How does a male sports and orthopedic physical therapist come to teach about pelvic health and wellness? I was fortunate enough to spend ten years in the NHL as the physical therapist and athletic trainer for the Florida Panthers. Ice hockey is one of the sports that has the highest incidence of groin strains among other pelvic related pathologies.1 As a clinician that was responsible for taking care of the world’s best hockey players, I was challenged to understand the interconnected relationships between the lumbopelvic-hip complex very quickly.
In the early years of my career development and the treatment of mostly males with pelvic pathologies, I leaned heavily on pelvic health professionals to help me understand an area of the body I received little training on in school and even less in my clinical care as a sports and orthopedic manual physical therapist. After years of treating hip and pelvic pathologies on my players I became more comfortable in this enigmatic area of the body. A good friend of mine was on faculty with Herman & Wallace and we frequently would communicate and compare notes. She was treating an increasing number of “sports hernias” (now termed athletic pubalgia or core muscle injury) and was relying on me to help her understand this injury and how to treat it. In turn, she helped me understand what went on in the pelvic health profession and what those therapists were trained to treat and how they went about it.
This collaboration eventually led to me joining Herman & Wallace and offering a sports and orthopedic perspective to pelvic floor consideration. I have attended Herman & Wallace’s Pelvic Floor courses to fully understand the training that a pelvic health therapist undergoes. Admittedly, I do not perform internal work because I have found a niche helping clinicians such as myself who understand that the pelvic floor is a key variable in human movement and we need to understand it at a much higher level than what we are exposed to in school, but don’t have the career trajectory of becoming an internal practitioner of the pelvic floor.
I have designed the Athletes and Pelvic Rehabilitation course to reach both the sports and orthopedic clinician as well as the pelvic health practitioner who might be a veteran of pelvic floor education and treatment. Both groups will leave this course with additional tools for their clinical tool box in the realms of manual therapy and exercise.2 Here are some of the objectives for the course:
What do people who have attended courses with Dr. Dischiavi have to say? Janna wrote the following email to Herman & Wallace about Steve's Course:
"Good morning. I wanted to make sure that you knew what a fantastic clinician you have to join your team in Steve Dischiavi. I am a practicing OB and orthopedic therapist and felt this course was fantastic! Usually the main goal is to come away with a couple of clinical "pearls." I felt as though I came away with a full days worth of "pearls." I really liked that the course was not totally pelvic floor based, however was totally relevant to the women's health population, but it will also apply to the majority of my current patient population as well. Thank you for the opportunity to learn from Steve!"
1. Orchard JW. Men at higher risk of groin injuries in elite team sports: a systematic review. Br J Sports Med. 2015;49(12):798-802.
2. Tuttle L. The Role of the Obturator Internus Muscle in Pelvic Floor Function. Journal of Women’s Health Physical Therapy. 2016;40(1):15-19.
Dr. Dischiavi is a Herman & Wallace faculty member who authored and teaches Biomechanical Assessment of the Hip & Pelvis: Manual Movement Therapy and the Myofascial Sling System, available this August in Boston, MA.
STEM is an acronym for science, technology, engineering, and math. These fields are deeply intertwined and taking this approach could potentially be a way to facilitate the physical therapist’s appreciation of human movement.
Science: I would bet most physical therapists would agree that science is the cornerstone of our profession. It is time to look across all the landscapes of science to better understand the physical principles that govern movement. Biotensegrity is a great example of how science from a field such as cellular biology can help possibly explain how we maintain an erect posture when the rigid bony structure of our skeleton is only connected from bone to bone by soft tissues . The brain and central nervous system regulates muscle tone, and it is resting muscle tone that give our bodies the ability to be upright. Without resting muscle tone, we would crumple to the ground as a heap of bones within a bag of skin. Since the CNS can either up or down regulate muscle tone, this allows us to create the rigidity we need to accomplish higher level movements such as sport, and then return to a resting state after the movements are performed (see running skeleton picture below). This theory of organismic support was bred within the scientific field of cellular biology, and can potentially be applied effectively to the human organism. As physical therapists, I agree we need to be skeptical of new ideas, but we also need to embrace the idea that the physical sciences have applied to nature for centuries, and it is possible these various scientific fields can help us unlock new ideas and allow us to look at things through a different lens.
Technology: As not only a practicing physical therapist, but as a newly appointed assistant professor within a budding physical therapy program it is my duty to embrace evidence based practice. I believe without question, when evidence that is sound exists it should help direct patient care. It is also clear that our tests and measures that are currently being utilized to help develop new evidence are lacking, specifically with regard to human movement and sport performance.
