Freelap Friday Five with Doug Kechijian
Doug Kechijian is a performance-based physical therapist who specializes in treating orthopedic injuries and chronic pain. He recognizes the continuum extending from acute rehabilitation to high-level sports conditioning. His comprehensive and integrated approach helps to not only relieve one’s symptoms, but also address the underlying biomechanical and neurophysiological patterns that contribute to injury. A co-founder of Resilient Performance Physical Therapy, Doug consults with professional sports teams and military and law enforcement special mission units.
Before completing his doctoral studies, Doug was a pararescueman in the U.S. Air Force, where he trained and conducted operational missions with elite military units throughout the world. He is a nationally certified paramedic with advanced training in emergency, trauma, and wilderness medicine. In 2015, he was selected as the Noncommissioned Officer of the Year by the U.S. Air Force.
Doug received his AB in Biology from Brown University and MA in Exercise Physiology/Doctor of Physical Therapy from Columbia University. He is Postural Restoration Certified, and has undergone advanced training in joint and soft tissue manipulation, movement screening, and dry needling.
Freelap USA: You have a lot of experience coming from the military and have voiced your displeasure with the clichéd “toughness” style workouts that sometimes lead to injuries. What are your top lessons of real training from the military that can help sports versus just looking like a wannabe boot camp at 5 a.m.?
Doug Kechijian: The construct of mental toughness is too abstract to apply across multiple domains because, in practice, an athlete is either adequately prepared or insufficiently prepared. Preparation is context specific. Military special operators are not prepared to pitch in Game 7 of the World Series or to play on the defensive line in the Super Bowl, despite their ability to endure sleep deprivation and extreme physical hardship. The way in which the military influences the sporting world generally has nothing to do with training. When selecting civilian candidates with no aptitude for small unit tactics, marksmanship, parachuting ability, and other combat-related disciplines, the military must find a way to impose physical and psychological stress in a controlled, logistically manageable environment.An athlete is either adequately or insufficiently prepared. Preparation is context specific. Click To Tweet
The military relies on the boot-camp-style workouts adapted by many fitness professionals because it can’t effectively simulate combat stress in untrained people. Once special operations candidates have been selected, they don’t run around with boats on their heads or bear crawl for two hours anymore. Instead, they individually and organizationally prepare in a way that’s much more specific. The manner in which the military trains to exchange bullets with enemy forces is, in principle, no different than the way the cast of a Broadway show prepares for a tour. Both groups individually and collectively rehearse until they can confidently execute under “game like” conditions. Instead of unnecessarily tiring athletes with military-style workouts, sport coaches should implement these practices utilized by the military:
- Truly demanding accountability to one’s teammates
- Planning for a variety of contingencies
- Implementing systematic training progressions and adhering to standards
- Emphasizing procedure and execution instead of playing with emotion and passion
- Performing frequent after-action reviews
- Cultivating leadership at every level
Freelap USA: Do you have a quick thought on the more aggressive “training” we see with physical therapy; a trend that is growing with sports medicine? How can we use the two professions, sports medicine and sports performance, to get better outcomes? It seems we have a problem with roles and skills.
Doug Kechijian: The distinction between physical therapy and performance is mainly political and legal, but not always practical. As a medical provider, it really doesn’t bother me when well-educated and competent coaches perform a manual therapy technique on an athlete or supervise an exercise that addresses joint position. Fundamentally, physical therapists really just help to establish movement variability, capacity, and power—not much differently than coaches do. Both physical therapists and coaches do need to know when a movement-related problem is of structural or medical origin so they can refer out. While physical therapists are licensed medical providers, they don’t “fix” medical problems. They’re effectively movement teachers with a license to touch people and evaluate the neuromuscular system.
The distinction between physical therapy and performance is contingent upon self-awareness and knowledge. Individuals from both professions should be honest with themselves about the scope of their expertise. How can a physical therapist that doesn’t understand sprint progressions legitimately discharge a running sport athlete without first consulting another professional? Likewise, how many times should an Olympic weightlifting coach cue an athlete about technique before recognizing that one or more of the requisite joints, not motor skill, is the performance limiting factor?
In both these instances, the physical therapist and the coach both need to broaden their knowledge and/or collaborate with another professional, while respecting any legal restrictions. In a collegiate or professional setting, the distinction between physical therapy and performance is a matter of leadership. Ideally, a program manager would define the expectations of the medical and performance staffs very clearly to avoid any ambiguity. Transparency and humility ensure a seamless integration between medicine and performance, regardless of the setting.
Freelap USA: Pain science is a topic that gets kicked around, but when the rubber hits the road and we are in the clinical world, how do we listen to patients or athletes? Some problems we are seeing with injuries are because subjective feedback is often difficult to separate from chronic pain symptoms. Re-injury and “brain pain” are hard to differentiate with coaches; how do we do better here?
Doug Kechijian: Your question speaks to why pain science alone is an insufficient paradigm for sports medicine professionals. For the sake of this discussion, I’m assuming that a structural or medical red flag is not the pain generator. While coaches and medical providers should certainly value an athlete’s emotional experience, pain is too subjective and too poorly understood to serve as a primary outcome measure.
