Reading List: December

Reading List: December

What do they want? They want to be free from concern.
— Jim Carrey, "Jim & Andy: The Great Beyond"

As a growing therapist, I believe it's crucial to take advantage of what the internet has to offer in terms of having access to knowledge of experts around the world. Here is a compiled list of the articles I've read in the month. Feel free to share with me articles that you found insightful and useful for your development as a person and as a clinician!

Many Orthopedic Surgeries Don't Work by Todd Hargrove (10 min)

  • “Instead, successful treatment for chronic knee pain, through surgery or otherwise, is probably more about creating complex changes in psychological or neurological processes, rather than altering joint structure."

  • “There is also evidence suggesting that when surgery is effective at relieving pain, it is not because of actual repair of structure. MRIs of repaired rotator cuffs taken within a year after surgery often show that the cuff has fallen apart again, even though the patient has recovered. According to Dr. Lawrence Gullotta, “When your rotator cuff is torn, you attribute all your pain and dysfunction to your torn rotator cuff, then you have it fixed and you feel better, but sometimes when you take an ultrasound or an MRI, the rotator cuff looks exactly like it did before you had the surgery.”

  • Todd Hargrove shares an exerpt from his next textbook that he is writing that exposes the literature behind specific surgeries that seem to be ineffective yet popularly used. This is a good article to read COMPLETELY through because the title itself can get everyone up in arms to take a black or white stance on whether surgeries should be a thing for pain. As with most cases it’s in the gray. Understanding which specific surgeries the patient is considering is important. As a practitioner you should have an understanding of the biases at play and do your best to guide the patient toward a well informed decision. Why do doctors trust their experience more than the evidence? Maybe because the physical therapists they send their patients to for conservative care are terrible and the placebo of surgery is better than what a poorly informed PT is providing. Just some food for thought.

Is central sensitisation a feature in tendinopathy? by Tom Goom (5 min)

  • “The involvement of psychosocial factors doesn’t guarantee that central sensitisation will be a feature. Tendon pain, especially in the lower limb, tends to be well localised and fairly load dependent (i.e. painful during activities with higher tendon loads). Local nociception may be a key factor in tendon pain, however some features, such as tenderness to palpation may suggest some central involvement leading to hypersensitivity to load but typically without spread of symptoms."

  • This article by Tom Goom is short and sweet and highlights another gray area in the current evidence on the nature of pain in tendinopathy, namely the achilles. Listening more and more to different tendinopathy research reviews, as expected, we are still far from the answer as to what drives the pain. With current research and boom of the biopsychosocial model trend, readers tend to swing towards possible central sensitization component of pains ignoring possible nociceptive component. Tendinopathy, at least for the lower limb, may have both a nociceptive and a central sensitization component. Tom Goom provides a great resource in the TendonQ for the clinician to better frame your client/patient’s LE tendon pain.

Squatting with Patellar Tendinopathy by Jason Eure (20 min)

  • “Not all tendons serve the same functional role. Tendons are classified into two distinct categories: positional tendons, which act to predominantly position limbs, or energy-storing tendons, which act more as springs to allow for more efficient movement.”

  • “The patellar tendon is an energy-storing tendon due to its specific functional role and altered physiological properties. In order to effectively store and return energy efficiently, the patellar tendon has higher elastin content, lower absolute levels of collagen, and a higher relative proportion of Type III collagen versus Type I (Type III has lower stiffness, allowing for improved extensibility and recoil) when compared to positional tendons.”

  • “Stiffness refers to the ability to resist deformation, and Young’s modulus refers to stiffness when tendon dimensions are taken into account. Alterations in material properties are believed to be the acute response to tendon loading, with significant increases noted within the first several months of training (increased stiffness reportedly ranging from 26% to 85%), and changes in morphological qualities are believed to be the chronic adaptation after years of training (increased cross-sectional area reportedly ranging from 1.5% to 36%).”

  • “Additionally, the causative mechanism of “overuse” is antiquated and perpetuates an inaccurate notion of how biological organisms respond to stress. The amount of stress required to evoke a mal-adaptive tendon response is constantly changing based upon fluctuating individual constraints.”