Sports performance is such a complex system (more on this later) we can’t expect to study things such as injury prevention at slow speeds utilizing maneuvers that aren’t even seen in the sport itself. Recently, Bahr  suggested that screening for sports injuries is pretty much a futile effort as he titled his article “Why screening tests to predict injury do not work - and probably never will…: a critical review.” Eventually technology will need to be developed that can measure high speed movement across multiple planes and ranges of motion, and essentially capture the complex spiraling that occurs with human movement and the bodies effort to attenuate ground reaction forces. This concept can be illustrated in the current work of Tak and Langhout  who have developed a novel approach to measure hip ROM in soccer players. They have essentially performed a thorough needs analysis of the kicking motion and determined that the classical method of measuring hip ROM doesn’t take into account the body’s need to spiral itself to gain the energy in the system needed to kick a ball [Fig 1]. This global understanding of the dynamic integration of the kinetic chain (which is covered in my hip course!) is what has led them to design this new method to measure hip ROM. Now, we will need technological advancements to capture, record, and measure these types of positions across three planes and at high speeds to establish the data that will eventually lead to evidence that will translate into sport. This is a great example of how clinical innovation sometimes precedes actual evidence to support its use. As William Blake was quoted as saying “what is now proven was once only imagined.”
Engineering: Structural engineering should be included in every physical therapy education program. There are many basic structural engineering principles that directly apply to a physical therapists practice. For example, the principal of elastics is frequently discussed within structural engineering. Elastics describes to what extent deformation is proportional to the forces applied to a particular material. In physical therapy muscles are that particular material, muscles must have elasticity and extensibility, not flexibility! In elastics, a rubber band is often used as a simple example to explain this engineering concept.
A rubber band will elongate and develop potential energy until release and then unleash kinetic energy. Our human movement system relies heavily on the principle of elastics. The rectus femoris is a two-joint muscle across the hip. During gait and running the rectus femoris is elongated as the hip moves into extension, this elongation builds its potential energy until the foot comes off the ground to initiate the swing phase, and the kinetic energy released in the system allows momentum to carry the lower extremity forward.
I would add that possibly the twisting created by the contralateral counter trunk rotation and reciprocating arm and leg swing that accompanies the hip extension is what creates tension throughout the entire anterior chain, similar to why Tak and Langhout feel its important to take up all soft tissue slack three dimensionally to effectively measure hip ROM needed for a soccer kick. It is considering that the elasticity in the entire system (organism) is needed to create an efficient human movement, which is kicking a ball in this example. When the body utilizes passive lengthening of muscle chains, as in elastics, it allows the body to move more efficiently. This is described by Chu  who reports that in the pitching motion maximizing force development in the large muscles of the core and legs produces more than 51%- 55% of the kinetic energy that is transferred to the hand [Fig 2]. The thoracolumbar fascia is involved in the kinetic chain during throwing activities and connects the lower limbs through the gluteus maximus muscle to the upper limbs through the latissimus dorsi. This idea of a dynamic integration of the kinetic chain is the main concept of the exercise portion of my hip course!
Math: The dynamic systems theory is an area of mathematics that most physical therapists probably don’t consider during everyday treatment. Little do they know, every treatment decision we as therapists make for our patient/clients has some root found in the dynamic systems theory. In fact, it is a fitting description when this theory is applied to human movement. Human movement is an incredibly complex system comprised of many different systems all working at the same time. Paul Glazier recently offered a Grand Unified Theory (GUT) for sports performance  and he discusses in detail the various systems and dynamic elements involved in sports performance from musculoskeletal, to neural, to cognitive, environmental, hormonal, and emotional just to name a few. The systems at work during sport when combined are exponential and most likely infinite. This is why it is so difficult to try and capture all these dynamic systems in a laboratory setting with the current technology available. In my hip course offered through Herman & Wallace I offer a novel paradigm to help clinicians construct therapeutic exercise programs using the hip as a cornerstone to human movement. I try to compact these various systems into 8 overlapping elements related to sport performance. When each of these 8 components are “exploded” as you might see in an engineering schematic where an engine is exploded to see all the parts that make the engine or more simply explained using a cheeseburger as the example [Fig 3]. Sure its easy to spot the cheeseburger when its whole just like when you see an athlete on the field running it seems obvious. Once the cheeseburger is “exploded” you can now isolate each sub-element included in your cheeseburger. This cheeseburger example is an obvious over-simplification, but if we exploded the bun to see the underlying grain and the seeds and so on…you now start to get an idea of how deep and intertwined all these subsystems are. Interestingly, the engine and the cheeseburger have finite parts and fit together, the human system has different parts in different systems depending on the sport and who might be playing it, under ever-changing scenery, and so on. So you can now see how the 8 components I outline in my course can house many different aspects of these dynamic systems. Although, I think this is progress with regard to the current state of the evidence, specifically with regard to utilizing the hip during movement, there are other systems at work that clinicians simply cannot control, such as gender, hormonal, environmental, etc…The idea is to try to identify and then manipulate modifiable factors whenever possible. These concepts are more clearly described and implemented in my hip course! Please come and check it out, and let me know what you think!
