Most of us think about exercise in this way. The same goes for home exercise programs given to patients in physical therapy.

This approach assumes that the body will make positive adjustments via continuous performance of an activity. While this may occur to a certain extent, the body will make these adjustments much faster and more effectively when sensory awareness is appreciated.

Motor output, in this case movement, is a reflection of the sensory input given to the body. For example, if one were to touch a hot stove, pain is detected (sensation) and the individual withdraws his or her hand (motor output-movement).

Similar interactions in response to less extreme stimuli occur with everyday movement. When walking the pressure of our body weight is sensed through the arch of our foot during the stance phase which triggers a cascade of events to advance the body onto the opposite leg. The arch of our foot is just one “reference point” that the body detects to trigger an appropriate reaction.

Being aware of these “reference points” during home exercise programs allows the brain to detect what is happening with greater ease. When the brain is in tune with what an individual is trying to accomplish, learning occurs and the objectives of the activity become more en-grained.

Next time you perform your home program, ask yourself, what is working? If you are standing, where on your feet is the majority of your bodyweight? If you are sitting, where is your bodyweight?

If you have been to physical therapy you should know the correct answers to these questions in great detail. Now you simply have to remind yourself to ensure that the body is continuing to get proper feedback so that optimal movement can take place.

The Key to Athletic Physical Therapy: Finding Balance in a High-Stress World

I am incredibly fortunate to work in the field of athletic physical therapy in Bethesda, Maryland, and McLean, Virginia. The Washington, DC area is home to a remarkable community of driven, highly accomplished individuals who often lead impressive and fast-paced lifestyles. Many of my patients possess “type A” personalities, which is probably why we get along so well. They take a keen interest in their health and are eager to understand the root causes of their injuries, as well as what they can do to address them.

Working with such an informed and proactive population makes my job not only rewarding but enjoyable. I love “talking shop” about clinical topics and helping patients fully grasp their conditions. A well-informed patient is often highly engaged in their rehabilitation, diligently following home exercise programs and making meaningful changes in their daily routines, such as adjusting their workstation setup or refining their posture while sitting, standing, or sleeping.

However, patients with these high-achieving, hard-working personality traits can present unique challenges. Many of them have achieved significant professional success but struggle to manage the relentless stress that comes with demanding jobs—stress that is often compounded by everyday life.

The human body perceives stress as a cumulative load—whether physical, mental, or emotional. This can lead to an overactive sympathetic nervous system, leaving the body in a constant “wound-up” state. While short-term stress is manageable, chronic stress can keep the body in a heightened state of activity, resulting in accelerated heart rates, hormonal imbalances, and a host of other issues. In this state, the body is essentially in overdrive, making it difficult to recover from injuries and adapt to physical therapy.

In athletic physical therapy, one of the first and most important steps toward recovery is teaching the body how to “turn off” and shift into a state of relaxation. Achieving this balance allows the body to recover more efficiently and function at a higher level.

How Do You Turn Things Off?

At Cohen Health and Performance, one of the first techniques I teach my patients is proper breathing. Breathing correctly stimulates the parasympathetic nervous system—the branch responsible for calming the body and promoting relaxation. This helps dial down the overactive sympathetic nervous system, which controls our “fight or flight” response.

Once patients have mastered breathing techniques, we move on to retraining the body to move efficiently. Chronic stress often leads to poor movement patterns, characterized by excessive extension and rigidity in the body. One of the best exercises for counteracting this is the 90-90 Hip Lift, a popular drill from the Postural Restoration Institute.

Here’s how it works:
1. Lie on your back with your hips and knees bent at 90 degrees. Place a small towel or ball between your knees and rest your feet flat against a wall.
2. Inhale through your nose, and as you exhale through your mouth, gently perform a pelvic tilt, lifting your tailbone slightly off the ground.
3. Focus on digging your heels into the wall, engaging the back of your thighs rather than your hip flexors.
4. Hold this position while taking 4-5 deep breaths in through your nose and out through your mouth.