  • “First and foremost, we are concerned with optimal tissue loading to facilitate the desired response. There is a pervasive notion that more is better. However, as mentioned above, loading beyond our ability to adapt will have detrimental consequences and will only serve to perpetuate our cycle of frustration.”

  • “Considering these findings, it is best to space training sessions out by at least 36-48 hours to facilitate desired outcomes.”

  • “the most important time frame for careful monitoring is within the first 8 to 12 weeks from the start of rehabilitation efforts. The literary consensus is that improvements in tendon pain and function are not correlated to changes in tendon structure."

  • “Deliberate efforts should be made to account for total stress within the first three months independent of the presence of pain, and progress should be made in conservative increments.”

  • Jason Eure has produced some solid education online with regards to tendinopathy rehab. Recently I tuned into his podcast with ClinicalAthlete where he discusses the current literature surrounding tendinopathy rehab and his recommendations for assessment and intervention. What I really like about his work is that he is clear that he is not the authority on the issue, and he spends time explaining why his theories may make more sense than others. What also is important in this article is that he clearly examines the role of the patellar tendon, a specific tendon. As all therapists are looking for some reductionist understanding of rehabbing all tendons, it’s important to know that each tendon will have unique properties and demands that makes each optimal rehab protocol different.

The Pain Expert series by Lars Avemarie



  • Nothing to quote here. Lars here compiles a list of great experts within the pain rehabilitation world. People always ask me where I find my articles on pain and where they can start. Well if nothing has worked on my previous reading lists, here is a great direct link to another directory of GREAT information from the leaders in the field.

20 Minutes of Exercise May Suppress Inflammation (5 min)

  • With the click bait title I can understand why people would rather not read this, however this does provide a good window and discussion in why physical therapy is a great way to get people to cope/resolve their pains. Key points I take from this article is that as practitioners we will always have to encourage movement. Whether the anti-inflammatory properties stem from the actual physiological components to movement or the psychosocial aspect of breaking expectations, movement for some time (20 minutes) needs to be prescribed to any individual. Simply telling your patient to walk more every day is pretty useless. Instead of spending your time in the clinic doing leg raises and clam shells, spend time attempting to show to your patient that it is safe to move again. Challenge their expectations appropriately.

When Evidence Says No, But Doctors Say Yes by David Epstein (30 min)

  • “Brown had coauthored a paper that examined every randomized clinical trial that compared stent implantation with more conservative forms of treatment, and he found that stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all.”

  • “Even if a drug you take was studied in thousands of people and shown truly to save lives, chances are it won’t do that for you. The good news is, it probably won’t harm you, either. Some of the most widely prescribed medications do little of anything meaningful, good or bad, for most people who take them.”

  • “Striking the right balance between innovation and regulation is incredibly difficult, but once remedies are in use — even in the face of contrary evidence — they tend to persist.”

  • “According to Vinay Prasad, an oncologist and one of the authors of the Mayo Clinic Proceedings paper, medicine is quick to adopt practices based on shaky evidence but slow to drop them once they’ve been blown up by solid proof. “

  • “The study authors concluded that cardiologists were being influenced by the “availability heuristic,” a term coined by Nobel laureate psychologists Amos Tversky and Daniel Kahneman for the human instinct to base an important decision on an easily recalled, dramatic example, even if that example is irrelevant or incredibly rare.”

  • ““Yes, we can move a number, but that doesn’t necessarily translate to better outcomes,” says John Mandrola, a cardiac electrophysiologist in Louisville who advocates for healthy lifestyle changes. It’s tough, he says, “when patients take a pill, see their numbers improve, and think their health is improved.””

  • [Meniscus] “The sham surgery performed just as well as real surgery. Except that, in the long run, the real surgery may increase the risk of knee osteoarthritis. Also, it’s expensive, and, while APM is exceedingly safe, surgery plus physical therapy has a greater risk of side effects than just physical therapy”

  • “For one, the results of these studies do not prove that the surgery is useless, but rather that it is performed on a huge number of people who are unlikely to get any benefit.”