I’m hoping the STEM approach can possibly make it into physical therapy curriculums to illustrate to future physical therapists that there are many different disciplines at work with regard to physical therapy, and taking a global view of these elements can certainly be worthwhile.
1. Ingber, D.E., N. Wang, and D. Stamenovic, Tensegrity, cellular biophysics, and the mechanics of living systems. Rep Prog Phys, 2014. 77(4): p. 046603.
2. Bahr, R., Why screening tests to predict injury do not work-and probably never will...: a critical review. Br J Sports Med, 2016.
3. Tak, I., et al., Hip Range of Motion Is Lower in Professional Soccer Players With Hip and Groin Symptoms or Previous Injuries, Independent of Cam Deformities. Am J Sports Med, 2016. 44(3): p. 682-8.
4. Chu, S.K., et al., The Kinetic Chain Revisited: New Concepts on Throwing Mechanics and Injury. PM R, 2016. 8(3 Suppl): p. S69-77.
5. Glazier, P.S., Towards a Grand Unified Theory of sports performance. Hum Mov Sci, 2015.
Dr. Steve Dischiavi, MPT, DPT, SCS, ATC, COMT, a Herman & Wallace faculty member, recently co-authored a peer reviewed manuscript which reviewed hip focused exercise programs. Dr. Dischiavi currently teaches a hip related course in the Herman & Wallace curriculum titled “Biomechanical Assessment of the Hip & Pelvis: Dynamic Integration of the Myofascial Sling Systems.”
"An evidence based review of hip focused neuromuscular exercise interventions to address dynamic lower extremity valgus", published in the Journal of Sports Medicine, presents evidence related to current hip focused interventions within the physical therapy profession. We know that there has been an enormous increase in the amount of hip related diagnoses and surgeries, and this calls for better knowledge from the clinicians on how to manage these particular hip related pathologies. The review finds that insufficient research has been done "to identify and understand the mechanistic relationship between optimized biomechanics during sports and hip-focused neuromuscular exercise interventions... improved strength does not always result in changes to important biomechanical variables, and improved biomechanics in sports-related tasks does not necessarily equal improved biomechanical variables in performance of the sport itself".
Biomechanical Assessment of the Hip & Pelvis is an opportunity to explore manual movement therapy with a skilled researcher and practitioner. Dr. Dischiavi has woven a very creative and innovative philosophy to help clinicians design more comprehensive hip focused therapeutic interventions. His in-depth knowledge of the evidence has allowed him to create a program that will challenge clinicians in new ways to look at the hip, pelvis, and lower extremity and how the kinetic chain can be influenced by approaching it using a new lens.
Participants of his course will learn new ways to activate and strengthen groups of pelvic muscles that will benefit all patients from pelvic health clients, to professional athletes, to your elderly population. “All patients have the same bones, muscles, and gravitational pulls acting on them, its how they use these systems that varies significantly. A philosophical science can be generated, but the art is in implementing that science.”
Participants in the Biomechanical Assessment of the Hip & Pelvis course have enjoyed being challenged to look at the hip and pelvis in a different way. Practitioners will leave the course having learned a whole new way to develop and implement therapeutic exercises which are a different approach from the single plane non-weight bearing exercises that are traditionally prescribed to patients.
There are many courses and philosophies on how to screen for lower extremity injuries and how to evaluate movement dysfunction. What is really lacking for clinicians are options for therapeutic exercises which target the hip and pelvis in a relevant and functional manner. Most hip focused programs currently emphasize single plane movements and are dominated with concentric focused exercise. Dr. Dischiavi’s focus is targeted directly at human movement emphasizing tri-planar movements that are primarily eccentric in nature, recognizing that this is how the human body functions.
This post was written by Steven Dischiavi, MPT, DPT, ATC, COMT, CSCS, who teaches the course Biomechanical Assessment of the Hip and Pelvis. You can catch Steve teaching this course in May at Duke University in Durham, NC.
