Thoughts on Motor Control, Dry Needling, and Some Advice from "My Interview with Dr. Seth Oberst, DPT, CSCS"
I am fortunate to have been recently interviewed by the PT website CinemaSays.Wordpress.com. It has gotten quite a bit of traffic so I thought it would be interesting to share my interview here. Check out this website, there are some fantastic interviews with big names in the Physical Therapy profession - I'm thankful for the opportunity.
Interview with Dr. Seth Oberst, DPT, CSCS
If you haven’t been reading Dr. Seth Oberst’s blog, then you’re truly missing out on some quality content. It has become one of my favorite reads lately. I had the opportunity to interview Seth, and it turned into a great introduction to a very curious mind. You can also find Seth on Twitter.
In this interview, Seth shares his views on Motor Control, Dry Needling, his PT Residency, and more. Enjoy!
First, what did you have for breakfast today?
4 hardboiled eggs, bulletproof coffee, and an apple
What sparked your initial interest in Physical Therapy?
Initially, I went the cliche route where I had some orthopedic injuries and surgeries in high school that necessitated going to a physio. I remember thinking how cool it was to know so much about the human body and being able to fix it (I’m obsessed with fixing stuff). I went to undergrad knowing I wanted to be a physio so I majored in Exercise Science which really aided my progression as a strength & conditioning coach. When I first started my undergraduate, I thought it would also be beneficial for me to get a degree in Athletic Training. However, I really did not enjoy my first athletic rotation within the ATC courses so I decided to stick with Exercise Science in preparation for PT school. I did have a strong dalliance with going to medical school while in undergrad, however ultimately I decided that PT was the best profession for me to impact the whole person with a holistic approach as I thought (and still think) that medicine was much too reactionary, short-sighted, and narrowly-focused.
Why did you take on a Sports Residency? And was it worth it?
I took on a Sports Residency to gain more clinical insight and mentorship. I am intensely, obsessively curious and thought the residency was the next logical step for me to answer some of my questions and help focus my clinical decision-making. I enjoy treating and training athletes so I decided a Sports Residency was the best way to interact with a lot of athletes.
Overall the residency was certainly worth it. I gained some valuable mentorship, was able to see a ton of clients which helped me with pattern-recognition as well as my manual skills, and was able to better manage the overall care of an athlete.
What were you biggest take-aways from the Residency experience?
Improved clinical practice and pattern recognition. I have been better able to quantify and qualify some of my ideas. I also learned that it is critical to take pride in becoming a great generalist prior to specializing, something that is totally lost in our current healthcare environment.
I love your blog. Why did you start it?
I’m glad you enjoy it. I started SethOberst.com because I really enjoy the process of teaching and disseminating information and I thought that starting a website would be a way for me to do so. It gives me a platform to reach more than just those whom I interact face-to-face. And I love the collaboration it has spurred and the learning opportunities it has opened.
You’ve done some work on Motor Control. What aspects of Motor Control should every Physical Therapist consider & apply?
All of them! Motor control is really the end-goal of our interventions as physios (and as S&C coaches) because the target of our training and rehab is ultimately the nervous system. I think a huge part of what makes manual therapy (whether it’s manipulation, soft-tissue, dry-needling) so effective is that it’s a way into the nervous system that ultimately allows better expression of movement. When you really consider why our interventions work, much of it is neurophysiologic with improved function and decreased pain as a result of improving positional competency to positively impact the motor control system. So I think we need to realize that nearly all of our interventions are, and should be, impacting the motor control system. If all we do is expose someone to an input with no thought or appreciation for the expression of movement, I think lots is left on the table.
I guess I digressed there a bit….to answer your question, we MUST consider the nervous system as “orthopedic or sports” PTs. To me, treating and training an athlete is not a whole lot different than treating a neurological-injury (aside from the obvious pathologic differences). I had a fantastic neuro professor in PT school at Ohio University (Dr. Petra Williams), and she continues to influence my thinking in treating/training athletes. Task-oriented training is the best way to treat neurologically-injured people so why are we not using these same paradigms for our orthopedic clients? Put the client in the best position to execute the task, using inputs as necessary to get them in the right position and have the task drive the right motor program. Then we can improve physiologic variables of performance (strength, endurance, etc.) once we have addressed the rate limiters.
