Home Baseball Content Dr. William Brady: Integrated Diagnosis

Dr. William Brady: Integrated Diagnosis

Written on November 25, 2008 at 9:29 am, by Eric Cressey

This past weekend, I attended a great seminar here in Boston with Dr. William Brady.  In fact, it was among the best I’ve seen.  I was the only non-chiropractor/manual therapist in attendance, but walked away from the seminar with some tremendously valuable insights that’ll help me with each and every one of my clients moving forward.

The first lesson of the day is that those of you who have an opportunity to see Dr. Brady speak should absolutely, positively check him out: Integrated Diagnosis.  Diagnostically, he’s among the best I’ve ever seen – and that includes his ability to teach others.

The second lesson of the day revolves around an important concept Dr. Brady extended – and my take on how you can modify this message to accommodate your role as a coach, trainer, or fitness enthusiast/athlete.  There is a reason that almost any doctor or physical therapist gets results – and it resolves around understanding where symptom threshold occurs.  To illustrate this, let’s examine a shoulder problem purely from a soft tissue perspective.

Dr. Brady talked about how you have building blocks to threshold.  Let’s say that after an accurate physical examination, this particular shoulder problem (supraspinatus tendinosis, for example) presents with soft tissue restrictions at the infraspinatus, teres minor, subscapularis, inferior capsule, and pec minor.  So, symptom threshold (the dotted line) might look like this relative to baseline (straight line):

Pec Minor
– – – – – – – – – – –
Inferior Capsule
Subscapularis
Teres Minor
Infraspinatus
BASELINE – NO SYMPTOMS

So, imagine a therapist who just addresses pec minor.  He gets that patient below threshold, but doesn’t necessarily “fix” him; he might be back in with the same problem weeks later.  This is confounded by the fact that “overuse” is actually one of the building blocks, too.  So, even if you leave all the soft tissue restrictions alone, simply resting will get someone below threshold – even if the therapist has done ZERO to address the underlying problems.

This is one reason why a MRI might not tell you much at all about someone’s problem.  With this problem, the MRI would probably just say “supraspinatus tendinopathy” and recommend physical therapy and rest from painful activities.  So, in the “full picture” – where soft tissue work is one of several components (assume they are equal contributors, for the sake of our argument) – the building blocks to threshold might look something like this:

Overuse
Rotator Cuff Weakness
Scapular Stability
Poor Glenohumeral (Ball-and-Socket) Range of Motion
– – – – – – – – – – – – – – – –
Soft Tissue Restrictions
Poor Thoracic Spine Mobility
Type 3 Acromion (non-modifiable, without surgery)
Poor Exercise Technique
Poor Cervical Spine Function
Opposite Hip/Ankle Restrictions (baseball pitchers are great examples)
Inappropriate Structural Balance in Programming (e.g., pressing more than pulling)
Faulty Breathing Patterns
BASELINE – NO SYMPTOMS

So, we’ve got 12 factors, and it’s been my experience that conventional physical therapy only treats the first four – which would, in fact, bring a patient below symptom threshold.  Put that patient back in the real-world with the other eight factors still present (seven of which are modifiable), and as soon as he gets back to bench pressing with terrible technique Monday, Wednesday, and Friday, he’s going to be back in for more physical therapy sooner than later.

So, what do we do in an ideal scenario (not always possible with today’s insurance plans)?

1. More time with patient education (exercise technique, programming strategies – or just outsource it to a qualified professional or good book/article or DVD).
2. Address Thoracic Mobility (Assess and Correct is a great resource for this)

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3. When present, address Hip and Ankle Mobility
4. Retrain some breathing patterns with initial instructions home exercises
5. Provide some take-home neck drills and get people out of chronic forward head posture

All told, I think this could be as simple as 4-5 extra drills in each shoulder rehab program plus a brief sit-down conversation with each patient on exercise program modifications; it really is that simple.  Unfortunately, it rarely happens – and that’s when things become chronic.

So, fitness professionals and coaches need to step up as advocates for their clients and athletes, respectively, and fitness enthusiasts need to be relatively informed “consumers” to look out for themselves.


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  • Good article. The tough part as a clinician is addressing all these issues and have good patient compliancesince so many very fast get past the threshold of symptoms and start feeling better. Full function of all functions is the key. I tell peopel I’m glad they are feeling better but stick to the care plan for full recovery, function , and vitality. The smart one’s stay the rest get to experience a probable relapse or further dysfunction all without symptoms until they go above the pain threshold line. Steve Edling D.C. CCSP

  • Eric- any specifics on what would constitute “take-home neck drills and get people out of chronic forward head posture” ?

  • Great food for thought! Keep it coming. I’ll send this off to a few chiro’s in the area.

  • David Bull

    Eric,
    I have the same question as Greg. I have a son with this situation.
    Thanks in advance,
    David

  • Great info. My brother is going through physical therapy, and we had the “full picture” discussion today.

    Eric continues to raise the performance education bar. Keep up the good work.

  • I couldn’t agree with you more. Everyone has a different threshold and will respond accordingly. With less subjective complaints once the pain subsides the healing process is just the beginning, not the end of a shoulder problem. The next step is to determine their functional capacity objectively. The key to avoiding recurrences as well as enhancing permormance, in my experience, is to address the soft tissue immobolity, increase proper joint function and TEACH proper movement patterns with a watchful eye on quality of movement and proper posture during rehab. A cd/dvd/ or pamphlet is good info to take home and reiterate in conjunction with or after these 12 factors have been addressed.

