A few weeks before I trekked out to California for my last and current internship, I was grabbing drinks with a group of friends in NYC. It’s always fun catching up with friends in between breaks especially since it becomes tougher to get every together as you become an adult(trying out here).

A lot of my buddies are either in physical therapy school or enrolling so it was natural for our conversations to slowly revolve around the field we are pursuing. We eventually started talking about how in the world I was able to find time to read while I was doing my didactic work.

The truth is, I made it a priority and it becomes easier when you develop the habit. I would dedicate anywhere from 30 minutes to 2 hours a day on reading ANYTHING that I could get my hands on whether it was books, research articles, blogs, etc.

You don’t have to read fast, you can read at your own pace. No one is handing out awards to people for being well-read, you do this for yourself. The most important thing is that you’re reading. If you’re only getting through one book a month, that’s 12 books in a year which equates 120 books in 10 years. Even if we cut that number in half, 60 books in 10 years is a substantial amount.

The bottom line is we need to find time for the important things in life such as relationships, exercise, reading, and sleeping. These are non-negotiables when it comes to physical and mental health. We can’t afford to NOT do these things and if they are important to you then you’ll find the time.

Anyways, my friend Danny is starting his program this year in North Carolina and told me I should make a reading list because he would love some recommendations. At this very moment, I am procrastinating on going to the gym for my SBD day. I figured I would buy myself some time to make a list since I have been meaning to blog more often so here we go:

1.) How to Win Friends & Influence People by Dale Carnegie

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“When dealing with people, let us remember we are not dealing with creatures of logic. We are dealing with creatures of emotion, creatures bristling with prejudices and motivated by pride and vanity.”

This is probably one of the most recommend personal development books and although it may seem like common sense…a lot of people need to understand that it’s more important to be interested than interesting. The book has been around for ages and for good reason. It’ll either reinforce some of your habits and thoughts on communication or give you actionable steps on how to develop your skills. Whether we’re helping a patient or networking with other people, the principles in this book are timeless.

2.) Start With Why by Simon Sinek

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“People don’t buy what you do; they buy why you do it.”

To piggyback on the theme of communication with the first book, this is definitely a solid segway. Simon Sinek has developed a concept to help you clarify the message called the “Golden Circle”. It’s a very easy to read book and my only caveat is that I wish he used more examples aside from Apple but we can’t blame the man, Apple does such a great job at communicating this principle. The world we live in now, people can easily be detracted due to the surplus of information all around us. If we want to effectively communicate to patients then it is important to communicate WHY.

3.) Why We Sleep by Matthew Walker

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“It is disquieting to learn that vehicular accidents caused by drowsy driving exceed those caused by alcohol and drugs combined.”

Don’t sleep on sleep. Sleep plays a huge role in overall health and this book is PACKED with research on the benefits of sleep as well as the detriments of lacking it. It’s super easy to digest and meant for the lay person. Matthew Walker is a leading expert in this field and if you want a snippet of some of the content then I would highly recommend his episode on the Joe Rogan Experience(JRE) podcast. Also, day drinking is better for your sleep hygiene!

4.) The Brain That Changes Itself by Norman Doidge

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“The brain is a far more open system than we ever imagined, and nature has gone very far to help us perceive and take in the world around us. It has given us a brain that survives in a changing world by changing itself.”

Neuroplasticity is a concept we are introduced to in school and we learn Hebb’s theory “neurons that fire together, wire together” which is great but this book is filled awesome clinical examples of neuroplasticity in action. One of my favorite things about the book is that each chapter is a different case. It relates neuroplasticity to other things rather than  rehab for patients that sustained a TBI, CVA, etc that we are often taught. Most lit chapter? Chronic pain but maybe I’m a bit biased haha.

5.) When Breath Becomes Air by Paul Kalanithi

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“Science may provide the most useful way to organize empirical, reproducible data, but its power to do so is predicated on its inability to grasp the most central aspects of human life: hope, fear, love, hate, beauty, envy, honor, weakness, striving, suffering, virtue.”

Dr. Paul Kalanithi was a neurosurgeon resident at Stanford University. He was diagnosed with stage IV metastatic lung cancer during his last year of residency. This book is an autobiography on his life, experience with facing death, medicine, and so much more. I have never cried when reading a book or watching any sort of television but this book got me. The way it was written, his reflections…everything is extremely raw and authentic. There is so much perspective to be gained from this book as future clinician and more importantly as a human being. It’s a book that I will be reading every year.

Well, that’s it. There are a lot of other books that I could recommend but I thoroughly enjoyed these five a lot. I hope you guys find some value in these books and if it something you’d like to see then I can compile another list haha.