  • ““There’s this cognitive dissonance, or almost professional depression,” Walker says. “You think, ‘Oh my gosh, I’m a doctor, I’m going to give all these drugs because they help people.’ But I’ve almost become more fatalistic, especially in emergency medicine.” If we really wanted to make a big impact on a large number of people, Walker says, “we’d be doing a lot more diet and exercise and lifestyle stuff. That was by far the hardest thing for me to conceptually appreciate before I really started looking at studies critically.””

  • This is one powerhouse of an article that discusses the controversy in the medical field about the difficulty of implementing evidence into practice. Thought not necessarily addressing issues in physical therapy, similar themes are constantly popping up in each healthcare field. This is a great read to gain perspective on why it’s important on being aware of what and how you’re discussing with your patient as a provider and spark an urge to seek more knowledge for the better of the population you treat. It’s humbling to know how far the medical field is from perfect. It should encourage practitioners to acknowledge and take the opportunity to push the field forward.

Dizziness can have psychological consequences by Sheelah Woodhouse (10 min)

  • “dizziness may make the brain think that there is some sort of threat, causing a person to pay even more attention to their motion or the motion going on around them, particularly if predisposed to PPPD because of anxiety-related personality traits.”

  • When treating individuals with complaints of dizziness, I wasn’t aware that there was a term for a patient with PPPD. What I saw with many of these patients were similarities to that of a person with chronic pain. I recognized that such a removal from equilibrium elevates the patient’s anxiety and stress leading to a chronic cycle of pathology. It will be interesting to see how additional interventions addressing the psychosocial component for those with chronic vestibular disorders will be researched in the future.

What is Pain and Why Do We Experience It? by Ellie Somers (15 min)

  • “In the end, pain as a protective mechanism is quite amazing. It is important that when we experience a painful sensation, we work to approach it with curiosity, rather than fear, ultimately viewing pain as a friend, as our fierce protector.”

  • Ellie writes a great succinct and practical article about pain and what it means to the human body. Reconceptualizing pain as a protector is an incredibly important step in helping manage your patient’s pain. Though the blog itself is targeting the fitness field, this is a great entry point for any therapist who wants to begin learning pain for their own knowledge and to educate their patients.

Beyond the Joint: The Role of Central Nervous System Reorganizations in Chronic Musculoskeletal Disorders by Jean-Sébastien Roy, PT, PhD et al. (20 min)

  • “Overall, these changes in cortical maps or in the balance between inhibition and excitation may disrupt the facilitation of the muscles needed to execute a motor task, as well as the inhibition of other muscles for fine tuning movement.”

  • “Using a more global approach that includes retraining an appropriate movement control could therefore be an approach to favor during rehabilitation in individuals with chronic conditions.”

  • “we have argued that chronic musculoskeletal disorders may not be confined to the joint, as once thought, and that growing evidence shows that the maladaptive CNS reorganization associated with these disorders might be involved in altered joint control and chronic pain.”

  • Incredibly insightful article linking the pain science to our purpose as musculoskeletal clinicians. When reading Aches and Pains by Louis Gifford, the first thing that helped me understand pain was the idea of maladaptive behavior. As movement professionals, this provides further reason to put more focus on movement variation and exploration with our patients and less focus on passive treatment.

Therapeutic Exercise Database by Scot Morrison

  • Scot Morrison has curated this therapeutic exercise database that is SO incredibly useful. As a trusted and reliable source, Scot puts together this database that directs the reader to spend time learning the concepts behind the exercise rather than giving a patient an exercise that they saw on instagram this morning. I’ll need a lot of time to navigate this, but really too great of a resource to not share it.


Reading List: November

Reading List: November

Pain is a normal human experience, but also a powerful driving force to seek help.
— Louis Gifford

As a growing therapist, I believe it's crucial to take advantage of what the internet has to offer in terms of having access to knowledge of experts around the world. Here is a compiled list of the articles I've read in the month. Feel free to share with me articles that you found insightful and useful for your development as a person and as a clinician!