  • Great article Eric. Some really good stuff to think about it. Thanks for all this terrific free information. Like Paul said, keep it coming.

  • Dale .G. Hansford

    Its a breath of fresh air to have someone like you bridging the gap between the medical and training communitys. Keep up the good work.

  • Todd Heller

    Eric – thanks for passing along the information! In connection to this whole concept and thinking more critically about this information and how it applies to current and upcoming health and strength professionals – what we all do from here with this knowledge is what will make the difference. As Eric shows on a consistent basis (writing articles, books, speaking, attending seminars) he truly cares and is passionate about getting a person from A to B. Now stepping aside, from experiences and listening to other stories from clients who have had therapy or rehab, I don’t know how many times I’ve asked “what was the diagnosis?” and getting answers like “well, it’s impingement and he gave me an anti-inflam drug for 3-4 weeks and I’ll visit the PT again after that period.” or “I’m suppose to do some front, lateral, and bent over raises every day.” Obviously, from Eric’s outline above, these strategies aren’t going to do crap to correct the problems. But all in all, my main point is and I might have to be corny a bit, but excellence is not something you do from 8am-5pm and it’s not something you turn on and off with a switch. I think some therapists or doctors get into this mode of “yeah, do a few of these exercises, take this pain killer, and come back in a month and we’ll take it from there AKA (therapist saying to him or herself “Shoot it’s 4:30, I need to finish up with this patient.” Now, there are awesome therapists, I’m just saying I think if we are having a discussion about poor diagnostic practices, these are just some factors because things seem to be rushed or there is a lack of passion to really dig deep and find out what is wrong with a client. Obviously, I understand therapists and doctors have schedules and other clients, but I still feel like efforts could be increased which brings me back to my excellence quote. If you’re going to be great at your job or anything in life, you have to work at it all the time, even if your shift is slowly coming to an end. Do the job and finish the job the best you can, offer the best programming you can, learn more, ask questions and if you’re a current professional or an up-and-comer like myself, I think we all soon realize this industry isn’t a 8am-5pm job, but a complete around the clock lifestyle with your job tossed in there. Just some random thoughts I had on the subject as a whole. Happy Thanksgiving everyone! Eric – thanks for all the free information, and all stay well.

  • Nick Chertock

    Eric, As someone who ruined his shoulder playing tennis in high school, I’m astonished at how poor my treatment has been over the last 15 years from dozens of PT’s, trainers, and chiropractors. Not one has ever mentioned t-spine mobility, soft tisse restriction, breathing, opposite ankle, etc. Hopefully in the future you won’t be the only trainer in the room, this is the kind of stuff all practitioners need to be aware of. Rest and advil can make anything feel better, for a little bit. Addressing the underlying problems takes patience and awareness that those problems are causing the symptoms being experienced.

    Keep at it, hopefully years from now this won’t seem like such a unique way of looking at sports injuries.

  • Superb article Eric. Writing from Australia to say I LOVE YOUR WORK. Looking forward to your visit here.

  • Hi Eric,

    We have’nt spoken in a while but its great to see your moving from strength to strength and still putting out all the right information! You touched on assessment of the foot, ankle and hip when faced with shoulder problems. I could’nt agree more! A large portion of my business comes from physio referral. Once traditional treatment modalities have been exhausted and it is decided that a more functional approach is a good idea, i get to have a go at fixing the client.

    With regards to shoulder pathology, i begin with assessment of the immediate surrounding tissues and structures – glenohumeral, scapulothorathic etc and record that information. I then put that to the side and look to assess more globally.

    It is amazing the number of musculoskeletal problems that can be fixed by correcting the foot and ankle! After all when we’re in standing posture, the vast majority of the information being fed proprioceptively to the entire kinetic chain is coming from the only part of the body that is in contact with the ground – the feet!

    Looking for A-symmetries between relative calcaneal eversion and inversion during each phase of gait as well as the function of the windlass mechanism during propulsion gives great insight into why the pelvis and subsequently the spine adopt faulty movement patterns. Often, the cervical spine is responding to the thoracic spine which is responding to the hips which are being given there information from the feet. If a client presents with a tight and inhibited FHL, post tib and tib anterior, they are likely bailing out on the 1st Mtpj during propulsion and getting very poor, if any rear foot inversion. With poor toe off comes poor hip extension. Poor hip extension can result in poor thoracic extension and mobility and the shock from the ground contact that was supposed to be reduced to zero by the time it reaches the skull is going to come out as pain somewhere or another!

    It is so important to try and adopt a process that allows you to humbly try and find the true cause of a compensation and not just treat the symptoms.

    Still an avid reader of yours Eric. Keep it up!

    Dave Fleming.

  • Ryan

    Hello Eric,

    Thank you for all of the great information. I first found out about you as an author on T-nation. I’m a chiropractor, and it’s clear you have a very large knowledge base about health, fitness, and musculoskeletal diagnosis and treatment. I’ve enjoyed your newsletter and your website. I was curious as to who you use for your website, as I am interested in having my own website in the future, but not sure where to start. Thought I’d ask you.

    Thanks again for sharing your knowledge,
    Dr. Ryan Rogers

  • John

    Have always understood this concept clinically, but nice job breaking it down since most patients don’t understand this and fail to follow up when needed when the pain first leaves and then complain when it returns.


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