Thanks for reading and remember to…

#moveandEMBRK

There are two different types of shifts that happen during the squat. The first is when the person is moving side to side while descending into a squat. This tends to be a flaw in the technique where one fails to keep tension in the lumbopelvic region and it looks like this:

(yes, that’s me from earlier in the year and yes, that’s my shorts being eaten by my buttcrack)

The other squat is when a person squats and they tend to favor one side which looks like this:

(video courtesy of Ray Williams who is a world record squat holder)

What we are going to discuss is the latter version where we tend to favor one side. It’s an asymmetry without a doubt but is it a cause for concern? In the grand scheme of things, I would say that it is not ESPECIALLY if it’s small(larger asymmetries can hinder performance) and let me explain why.

As human beings, we move differently and this is in large part due to the variation in our anatomy. We’ve seen differences in the hip anatomy through cadaver studies whether it’s in the hip socket, the femur bone or a combination of both.

(photo credit to Ryan Debell of The Movement Fix)

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This is already an indicator that individuals will tend to squat differently. People with retroverted hips typically prefer a wider stance while people with anteverted hips will adopt a narrower stance(see below):to1-figure-9.jpgI know those differences would not be able to account for an asymmetry. Now, we’ve seen research to show that your hip anatomy can vary from left and right.1 The differences in the range were anywhere from 0.2 degrees to 17.3 degrees which is quite significant.1 This leads me to my point that shifting in the squat is completely NORMAL especially when trying to place symmetric loads on asymmetric structures.

(photo credit to Ryan Debell of The Movement Fix)

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Another factor that comes into play is leg length discrepancy and research has shown that it may be more common to have one than NOT to have one.This is another rabbit hole to dive into determining whether the discrepancy is due to structural(bones) which we cannot change or functional(muscle length).2 If there is a longer leg present, the squat will shift towards the longer side as it needs to go into a deeper hip internal rotation during the descent so that the bar and pelvis stay level during the movement.

Are we doomed? Not at all. The great thing about being human is that our bodies adapt. When stress is placed on our body, the tissues(muscles, ligaments, tendons) will remodel to become stronger. We have the Wolff’s law for bones and Davis’ law for soft tissue which explains how our body adapts to the imposed demands placed on it. This prepares the body for it’s next encounter to that same stimulus. Subsequent exposures to that particular stress(in this case, the shifted squat) will gradually increase the tolerance of your body to the movement.

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“So…what you’re saying is forget form and keep squatting?” Kinda but it always DEPENDS(context is king). If we can clear the range of motion, motor control and other factors that could potentially influence the shift in the squat then we need to finally take into account the person in front of us. People have certain variations in their bone structure that could potentially lead to different movement patterns and this isn’t a cause for concern. Asymmetries can exist and our bodies can adapt. The key is to keep the asymmetry to the minimum so it does not potentially hinder our squat performance(losing balance/control).

If we apply this clinically, let’s say a patient is experiencing right sided glute pain while squatting. We look at the pattern and we see that the patient has a slight shift to his right side during the squat. Ding ding, you’ve got the answer? Let’s slow down a bit. If we know that shifting to one side of the squat is a pattern that could potentially be adapted to and may be natural due to the anatomical structure then is this patient having a biomechanics problem, a volume management problem or is it BOTH?

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Well, it could go a variety of ways. First, we need to assess the person’s range of motion. If that is cleared then check motor control under different loads. Is the person able to squat symmetrically with their body? How does it look at 50% of 1RM, 60% of 1RM, etc? If you’re training at 80-90% of your 1RM and still maintaining a relatively symmetric squat but your hips start to shift after those %’s then it’s a motor control(these are numbers are arbitrary, you can plug in anything depending on the context of the situation).

If the form is relatively uniform throughout all the percentage ranges then we may have to appreciate the asymmetry that could be present within the individual. We can spend months trying to re-pattern the squat but we might be trying to fix a problem that might not be there especially if the underlying cause is structural.

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Asymmetry is evident in life and often gets labeled as dysfunctional. This creates kinesophobia(fear of movement) when people begin to label variable ways to moves as poor or detrimental. Our body is capable of being resilient in a range of positions and shifting in a squat is one of them. Remember that any movement can be harmful if the volume and intensity exceed what the person is capable of handling. This concept is evident in the acute:chronic workload literature.

Still not convinced that it might not be safe? Let’s break it down logically. If you were performing a side lunge only to one side, would that cause you to have pain just because you weren’t working the other side? Most likely not. Asymmetric loading is normal and asymmetry in the anatomy is normal as well.

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What can we do? Clear range of motion and motor control. Minimize the asymmetry so it does not hinder our squat performance. Make sure we are training smart in regards to volume, intensity, and recovery. POTENTIALLY change our stance to accommodate the differences between the R and L hip but I think the latter options are more viable(a friend of mine had recently brought to my attention that Dean Somserset changes his deadlift position to accommodate his hip variation so just a thought).

If you’ve got any questions or want to discuss anything pertaining to the topic, always interested to hear the perspectives of others and engage in thoughtful conversations.

Citations:
1.) Dimitriou D, Tsai T-Y, Yue B, Rubash H, Kwon Y-M, Li G. Side-to-side variation in normal femoral morphology: 3D CT analysis of 122 femurs. Orthopaedics & Traumatology: Surgery & Research. 2016;102(1):91-97. doi:10.1016/j.otsr.2015.11.004.