Listening is therapy: Patient interviewing from a pain science perspective by Ina Diener, Mark Kargela & Adriaan Louw (20 min)

  • “However, with the increased focus on TNE as a treatment, PTs may have shifted their focus too much on the treatment, leaving behind very impor- tant aspects of TNE, such as information gleaned from the interview and physical examination.”

  • “PT therefore, first needs to know how the patient is doing, their perception of their own problem, how the problem impacts their life, and vice versa, and how their lifestyle impacts their problem”

  • “Specifically, the exact intervention may not be as important as the individual expectation for the intervention”

  • “Patients experiencing pain and attending physical therapy may be particularly vulnerable, and in certain circumstances are not able, or unwilling, to carry the sole burden of their medical decisions. Using both active and reflective listening skills allows the PT to accommodate individual patient preferences and help develop and further patient capacity for autonomous decision making”

  • “Words have emotional power, and may impact the outcomes of treatment in medical settings. Studies have shown that orthopedic words trigger specific emotional reactions in healthy subjects, which are likely similar in patients with orthopedic conditions”

  • “Therefore, assessing pain needs to be done with caution. Even though a “pain rating” may be needed for third party payers, the astute PT should sparingly consider using the word “pain” in the assessment and be cognisant that the “manner in which they ask” about pain may influence a pain experience”

  • Great article by this team covering the most crucial part of this "Pain Science" trend. What frustrates me the most is that people ask about pain science as if it’s another modality or intervention that they can add to their treatment choices. Without taking time to read the literature, listen to podcasts, or picking up textbooks, the examination is swept under the rug and people bastardize the concept of pain science with catchy phrases and think you can talk away their pain. This article gives a thorough explanation on concepts to consider when doing your typical orthopedic examination with the context of pain science.

The Corrective Exercise Trap by Nick Tumminello and Jason Silvernail (20 min)

  • “As noted by Bahr, tests purporting to predict injury must go through three steps (2): 1. Identify risk factors in a prospective study design and establish cut-off values. 2. Validate the predictors and cut-off values in several different groups in separate studies. 3. Demonstrate the value of the screening and intervention program through a randomized controlled trial. According to Bahr, several studies have achieved the first step, a few have achieved the second step (with mixed results), but there have been no successful examples to date of interventions completing all three steps on a scale applicable to training”

  • “Training in a corrective system can improve the performance on the particular test battery one uses as an evaluation but does not generally translate to improved athletic performance”

  • This brings into question the hypothesis that upper body posture is reliably associated with shoulder and neck pain and therefore, the need to “correct” a proposed postural “distortion.” Posture and muscular imbalance appears to be a normal component of human variation and more likely depends largely on the type of activities performed.

  • “The proposed technique for the correction of postural deviations is to strengthen the “longer, weaker” muscles and stretch the “shorter, tighter” muscles. Although a stretching and strengthening approach to shoulder exercise had an effect on certain parameters tested by Wang et al., the resting scapular position or scapula posture remained unaltered (48). In a review of resistance exercises for postural alignment, Hrysomallis and Goodman found that no objective data was present to support the concept that exercise will lead to changes in postural deviations and it is likely that they are of insufficient duration and frequency to offset daily living activities”

  • “These above research results are extremely positive and empowering to the fitness professional. In that, they demonstrate that many fitness professionals who may have added additional steps and potential complications to the programming process by making it less about using basic principles of good personal training and more about corrective exercise evaluations have done so simply because of a common undervaluing of the benefits exercise in general offers from a therapeutic perspective.”

  • “The practical implications of this are that the fitness professional should not immediately qualify a movement pattern as a dysfunction just because it does not fit within certain standards of a given corrective exercise evaluation, and that fitness professionals can better appreciate that exercise in general is far more valuable from a therapeutic perspective than is often thought in corrective exercise belief circles.”

  • “One of the biggest training mistakes fitness professionals often make involves trying to fit the individual to the exercise instead of fitting the exercise to the individual. For example, many fitness professionals attempt to fit everyone into the mold of performing deadlifts in the conventional style with a barbell. Though well-intentioned, this approach is misguided. Given the natural and normal variations between human beings, just because some individuals can perform the conventional-style barbell deadlift, that does not mean that everyone should be expected to perform that same movement in the same manner.”

