexion and support of the cervical spine) with subsequent increased compensatory SCM activity.
a.   co-contraction of SCM & Splenius
b.   SCM activity increased regardless of the severity/ intensity of the symptoms

Slide from D. Falla seminar

Injected saline solution to upper traps resulting in immediate pain.

Slide from D. Falla seminar

1.   Reduced directional specificity
2.   Reduced Semispinalis cervicis activity
3.   Poor postural endurance
4.   Structural changes present over time with chronicity ( > 3months)
- muscle fiber transformation from Type 1 to Type 2   (Uhlig et al, 1995)
- Increased fatty infiltration
Occurs soon following neck trauma, but not immediately, Andrey et al, 1998, Hallgren et al 1994, McPartland et al 1997, Kristjansson 2004, Elliott et al 2006
Use this window of time following neck trauma to minimize the secondary structural adaptations

Clinical Implication:
Changes are primarily in motor control.  However, if alterations in motor control is sustained beyond the acute pain phase, its effects may contribute to chronicity of neck pain & structural changes. 
Motor control training must be initiated in early rehab.

Deep neck flexor training using Bio-Feedback

Key Rehab Principles for Cervical Spinal Pain & Therapeutic Exercise Program
For both rehabilitation and prevention of recurrences.

1st phase - Motor control to target the deep postural muscles
2nd phase - Introduce higher load strength & endurance training. 

-       Need for Selectivity and specificity of exercise
-       Target & activate Deep Neck Flexors (DNF) with low load specific exercises.
-       Retrain endurance capacity of DNF
-       Retrain the patterns of activation of deep & superficial neck muscles
-       Co-contraction exercises (DNF and extensors)
-       Re-ed the use of muscles in posture & ADL
-       Address strength & endurance for functional requirements

Re-education of co-activation of deep cervical flexors/extensors using developmental position- prone 3 month position 

Re-education of deep neck flexors using isometrics

Reflexive activation of deep cervical muscles using a theraband

Long term efficacy for neck specific exercise.  Landén Ludvigsson et al., Eur J Pain, 2015

-       Participation in a neck-specific exercise intervention, in contrast to general physical activity, was the only factor that consistently indicated higher odds of treatment success.
-       At 12 months, patients in the neck-specific exercise intervention had up to 5.3x higher relief of disability reduction, and 3.9x higher odds of pain reduction compared to those in the physical activity group.

Clare Frank is the founder of Movement Links, Inc, a company borne out of a desire to enhance clinicians’ understanding of the movement system. She is the program director of Azusa Pacific University Advanced Fellowship in Movement & Performance and clinical faculty of Kaiser Permanente Spine Rehab Fellowship.  Clare is a lifelong learner, implementor and advocate for the movement system.

Key References:

Falla D, Jull G, Russell T, Vicenzino B, Hodges P. Effect of neck exercise on sitting posture in patients with chronic neck pain. Phys Ther. 2007;87(4):408-17.

Jull G. Whiplash, Headache, and Neck Pain, Research-based Directions for Physical Therapies. Elsevier Health Sciences; 2008.

Neck pain: combining exercise and manual therapy for your neck and upper back leads to quicker reductions in pain. J Orthop Sports Phys Ther. 2013;43(3):128.

Sremakaew M, Jull G, Treleaven J, Barbero M, Falla D, Uthaikhup S. Effects of local treatment with and without sensorimotor and balance exercise in individuals with neck pain: protocol for a randomized controlled trial. BMC Musculoskelet Disord. 2018;19(1):48.