One thing that jumps out at me when treating a professional athlete, is that they have “a guy or gal” for everything! Most high profile athletes have a physical therapist, athletic trainer, acupuncturist, nutritionist, massage therapist, personal trainers for speed, power, cross fit, and pretty much “a guy or gal” for anything that has something to do with athletic performance or injury prevention. In most recent years I have been hearing more and more that athletes use someone that can analyze their movement and develop corrective exercises for them. These professionals are not just physical therapists, but some are personal trainers, exercise physiologists, chiropractors, and so on…
This has clearly been leading to a paradigm shift in not only evaluation of the athlete, but more specifically how we treat our athletes and clients. The Functional Movement Assessment is a tool that is gaining more and more popularity. It identifies “movement dysfunction” and then sets out to manage these movement patterns. I am a firm believer in functional movement assessment, and I believe it does need a larger role in our profession…I believe this so strongly I have recently changed gears professionally and have accepted an assistant professor position on the Physical Therapy faculty at High Point University. I want to affect change from within!
That said this is a very slippery slope right now in our profession. There are many people that believe that functional assessment is necessary. These same people cannot agree on the best way to do this and the there is a paucity of evidence to support a specific method at this time. This has driven me to continue to push the envelope in how to assess human movement and what is the cornerstone of this philosophy. I think the cornerstone is the hip and pelvis. I know this is somewhat broad, but after working professional hockey for 10 years I saw first hand what the hip and pelvis brings to the table. This led me to integrate this cornerstone into all facets of my treatments with all types of clients, young, old, big, small, athletic human, non-athletic humans! It was a quantum leap when the evidence caught up to practice and we stopped taping the patella because we were able to wrap our heads around the fact that it’s the track moving under the train! This momentum continues, because I am in a state of the art biomechanics lab everyday watching and learning how we can extrapolate these concepts and continue to move forward and advance movement theory. This has also allowed me to see that there is still a need about how we treat movement dysfunction. Which has led me to continue to work on the concept of the Dynamic Integration of the Myofascial Sling Systems!
If you attend this course I think you will look at human movement a little differently. I think you’ll enjoy the creative ways we can activate particular muscle chains to integrate and coordinate complex movements with more efficiency.
Yes, Herman & Wallace traditionally focuses on the women’s health practitioner. This course gives women’s health practitioners more treatment options to go with their unbelievable manual therapy skill set. This course offers many therapeutic exercise options that can help control the neurologic changes they are creating with their clients. Past course participants from the women’s health arena have continuously commented that they have gained a new tool in their toolbox to address movement imbalances and a way to integrate more function into their exercise programs. The sports and ortho PT will really enjoy this course. It will challenge some of their current paradigms and stir up some lively conversation on functional movement assessment and how to treat movement dysfunction when identified. Sports/ortho PTs consistently report how refreshing it is to consider new things in the profession. These PTs will leave this course challenging some of the traditional approaches they have taken. The reports back to me are usually that the sports/ortho PTs have had fun at this course and look forward to trying what they have learned and performed in lab sessions and applying it with their clients. I look forward to having you in class and having some fun and trying a lot of new exercises and discussing how the assessment of human movement and how identifying movement dysfunction is the direction things are going. William Blake once said “what is now proven, was once only imagined!” I don’t think movement analysis is quite proven yet, but we’re definitely applying science to the art of practice!
This post was written by H&W instructor Steve Dischiavi, MPT, DPT, ATC, COMT, CSCS. Dr. Dischiavi will be instructing the course that he wrote on "Biomechanical Assessment of the Hip and Pelvis" in Virginia this August.
In an outpatient sports medicine clinic the traditional model of physical therapy evaluation typically includes the therapist reviewing a patients chart and subjective symptom questionnaire of some sort. Then the therapist will bring the patient to an area to begin a subjective history and then onto a physical exam. After these procedures have been completed the therapist will typically assign a working clinical diagnosis and then begin treatment. In short, I would like to suggest a paradigm shift to this traditional model of thinking. Instead of starting the exam on a table with a static assessment of the structures involved and identifying the pain generator, I suggest the therapist begin with a specific set of movements used as an evaluative tool to identify movement dysfunction within the anatomical system as a whole.
All human interactions on earth occur between ground reaction force and gravity, our bodies are mostly just stuck in the middle of this constant battle and typically we succumb to whichever power exposes the weakest link in our biomechanical chains. One of the reasons the biomechanical chains in our bodies are so pliable and vulnerable to constant ground reaction force and gravity acting on them is because we are basically bones or struts suspended in a bag of skin all connected by soft tissue. Suggesting that without skin, fascia, and connective tissue supporting us, we would collapse to the ground in a pile of bones! Ingber (1997), suggested this concept, known as tensegrity, was the “architecture of life.” So in summary, the tensegrity structures are mechanically stable not because of the strength of the individual bones, but because of the way the entire human body distributes and balances mechanical stresses through the use of polyarticular muscle chains called slings. There will be more on slings in the upcoming blogs.