  • “Treating every exercise as an evaluation, which forces the fitness professional to pay careful attention to detail, provides some of the most meaningful data from which to make exercise prescription decisions based on individual differences.”

  • Clearly I found many gems within this article. I think this is a must read for any professional that works with exercise and movement. Nick and Jason are two great minds that I look up to and have created this thorough article to help address the ever growing bullshit in the movement industry. This is a go-to guide that encompasses strength and conditioning principles in the context of avoiding dogmatic dependence on corrective systems to guide your decisions making with your patients and clients.

The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain.  by Eyal Lederman (20 min)

  • “The lack of association between PSB factors and LBP has also important implications for what we aim to achieve and for our choice of techniques and exercise used to manage the condition. We can no longer justify the use of manual techniques to readjust, correct or balance-out the misaligned structure. There is an urgent need to redefine what the therapeutic goals are, beyond relieving the patient’s symptoms, e.g. is there any value in providing long-term maintenance/preventative treatments for asymptomatic individuals?”

  • This is one of the main articles that started me on this path of skepticism as to how physical therapy is practiced around the world. Low back pain is clearly within our wheelhouse, but are we treating it properly. This article by Lederman covers why the structural model to understanding low back pain is flawed and invites the reader to think more than just the biomechanics. Again this doesn’t mean that biomechanics isn’t important, this simply exemplifies how we don’t know as much as we claim.

Interview with Keith Waldron DPT by Mikal Solstad (15 min)

  • “With each course I got smarter and found new ways to help my patients. Nowadays, such therapists are considered eclectic. That is just a nice way of calling someone a physio-hoarder.”

  • “And don’t get me wrong, it wasn’t long ago that I was “that-physio”. You know the one … the guy with the meme-like phrases. Pain is in the brain. Know pain, know gain. The issue isn’t the tissue. It was an exciting time to be learning how powerful and important an understanding of the nervous system was, and I wanted every one of my patients to know that they needed to reshape their own understanding of why they were suffering.”

  • “More often, though, it is most important to help the patient craft their own story (over time) that affords them an opportunity to view their pain from (perhaps) a more stoic, less fearful perspective.”

  • “With a compelling narrative, any and all of the manual therapy tools and techniques at the physio’s disposal may provide short-term benefit to any given patient under specific (but as yet unknown) circumstances, and our colleagues will continue to become ever-more creative in the years ahead as they try to develop their own up-to-date, science-informed, neuromodulatory technique to market to an ever-increasingly large population of potential patients suffering with painful complaints.”

  • “Read enough to understand physiology and biology – it will help you laugh at bullshit, rather than be taken for an eventually embarrassing ride by the biologically implausible. Read about what interests you (and sometimes the stuff that doesn’t). Read about all the stuff that school didn’t teach you. Read about psychology. Read about socioeconomics and culture. Read about things like placebo, the scientific process, and patient interaction/motivational interviewing. “

  • Outstanding interview with Keith Waldron. Had a pleasure to meet him at the San Diego Pain Summit last year and wish I had talked to him more. This article covers misconceptions of pain science’s applications and how Keith has evolved as a therapist through different trends in PT. He also provides great advice for the student/new grad PT that I would definitely encourage you to read.

A neurobiologist’s attempt to understand persistent pain by Per Brodal (15 min)

  • “The complexity of the brain and the multitude of factors determining human mental life and behaviour strongly suggest that persistent pain cannot be understood by a reductionist approach alone “

  • “Nevertheless, pain is obviously not a thing that can be physically localized, in contrast to neurons and their activities (pain is not in the brain), inflammation, a herniated disc, and so forth. Neither is pain a perception: an object or event exists regardless of whether it is perceived or not, whereas a pain (e.g. in the knee) exists only as it is felt [17]. A perception may be falsified (I thought my pain was caused by a torn meniscus, but it turned out to be something else), while a sensation cannot. “

  • “The pain is exactly as the person describes it (if we exclude persons that for some reason lie); the cause of pain, however, may be located somewhere else or not be what the person believes. ‘