2.) Knutson GA. Anatomic and functional leg-length inequality: A review and recommendation for clinical decision-making. Part I, anatomic leg-length inequality: prevalence, magnitude, effects and clinical significance. Chiropr Osteopat. July 2005. doi:10.1186/1746-1340-13-11.

In the world of rehabilitation and health care, pain has often been quantified through the bottoms-up approach. With the bottoms-up approach, we see pain as being processed from a potential stimulus. This is where we usually put the blame on a specific tissue/s. When we look at it from this lens, pain is driven by a stimulus. The greater your pain is, the greater the stimulus that triggered it. While that approach holds a lot of merits especially when there is a clear mechanism of injury…there is a lot of interplay with the nervous system that can rightfully change the output. Now, this is where Drake comes in.

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Drake has had his share of heartbreaks, ex-es, hard days and long nights. In recent news, he’s found out that Kiki didn’t love him, and she wasn’t riding. He’s always suffered and it’s evident:

“You’re still the one that I adore, ain’t much out there to have feelings for.”
-Drake, Own It

“I know you still think about the times that we had.”
-Drake, Marvin’s Room

“You could have my heart or we can share it like the last slice.”
-Drake, Best I Ever Had

You may be wondering, how the hell does this go about helping me understand pain science? Let’s say Drake pulled up to the club with OVO. He’s chillin’, sippin’ some champagne and then someone catches his eyes. This woman is drop dead gorgeous and he has no choice, he approaches her. He buys her a drink and they’re hitting it off until she gently caressed his arms. To an ordinary individual, this would be fine…in fact in the bottoms-up approach, we can’t possibly see this stimulus providing any discomfort. Then it happens…

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In split seconds, the nervous system begins to process the stimuli. Drake’s somatosensory cortex activates which processes light touch as well as the location of the stimulus. This sensation feels oddly familiar the nervous system thought as the hippocampus began to light up which is where your long-term memory is stored.2,3,4 “This touch…it feels like Nikki…wait more like Rihanna…or was it Keisha?”. These memories are bringing back emotions which are brought on from our amygdala and insula.1,2,3,4 As all of this is happening so fast, our pre-frontal cortex, anterior cingulate gyrus and other parts of our brain take in all the contextual factors.2,3,4 The nervous system realizes that we are in potential danger to be heartbroken once again. The brain sends an output of heartache and Drake retracts his arms thinking to himself…

“Bad things
It’s a lot of bad things
That they wishin and wishin’ and wishin’ and wishin'”
-Drake, God’s Plan

That my friends…that’s the top-down approach. This helps us explain what Drake already understands. That sometimes…there might not be any real danger but there can still be pain. That sometimes non-threatening stimulus can be perceived as threatening depending on the context. We need to take the whole individual into consideration and begin addressing some of the different factors that come into play which can heighten the output whether its emotions, false beliefs, misconceptions, coping strategies, self-efficacy, thought viruses, etc.1,2,3,4

Image result for top down vs bottom up processing pain scienceThere are people who are terrified of training after they had a minor set back or experienced some soreness following a session. They’ll completely stop the activity altogether without seeing a knowledgeable health care practitioner to rule out anything that could be of potential danger(very unlikely in this case of training). They’ll remember all their friends telling them how deadlifts can “break” their back or maybe squatting past their knees will leave them crippled. All these false beliefs, misconceptions, and previous experiences can influence the output of the nervous system. If your body feels like it’s in danger, it’s going to let you know even if there isn’t anything inherently harmful happening…such as when you’re performing deadlifts or squats.

Sometimes friends, families, and clinicians don’t give great advice about training especially if they haven’t read past an abstract on a paper or have any formal knowledge on strength and conditioning. Remember a wise man once said:

“Should I listen to everybody or myself?
Cause myself just told myself
You’re motherfuckin’ man
You don’t need no help.”

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Citations:
1.) Sawamoto N, Honda M, Okada T, et al. Expectation of Pain Enhances Responses to Nonpainful Somatosensory Stimulation in the Anterior Cingulate Cortex and Parietal Operculum/Posterior Insula: an Event-Related Functional Magnetic Resonance Imaging Study. The Journal of Neuroscience. 2000;20(19):7438-7445. doi:10.1523/jneurosci.20-19-07438.2000.

2.) Pelletier R, Higgins J, Bourbonnais D. Is neuroplasticity in the central nervous system the missing link to our understanding of chronic musculoskeletal disorders? BMC Musculoskeletal Disorders. 2015;16(1). doi:10.1186/s12891-015-0480-y.

3.) Lumley MA, Cohen JL, Borszcz GS, et al. Pain and emotion: a biopsychosocial review of recent research. Journal of Clinical Psychology. 2011;67(9):942-968. doi:10.1002/jclp.20816.

4.) Butler DS, Moseley GL, Sunyata. Explain Pain. Adelaide, South Australia: Noigroup Publications; 2013.