If there is truly a paradigm shift with the way we initially assess our clients and we begin our evaluations with whole system movement patterns it would be because we want to actually see how this tensgerity model is essentially collapsing under the stress of gravity. We would get a first hand glimpse in real time how energy leaks and blocks occur during human movement. These concepts are the foundation for the course Biomechanical Assessment of the Hip & Pelvis.
Ingber, D.E. (1997). Tensegrity: the architectural basis of cellular mechanotransduction.
Annual Review of Physiology, 59, 575-59.
Dr. Dischiavi's course is designed to elevate the participant’s skill level through advanced training in hip and pelvic biomechanics, functional “slings” created by the myofascial system, and through use of sports medicine theory and applied science. Biomechanical Assessment of The Hip & Pelvis will be taking place in August in Arlington, VA
This August, Herman & Wallace is thrilled to be offering a brand new course, Biomechanical Assessment of the Hip and Pelvis in Tampa, FL. This two-day, orthopedic course was developed and is instructed by Steven Dischiavi, MPT, DPT, ATC, COMT, CSCS.
Pelvic Rehab Report sat down with Steve to learn more about his practice, his experience in the clinic and with the Florida Panthers hockey team and this brand new course.
What can you tell us about this continuing education course that is not mentioned in the "course description" and "objectives" that are posted online?
This course was designed to bring a sports medicine approach to pelvic health clinicians. The exercise philosophy is intimately integrated into the pelvic health specialty. As a PT who currently works with a NHL hockey team I am constantly challenged by a sport dominated with pelvic injury. It was crucial for me to learn more about a specialty that has always been known to me as “women’s health.” I feel this course blends some of the knowledge of the pelvic health specialty with the sports medicine arena to develop a series of functional exercises designed to treat individuals with pelvic issues.
What inspired you to create this course?
I have seen several exercise regimes targeted at the “core” for both the highest functioning athlete to the PT client whose functional goals are far less. None of these programs target the entire human system from an anatomic, orthopedic, and neurologic approach. I was once told “all orthopedic clients are neurologic clients, but not all neurologic clients are orthopedic clients.” I think this is a good axiom to describe how you may start treating your orthopedic clients with techniques typically reserved for neurologic clients. The exercise system uses orthopedic strategies applied with a neuroscience approach all based in functional anatomy.
What resources and research were used when writing this course?
This course was bred from many different approaches and thought processes. The main influences to my philosophy come from Thomas Meyers and his work with “Anatomy Trains.” Diane Lee is a clinician whom I dearly respect and she has heavily influenced my thought process with regard to the pelvis. Although, I felt that Diane Lee’s approach to corrective exercise is where the greatest demand lay. I cite numerous studies on the hip, pelvis, and rehabilitation, all of which can be found in the course manual. The manual therapy approach I utilize is mainly influenced by the Ola Grimsby Institute, where my manual therapy certification was obtained. As with any clinician, the philosophy behind their practice is a unique blend of art and science reflective of their experiences and exposures to the profession.
Can you describe the clinical/treatment approach/techniques covered in this continuing education course?
The whole focus of this course is to allow an individual to function on a centered or balanced pelvis. This is first achieved through a sound physical exam, which will be reviewed in the course. The course will offer manual techniques to help correct pelvic imbalance. The bulk of the class is then focused on the corrective exercises and aims to strengthen the whole body functionally through movement efficiency. The class should not be thought of as a manual therapy course, although there are manual strategies offered, it is not the primary focus of the course.
Why should a therapist take this course? How can these skill sets benefit his/ her practice?
The profession of outpatient physical therapy needs to change. Fitness and wellness centers are offering more and more programs targeting areas that should remain in the realm of physical therapy. This course outlines an exercise system that can be utilized by the physical therapist to cover a wide variety of clients. These exercises can be used for an elderly client who needs to move more efficiently in order to achieve a functional task. These exercises can also be used, for example, in a circuit fashion for the highest-level athlete. I have seen success with these exercises in my private clinic as well as with the professional athletes I work with on a daily bases. The skills learned, if implemented correctly, are a great way to market more than just physical therapy to the community.
If you'd like to learn more about these techniques and approaches from Steve, don't miss his course in Tampa in August. Seats are limited, so let us know if we can save you a seat!