Some important pieces of motor control are honestly some of the basics: saliency, joint centration and proximal stability, developmental patterns and the importance of fixed points, crossing midline, distributed practice, external cueing, breathing and its effect on deep stabilization, sensory inputs. Tapping into these fundamental, rate-limiting components can really yield some ruthlessly optimal output. As physios we are uniquely trained to integrate this into our training pieces because ultimately what matters most to people is they can go faster and go longer without the handbrake on.
Which continuing education courses interest you the most (if any)?
I just took both courses of dry needling thru James Dunning’s AAMT which I thought were fantastic. I also have done some PRI courses and want to do more. I also find the DNS school of thought right up my alley.
Now that you’ve had some Dry Needling course-work and experience, tell us what you think of this modality and how it fits your paradigm of treatment.
I think it’s a powerful input into the nervous system to reset the system and promote improved neuromuscular output. Like any other manual intervention it needs to be used appropriately, with the end goal to improve movement at the forefront of the decision-making process. My appreciation for pain referral patterns has certainly grown after my training in needling as well as how quickly someone can improve when we target the nervous system to facilitate or inhibit motor patterns. But the needling can’t be perceived as a threat; as Charlie Weingroff states so well if the client’s breathing pattern markedly changes during the needling they are likely not integrating the dry needling (or any other intervention for that matter) and full change is unlikely. Overall, it’s a game-changer that can get my clients back to training much more quickly and precisely than some other modalities.
Favorite books & authors (PT & non-PT)?
I seriously love to read as reading has literally opened so many doors for me.
What are your Professional aspirations and how do you plan on accomplishing them?
Positively impact and empower as many humans as I possibly can to take charge of their own movement and performance. For me that happens by growing a fee-for-service clinical practice in the human performance realm with a foot in PT and S&C as well as collaborating and educating with the best minds in disparate fields. All of which are very much a work in progress for me.
Since you have a strong exercise science background, this might be an interesting case scenario question. While many look to lose weight in today’s world, there are those who would love to gain healthy weight. My friend Genghis is one of them. He’d love to pack on some muscle mass, but has the toughest time gaining weight. He’s one of those guys who can eat whatever he wants without any weight-gain. What advice would you give poor Genghis?
Poor Genghis. Your friend needs to focus on at least some version of the main lifts that promote a big stimulus for growth: pulls, presses, squats, and carries. Isolation exercises just aren’t going to be a great stimulus, rather full body movements exploring large ranges of motions are best here. Also, calories need to be high with avoidance of inflammatory foods (gluten and the like) to promote a positive adaption for mass gain. Also sleep is huge, growth hormone release is predicated on appropriate and adequate sleep patterns.
If you could change Two things about the profession of Physical Therapy today, then what would they be?
One would be that a PT should know their value and that it’s not just the value of a co-pay. We need to move away from dependence on 3rd party payers and referrals as we are letting that dictate how physios operate. Fee-for-service and direct access are great for the profession as they make us more accountable. Stop providing a KIA and asking to get paid for a BMW. We need to take the banner of movement experts and the tremendous opportunity that comes with truly understanding and treating movement dysfunctions (NOT pathoanatomy) and run with it, own it before someone else does
The second would be that in order to seize this opportunity we have to truly understand movement and start intervening on the cause of dysfunction, not the symptoms which often present as pathology. It seems that in most cases pathoanatomy is the symptom with cause being a movement dysfunction. We’ve become really great at treating symptoms which is completely reactionary. Even in post-operative patients, too many physios are just treating post-operative symptoms rather than pre-operative causes. I think we need a holistic approach by empowering and educating the client and to take it upon ourselves to go after resolving and improving human movement not just isolating muscles and using bouncy balls and rubber bands. Understanding human movement is a noble cause and one we need to take much more seriously.
Next question I borrowed from Tracy Sher, MPT, CSCS:
What would you say to your 7-year old if you could go back?
Don’t be so mouthy to your parents and be warned that braces and headgear are in your future, bro!
Are you an APTA Member? Why or why not?
Yes I am an APTA member. I think it’s important because while I don’t agree with everything the APTA says/does, it gives us a professional voice and a seat at the table. It’s like paying for college: it’s expensive and you don’t love every class but you know it’s the best thing for you.