Once this basic activity is mastered, we gradually increase the complexity of exercises to better mimic the functional movements of daily life and athletic performance.

Bringing Balance to Everyday Life

Achieving balance doesn’t stop at the clinic. Incorporating stress-relieving activities into your daily routine is crucial for long-term success. These activities should be enjoyable and help you unwind from the stress of daily life. Whether it’s meditation, a peaceful walk, a hike, or spending quality time with family and friends, finding time to relax is essential for creating balance in your body and improving overall function.

In short, take time to enjoy life outside of work and responsibilities. Your body—and your performance—will thank you for it.

If you’d like more information on these techniques or any other topics related to physical therapy, don’t hesitate to reach out.

This post is inspired by an Olympic lifter that I work with. She has been experiencing chronic lower back pain which did not begin until she began intensely training. We have been working on a great deal of things to address the cause of the “pinching” she gets in her left lower back which has been successful in eliminating her pain.

I recently was speaking with her regarding how to prevent her pain from re-occurring in the future and the topic of movement variability came up. Many sports require and consist of a great deal of lower back extension which compresses the lumbar spine and can lead to lower back pathology/pain.

My advice was not to avoid lumbar extension when in the gym as this is necessary for specific phases of her lifts but instead to ensure that she is not getting stuck in this pattern. Total lower quarter extension (lumbar, hip, knee and ankle extension) is required to perform the acceleration phases of her lifts however must be capable of flexing (ie. Doing the opposite) in other situations.

This is essentially the premise behind movement variability. The ability to move in many different ways is an extremely valuable quality. If we can extend, then we also need to be able to flex. If we can rotate left then we should be able to rotate just as easily to the right.

Our nervous system perceives repetitive movements and postures as stress. As a result neuromuscular tone will often be increased causing people to feel tight or uncomfortable. These repetitive movements will consistently stress the body in the same way, breaking down tissue over time. Just imagine a paperclip continuously being bent in the same direction.

The Olympic lifter I work with must be able to turn the extension “switch” on for maximal power development however must then be able to flip the switch off as she leaves the weight room. If she is unable to do this then she will be consistently stressing the same areas of her body, regardless of her setting and injury will eventually result.

Clinicians will often recommend simply avoiding an activity to prevent pain however this rarely works when this activity is an individual’s passion. Many times this is also unnecessary. Simply having many different options for movement when outside of the individual’s sport/activity will allow for stress to be spread throughout the body, rather than be centered in one area. This will prevent individuals that are at a high risk of overuse injuries, such as Olympic lifters to have successful careers.

“I just need you to dig into this spot, right here.” “This needs to pop, then I’ll feel better.” “It just needs a good stretch.”

Does this sound like someone you know?

I am constantly hearing this from patients when they initially come to see me. They present with pain and an increased sensation of tension and stiffness that gives the impression that it will be relieved with soft tissue massage, manipulation or stretching.

Nearly all clinicians, coaches and trainers, myself included are people pleasers. As such we want to make our patients/clients happy and oblige their requests. However it is essential to ask ourselves, why? Why does he feel that he needs to “pop” his back to feel better? Why does she feel she needs a weekly massage to manage her discomfort?

An area of the body does not simply become tight or stiff. Soft tissue adhesions and trigger points do not just magically develop. These things occur when the body is moving poorly. If an area is being abnormally stressed during a commonly performed activity such as walking or running the brain will increase muscular tension in this region to protect from a more significant injury. The real magic is discovering where these movement compensations are occurring via a comprehensive evaluation.

Now don’t take this the wrong way and think that I am saying manual therapy is bogus. Manual approaches are often warranted and I perform a great deal of manual therapy in my own practice. However blindly performing such techniques without having a reason to do so is negligent.