  • “furthermore, merely anticipation of pain activates the “pain network”, whereas perceived ability to control the intensity of an impending nociceptive stimulus reduces the network activity and subsequent pain experience”

  • “Nevertheless, it seems safe to conclude that persistent clinical pain does not necessarily have the same cerebral “signature” as acute experimental pain”

  • “to feel the body as normal, motor commands need to be matched by expected sensory feedback from the moving parts”

  • “Knowledge about neurons, transmitters, and neural networks is, however, insufficient when trying to understand and alleviate the suffering of real people. More and more detailed knowledge down to the molecular level does not answer the clinically most important questions, namely what “drives” the pain network in one person, and what determines that nociceptor signals are prevented from evoking pain in another person with very similar injury or disease? To answer such questions, we need to go beyond the biologic and mechanistic level and search for the meaning the person ascribes to the pain”

  • Terrific article by Brodal explaining mechanisms of pain at the molecular level and providing strong points as to why reductionism fails to explain the phenomenon of pain. I believe there are a lot of reasonable bits of information in this article to help conceptualize how pain works at the molecular level without the author make erroneous correlations as to how it affects the whole person.

Cupping – an Attempt to Draw Evidence (10 min)

  • “Michael Phelps’s own athletic trainer made the statement that asking him about cupping for Phelps’s performance was the equivalent of asking a famous chef about the garnish on a plate.1 One, the athletic trainer comparing himself to a famous chef speaks volumes about the ego and the role clinicians can think they have in an athlete’s performance. Two; if Thomas Keller garnishes a plate with dog shit, chances are he’s going to be questioned over it no matter how many Michelin stars he has.”

  • “No study exists supporting the claim of toxin removal via cupping, or through any modality. It is ludicrous to think our best line of defense for our immune system can suddenly become permeable in one direction for the removal of harmful toxins.”

  • “Toxin is an ambiguous term as well, no literature has even been established regarding what toxin, in what amount, or even if the removal of said toxin is harmful. Instead, this is fear mongering of taking a word with a negative connotation and using its removal as a means for justification of treatment.”

  • “Patients buying into placebo can become classically conditioned to  the modality – each time something hurts or doesn’t feel right rushing to the clinician for a fix. We as clinicians should instead be building confidence in our patients.”

  • The team at the Logic of Rehab wrote this about a year ago. As with any article that bashes on a modality, the authors raise the manual concerns of tools in the toolkit/shed/belt. At the end of the day is it necessary, does it make us better clinicians, will the patient create this mindset of “I received A and felt like B, therefore I need A in order to feel B?” If we are to be considered medical professionals, I’d like to think we’d be more aligned with the evidence and be aware of the lack thereof.

When Biomechanics Matters in the Management of Pain, Injury and a Bit of Performance by Greg Lehman (10 min)

  • “Most people could tolerate low load dynamic knee valgus or even high load dynamic knee valgus with greater than 25 degrees of knee flexion but under some conditions dynamic knee valgus is capable of “overloading” the ACL and an injury might occur.   This is a nice example where one biomechanical variable (strength) may be protective and “allow” one to ignore another biomechanical variable (technique or preparation or muscle timing).”

  • “What is interesting with this adaptability model is that it is not just about mechanics and physical workload.  Our adaptability and response to the physical workload or our “preparedness” would be influenced by other psychosocial stressors.”

  • “Our challenge as therapists is to answer the question “Expose or Protect”.  Expose suggests the person needs some new stimulus to cause a positive adaptation and Protect suggests that the removal of stimulus is more important.  Or perhaps the person is not “prepared” for the exposure.”

  • “What is not saying is that there is a “correct” way to move.  Rather, there is a way to move that is less painful for them at this point in time.  Simple.  Nor should we think that it is the biomechanics alone that is the reason for less pain.  The biomechanical change might have a greater impact on the psychosocial factors.  We’ve just always explained our treatment in a biomechanical framework.  Perhaps making movement modifications is a cognitive challenger - it confronts them with their own strength and leads to them discomfirming their view of their pain.”