What advice do you have for today’s DPT Students?
Having a reason for everything that we do as physios. Having a paradigm for progression/regression as well as using a test-retest model that exposes the client to the intervention based on your hypothesis and then gauges their response is crucial! It’s what separates the zeros from the heroes. The key is to recognize patterns and that means a lot of deliberate practice. Experience itself does not equate to expertise; deliberate, thoughtful experience while being driven by what we don’t know yields expertise.
Expose yourself to other ideas outside of physio. Yoga, massage therapy, kettlebells, Oly lifting, anything. We try to own these little silos of information without considering other, often very effective, schools of thought. Way too many PTs have no clue about training methods and movements which is rather ridiculous. If you yourself cannot pull, push, press, and squat how the hell can you expect to have face validity when calling yourself a sports physio or trying to coach a patient (and yes everyone should be able to perform those movements in some capacity). Because ultimately PTs are movement coaches so take pride in owning movement.
Which blogs do you read the most?
I love Kelly Starrett’s mobilitywod.com, he has been a big inspiration for me. Charlie Weingroffalways has a ton of insight when he posts. Mike Reinold, Eric Cressey, Jarod Carter. Seth Godin’s blog. And obviously….CinemaSays.wordpress.com, your piece on “Evidence-Based” Practice was spot on.
Life is an adventure. Let’s close by you sharing one of your life’s best adventures so far.
Well, I thought about getting all philosophical here but I think I’ve done enough of that already in this interview. So instead I’ll keep it real: I did some rafting with friends on a bunch of class V rapids on the Upper Gauley in West Virginia last year and it was quite an adventure.
Thank you for the incredibly thoughtful questions, this has been a pleasure.
This is going to be Part 1 in a multi-part series on the feet as a doorway into the nervous system.
We know that having flat feet or collapsed arches has been touted as a risk factor for injury (albeit somewhat inconsistently). And it just doesn't pass the eyeball test... Flat feet just look unathletic. However, the static assessment of having feet flatter than Frodo is just that -- static. A more appropriate assessment of the feet should include a dynamic element that allows for pronation when they're supposed to pronate and supination when they're supposed to supinate. Which illustrates the point here: the foot is a dynamic system of sensory inputs and neuromuscular outputs. One way that we can upregulate and harness this dynamic system is thru maintaining the short foot position during movement. Or, to steal my own thunder, generation of the short foot may be an indicator of neurological readiness and capacity to safely tolerate high volume and load.
Developmentally, the foot has a few fixed points that were crucial when we learned to bear weight and eventually walk; points which we can reclaim as adults and undo our shoe-wearing, flat-footed foolishness. And most babies are not born with flat feet - we develop collapsed arches with our propensity for cushioned, heeled shoes and artificial arch supports robbing the foot of the demand to maintain the perfect balance of mobility and stability.
But I digress...
The three crucial points of the weight-bearing foot:
Essentially, this is the tripod or short foot position. This foot position is absolutely vital for powerful lifts, big jumps, and at the end of stance phase of gait when the foot re-supinates. Short foot puts the 33 joints of the foot on tension, centers the foot, and fires off the high density of proprioceptive nerve endings which are relayed to the brain. This stable position allows for a system-wide increase in force output and motor control. The strength of this stimulus probably improves motor learning due to the positive, feedforward stimuli. A centered foot position tells the brain that the position is a stable one and it is safe to generate a lot more force without risk of destabilization and injury.
It is no coincidence that the external cue to "screw the feet into the ground" helps to foster this short foot position. The system seeks joint centration for max output, so by bearing weight predominantly thru these 3 points the foot is most centered. The other thing you'll notice with this cue is that the foot is not a static, inanimate object! It is a prime source of neurological input and output (more on that with an upcoming post). Maintaining the short foot position can generate an arch and produce a monstrous feed-forward loop that maintains tension and stability throughout the system reinforcing to the brain that force can be safely produced. When the arch collapses the nervous system quickly downregulates in an attempt to avoid excess force thru the entire lower quarter while in an unstable position, yielding decreased output. This is not unlike how head/jaw position influences spine control or how chronically "tight" hamstrings are likely a protective response to prevent neurologic injury when in untenable positions.
Also, check out Charlie Weingroff and Andreo Spina for their take on this topic.