At Cohen HP we utilize dry needling as a soft tissue modality (among many others); however it is only implemented with the ultimate objective of improving movement and function. The immediate goal with this could be to reduce pain which would decrease soft tissue guarding. Perhaps the short term goal is to minimize soft tissue adhesions and tension that cause mobility restrictions. Both of these immediate goals allow the clinician to coach proper movement by gaining a full range of motion to work with.

Optimal movement patterns can now be restored. When the body is moving optimally joints are being stressed normally, soft tissues are being shortened and lengthened through a full arc of motion, and a neurologically rich environment is introduced which allows for optimal motor learning. The sensorimotor system will now be constantly adjusting to full ranges of motion which allows for mastery of optimal movement. Movement compensations are no longer necessary however these old motor programs are still present in the brain so they must be watched out for. The new and improved ways of moving will allow the brain to develop new motor programs or patterns (software) to control the body (hardware).

Often times the first step of utilizing manual therapy can be skipped altogether. If the patient/client possesses no significant soft tissue abnormalities, mobility restrictions or abnormal pain responses then treatment time would be best utilized elsewhere. This allows for the clinician/coach to immediately address the root cause of symptoms.

Weekly massages, multiple sessions of getting “adjusted” and constantly feeling the need to pop joints should not be essential. Having a massage is a great thing however if you fall apart without it then a larger issue is staring you in the face. All you have to do is ask why!

In a previous post, found here, I discussed why the term “tight” is an inadequate way to describe symptoms. The sensation of “tightness” typically stems from either musculotendinous shortness or stiffness. While shortness is a physiological issue that’s harder to address, excessive stiffness can be improved with movement and exercise.

It’s important to recognize that a certain level of stiffness is not only acceptable but often beneficial, particularly for athletes. This natural stiffness allows athletes to be more elastic, enabling them to generate maximum power with minimal effort. This quality often distinguishes elite athletes from the average person and is something both coaches and clinicians should be mindful of.

In other words, don’t automatically assume that any area with some stiffness needs to be mobilized or stretched. Athletes often depend on this stiffness for optimal performance (Remember, the principle of “do no harm!”).

Problems arise when stiffness becomes excessive, leading to alignment issues and dysfunction. The most effective approach to care is to restore tissue mobility through movement.

Stiffness often develops due to poor stability, motor control, and movement patterns. When stability is lacking, musculotendinous structures become stiff to compensate, providing stability that the appropriate areas should be supplying. As I mentioned in my previous post, the hamstrings, for example, often become stiff in response to insufficient proximal stability in the lumbo-pelvic region. An anterior pelvic tilt due to poor core stability can create an unstable attachment point for the proximal hamstring at the ischial tuberosity. The central nervous system then increases hamstring tone as a protective mechanism, trying to provide stability through stiffness.

Traditional stretching doesn’t address this issue because the root cause of excessive stiffness is often a lack of core stability and motor control.

The most effective way to treat this problem is by achieving mobility through movement. For proper movement patterns to occur, the body must dynamically stabilize throughout the available range of motion. When this happens, the smaller, intrinsic muscles function as intended, activating before the prime movers to provide the necessary proximal stability. This allows the larger muscle groups to do their job and generate the force required for movement.

For example, proper shoulder movement requires the trunk (including the transverse abdominus, multifidi, pelvic floor muscles, etc.), scapulo-thoracic region, and rotator cuff muscles to activate and create a fixed point. This stability allows the deltoids, pectorals, and/or latissimus dorsi to generate movement effectively.

In a similar way, an athlete may experience excessive hamstring stiffness due to poor core stability and dysfunctional hip extension patterns (think sprinting). Ideally, the trunk muscles should fire first, providing a stable base for the lower extremity to work from. When the proximal attachment is stable, hamstring tone decreases, allowing the glutes to activate properly and generate hip extension. This reduces hamstring dominance and further stiffness related to overuse.

Correcting dysfunctional movement patterns requires adequate joint stability and the appropriate muscular tension. By teaching an athlete to properly squat, lunge, roll, etc., you can help normalize their complaints of “tightness.” The athlete is forced to dynamically stabilize through the range of motion involved in the movement, thereby maintaining any mobility gained.