Most coaches, physicians, and therapists are not objectively measuring activity in the limbic system before and after an intervention. Sheets of paper with different relative degrees of happy and sad faces aren’t particularly productive outcome measures either. Good “pain science” is process-oriented because pain-based outcome measures are so abstruse. This process should consist of the following steps:
1. Evaluate painful movements and the constituent joints to assess the variability of the movement system. In other words, try to determine what the athlete does not do well from a positional or motor control standpoint. It’s not uncommon to hear that there are no movement absolutes. While that may be true, missing 30 degrees of passive shoulder flexion on a treatment table might be problematic for an Olympic lifter complaining of pain with overhead activity. That flexion needs to be restored to maximize performance regardless of whether limited range of motion is the symptom or the cause.
Pain is a protective response that limits the degrees of freedom in a variable system. Different sports require different degrees of freedom for optimal performance. The more adapted people become for a particular type of activity, the more delicately they navigate the tightrope between performance, health, and pain.
2. Once variability is restored with interventions (passive or active) that don’t further elicit a protective response, the athlete is systemically exposed to load, speed, and fatigue until the specific endpoint is achieved. Again, these progressions should be non-threatening to avoid additional sensitization. Pain is the body’s smoke alarm. You want it to go off when the house is on fire, not when you’re boiling water on the stove. With chronic pain, the smoke alarm goes off when there is a gross discrepancy between an actual threat and a perceived threat. Moving as aggressively and often as possible without setting off the smoke alarm helps to reset the threshold.
Using the Olympic lifter from the previous example, she might be able to substitute snatch pulls and kettlebell arm bars for the full snatch without symptom provocation en route to performing the full snatch. This paradigm requires objective tests that actually influence treatment (not screening for the sake of screening) and an expansive repertoire of regressions and progressions for an array of movement categories. No commercial screens or special tests are as diagnostic as the training process.
There is nothing wrong with chasing pain to provide relief to athletes and patients. Without an objective and systematic process that a clinician trusts, however, pain can be too confounding an outcome measure from which to gain meaningful insight. To be clear, pain education alone is not a good physical medicine.
Freelap USA: With your video working an Olympic weightlifter gaining popularity for its straightforward explanations, how do you use PRI (Postural Restoration) in a way that really demonstrates measurable change? Evidence-based medicine is trending, but is now requiring outcome data as well. How do you use the information you have to show results that are objective?
Doug Kechijian: People often develop emotional attachments to commercial exercise and rehabilitation models, and to their social media personas, which hijacks them from seeing the bigger picture. For me, PRI provides a more-integrated biomechanical and neurophysiological lens through which to evaluate movement than the method I learned in physical therapy school. PRI provides an insightful way to evaluate and maximize movement variability because its emphasizes specific adaptive patterns above the myopic structural diagnoses (none of which a non-surgical provider can actually do anything about) that tend to characterize traditional orthopedic physical therapy. PRI’s tests aren’t especially unique, but the way in which it connects various dots allows for a more efficient plan of care. PRI is a way—though certainly not the only one—to restore joint position, low threshold motor control, and variability.
Therefore, a “PRI” intervention might improve any outcome measure an evidence-based provider would use to evaluate these qualities, assuming they deem them important enough to assess. PRI is really a system of graded exposure whereby the process of progressing somebody through a series of non-threatening exercises provides information about their sensitivity and variability with respect to motor output. PRI does not explicitly tell you how to build power and capacity once sufficient variability has been restored, but you can extrapolate the biomechanical concepts it espouses to performance training.
Freelap USA: Medical imaging is either overly relied on or believed to be useless, with very little middle ground. Can you share when getting an MRI or similar makes sense with an athlete who is struggling?
Doug Kechijian: As you suggest in the question, a centrist approach is most reasonable. Imaging is probably overprescribed but it still matters. When warranted, it provides better information than that achieved with orthopedic special tests. The MRI is indeed the gold standard for structural diagnostic capability. Imaging should be prescribed more liberally in cases of severe trauma and when pediatric athletes are involved. Assuming an atraumatic mechanism of injury, MRIs are most warranted when motor weakness and significant sensory alterations exist and when motor control cannot be achieved even during low-level exercises secondary to joint instability or pathology.
Last week, I encountered a patient complaining of back pain who couldn’t actively dorsiflex his right ankle during the evaluation, even in supine. He had seen a primary care physician a few days before who told him to try acupuncture for a month. I’m not kidding. I told him that, if at the end of our session he was “passing” my normal movement and orthopedic tests but still couldn’t actively dorsiflex his ankle, he should get an MRI instead of following up with me. At the end of the session, his objective movement tests improved but his inability to dorsiflex persisted. An MRI a few days later revealed that a bony fragment was impinging in his L5 nerve. He had back surgery a few days after that.Motion is lotion, but it doesn’t remove bony fragments from nerve roots. Click To Tweet
In no way do I tell this story to suggest that I did anything particularly noteworthy. This referral was perhaps the easiest I’ve ever had to make. This story is worth telling because extreme aversion to imaging is just as egregious as its overutilization. This patient was a trainer who has studied under movement gurus with large internet followings. One person told him he couldn’t dorsiflex his foot because his gluteus medius is weak. Another person told him he needed to selectively strengthen his transverse abdominis. There is still a very important place for traditional orthopedic and Western medical thinking. Thankfully, this patient didn’t keep sucking in his belly button while doing band walks until he started pissing himself. Motion is lotion, but it doesn’t remove bony fragments from nerve roots.