  • It always comes down to how on how the therapist conceptualizes concepts to his/her patient while being aware of the different ways the patient can interpret these words. Greg Lehman delivers another blog with sobering thoughts to the current biopsychosocial hype, particular with the psychosocial. Great points are made in this article in how to communicate your thoughts to patients and when biomechanics are important to address in individuals.

Chronic Pain and Chronic Stress: Two Sides of the Same Coin? by Chadi G Abdallah and Paul Geha (20 min)

  • “The neurochemical properties of the learning circuitry and its adaptive response to chronic stress or pain are believed to be crucial in determining remission or persistence of pain and stress response beyond what is required for an evolutionary advantageous adaptive response.”

  • “release of cortisol and activation of the hippocampus are often observed following stress,35 but rarely seen after acute pain.”

  • Really solid article that addresses the neurobiology of chronic stress and pain and how there are many overlapping factors. Really informative and relays an important message to be cautious in linking stress mechanics with that of chronic pain. With the evidence at the neurobiological level, it is still not clear that the two are perfectly linked.

Mechanistic Reasoning and Science Based Physio by Kenny Venere (10 min)

  • “There are countless other examples of mechanistic reasoning that at the time appeared intuitive and physiologically sound based upon available knowledge, but actually ended up being completely wrong and and some tragic cases, harmful. This overwhelming complexity coupled with the human tendency to oversimplify can lead to significant errors in decision making when reasoning is based on what Howick describes as an empty or partial understanding of the mechanisms involved.”

  • “In physical therapy, there has been a recent swing in the proposed mechanism(s) for many of our interventions, from a strictly mechanical and structural basis towards a predominantly neurophysiological explanation. This has been a mostly welcomed change towards being less wrong, as many of our previous structural explanations for treatments have had difficulty holding up under scientific scrutiny. However, it is important to be cautious with our enthusiasm for the neurophysiological explanations of particular treatments given our likely partial understanding of the processes involved.”

  • “Manual therapy and other similar interventions have been popularly described as novel, non-threatening neurophysiological input altering a patient’s perception which very well might be true but in explaining them in such a way, we propose a mechanism so vague that it becomes meaningless. Nearly everything can be described as a novel neurophysiological input altering a patient’s perception — whether we are talking about rubbing cabbage, applying magnets, manual therapy, exercise or even a slap in the face.”

  • “The basic science that informs our mechanistic reasoning must co-exist with real world comparative clinical trial data. This is because the physiological measures and surrogate outcomes studied in basic science and early exploratory work may or may not actually influence outcomes that patients care about.”

  • Kenny writes a thought provoking article that highlights current shifts in physical therapy making a case encouraging more mechanistic reasoning while navigating results from the current research and our own outcomes with patients. The way Kenny reasons with the reader, I am to believe that this is the ideal and the gold standard as to how physical therapists should think. However with a lens of an individual who is just beginning his career in PT, I see how this mechanistic reasoning is repulsive to the therapist. Human culture has always been about results. In the infant stages of physical therapy, therapists will continue to be drawn to results skipping the mechanistic reasoning to derive ethical and just intervention to the patient. This is a constant quandary for all leaders in our physical therapy field now, and I don’t have a solution other than to continue learning as much as I can and affect those who interact with me.

The Academic Ideologies that are Dividing America by Alice Vitiello (10 min)

  • “There was nothing memorable about the presentation other than its utter absurdity. While it was original enough to earn him a spot doing something or other at America’s premier undergraduate institution, the scholarship he presented that day made no valuable contribution to the world whatsoever.”

  • “The problem is that academia creates and rewards this type of scholarship. The more outlandish, the better. Theory enables it.”

  • “The theoretical frameworks that we learn to employ — whether knowingly or unknowingly — become the lenses through which we view not just our scholarship, but the world.”

  • “The current state of affairs in the United States today is such that there is a great deal of conflict caused by the fact that theoretical “lenses” are being exported out of academia, instilled in the minds of students who don’t understand that a theoretical lens becomes a bias when you’re not aware that you’re using it.”