For these reasons, I rarely perform static stretching with my athletes or patients. Most of the manual treatment techniques I use involve Dry Needling or ASTYM to normalize muscular tone, desensitize nerve endings, reduce swelling, and/or stimulate healing. I follow these manual techniques with exercises to address the true cause of tissue dysfunction.

For example, I might perform Dry Needling on an athlete’s glenohumeral joint capsule or related muscles contributing to mobility restrictions or abnormal joint mechanics. I would then follow this with closed-chain exercises like downward-facing dog or side sits to bear. This sequence promotes proper co-contraction of the scapulothoracic and glenohumeral muscles, ensuring maximum joint congruency for optimal weight-bearing and functional capacity.

So, the next time you or an athlete/patient feels “tight,” think movement, not stretching!

As you can see above this head/neck position can not be a good thing.

Most clinicians and coaches understand the importance of achieving and maintaining an optimal spine position during exercise and daily life. Appropriate lumbo-pelvic posturing is often the initial focus towards correction however this will often take care of itself (or make correction much easier) when optimal cervical spine posture is achieved. Many rest in upper cervical extension and lower cervical flexion, manifesting as the typical forward head posture often seen. This results in a lack of joint centration or stability throughout the cervical spine, leading to overactive upper cervical extensors/scalenes and sternocleidomastoids, while the intrinsic stabilizers are inhibited, most notably the deep neck flexors.

The cervical spine is an area rich with proprioreceptors, and therefore plays a large role in the sensorimotor system. Afferent information related to cervical positioning is relayed to the central nervous system resulting in a predictable motor response, whether functional or dysfunctional.

When the cervical spine is positioned appropriately, balanced activity between agonists/antagonists, flexors/extensors and tonic/phasis muscles are achieved and the rest of the body follows suit.

The body also follows accordingly when the cervical spine is in a dysfunctional position. The forward head posture described previously occurs frequently with those sitting at a desk for extended periods of time. The individual is looking at a computer screen resulting in a tendency for the eyes to drift forward as gravity takes over and he/she continues to slouch resulting in a chain reaction of increase spinal flexion and posterior pelvic tilt (correlating with stiff hip flexors and inhibited glutes among a host of other issues).

This is often most exaggerated in the weight room with squat variations and Romanian Deadlifts (RDLs). Excessive cervical extension is commonly seen with squatting due to the old saying of “head up!” and it is often further increased with RDLs as people wish to keep their eyes level with the horizon. These dysfunctional cervical positions result in over-activation of the global extensor system, most specifically the paraspinal musculature leading to a host of other dysfunctions/pathologies.

Those that lack appropriate pillar strength/stability may require this for stability to perform these exercises with load as their internal stabilizing system is shut off. Therefore training of appropriate pillar stability, beginning with correcting the breathing stereotype is often necessary while paying particular attention to cervical positioning.

However others may simply require cueing, specifically for those coaches working with a group of athletes to “pack the neck.” Packing the neck is similar to the sensation of creating a double chin. The athlete/patient should feel as if someone is pulling him/her vertically from the hair on top of the head. When standing this would be towards the ceiling and when performing a correct hip hinge it would remain in line with the spine.

A helpful tool can be to give an athlete/patient a ball or some object underneath the chin, having him or her hold it there by performing a small chin tuck while elongating the cervical spine. This works tremendously with RDLs where this is most exaggerated and feels un-natural to many.

Correct cervical positioning leads to optimal joint centration, allowing the rest of the body to correspond accordingly resulting in improved activation of the internal spinal stabilizing system and overall movement patterning. Next time you are working with someone displaying dysfunctional cervical tendencies, have him/her pack the neck, waking up the central nervous system to make it easier on you in correcting the remaining dysfunctions. Final step, have the athlete/patient maintain this position throughout the day!