  • I’ve had this discussion with a couple close friends as to wondering why people choose to think they way they do. Since we currently live in a time where we can look up anything at any time, I feel that intuitively we all feel smarter. Going off the concepts well written by Alice Vitiello, I think it’s safe to say that the way we have learned through the current education system has rendered us into individuals who fail to question what we read and blinding expect that the author speaks the truth. It’s all very interesting and any discussion on this could spiral into hour long philosophical debate.

7 Ways to Reduce Risk of ACL Tear in Young Soccer Players by Ellie Somers (10 min)

  • “When I ask soccer players which leg they think is their dominant leg, 9x/10 they'll say it's their kicking leg. And while that leg is their dominant kicking leg, it's the leg that they're planting with that becomes the dominant one.”

  • “So much of the literature is showing us that a person's mental capacity to overcome, or one's psychological readiness, is paramount after sustaining an ACL injury.”

  • What I like off the bat from this article by Ellie Somers is that she makes it clear, all we can do is reduce risk of injuries… there hasn’t been a proven way yet that shows that we can PREVENT them. She provides great advice breaking down 7 important points to consider when you, as the physical therapist, are working with youth soccer players.

Excerpt from New Book: Playing With Movement by Todd Hargrove (10 min)

  • “In evaluating which program is better, we might remind ourselves of the “naturalistic fallacy”, which is the mistaken idea that whatever is “natural” is good for us, and that whatever is “unnatural” is toxic.”

  • “There is also an interesting rule of biology called Orgel’s second law which is that “evolution is cleverer than you are.” This means that animal characteristics, including behavioral instincts, that result from millions of years of natural selection are probably VERY good solutions to whatever problems they evolved to solve, and that human attempts to improve on them are likely to fail.”

  • Todd Hardgrove delivers one of the first excerpts from his upcoming new book. He consistently delivers thought provoking concepts to movement and does his best to make them applicable to the everyday mover. In this post, he discusses play and how incorporating play into our daily movement routines may overall help us in the long run. It’s a curious thought that he credits part of his rationale to the simple idea of “survival of the fittest.” I sit here thinking about what exactly does it mean to survive… longer life span, better fitness, etc? As he mentions, play should be a consideration and not a religion. At the very least it’s fun.

How Slow Breathing Induces Tranquility (5 min)

  • “The tiny cluster of neurons linking respiration to relaxation, attention, excitement and anxiety is located deep in the brainstem.”

  • “The investigators surmised that rather than regulating breathing, these neurons were spying on it instead and reporting their finding to another structure in the brainstem. This structure, the locus coeruleus, sends projections to practically every part of the brain and drives arousal: waking us from sleep, maintaining our alertness and, if excessive, triggering anxiety and distress.”

  • The article covers research done at Stanford with regards to specific neurons in the brain that are wired for breathing and also behavioral reactions. As we all should know, breathing is an important part of everything that we do, thus having it incorporated into rehab to help individuals relax and decrease accessory muscle recruitment, breathing exercises are a great adjunct. Thought this article was awesome because it is steps towards real scientific explanation of how breathing affects our bodies and perception of our bodies. Like anything else it’s great to establish sound reasoning for breathing’s positive effects rather than hearing “your diaphragm massages your vagus nerve thus causing you to become more calm.” (guess what using your accessory muscles in your neck to breath also ‘massages’ the same nerve). Better to admit that you don’t know something than educate others on something that makes sense.

The 5 Most Common Programming Myths by Nick Tumminello (10 min)

  • “A good workout plan isn't about balance. It's about addressing individual needs and helping you reach your particular goals.”

  • “But it DOES mean that the benefits core work has on performance is often misunderstood and overstated. This also means there's no need to treat core training as a universal aspect of programming that requires special emphasis.”

  • “It comes down to this: Are you using the exercise, or is the exercise using you? Given the natural variations between our bodies, it doesn't make sense to tell people that just because some lifters can do the conventional squat or deadlift that everyone should be able to do it the same way.”

  • Nick Tumminello writes about common mistakes he sees strength coaches make when designing programs for their clients. Granted I have my CSCS, I still have a ton to learn about programming for my clients. He makes a great point to stick to principles of S&C rather than techniques. In our current social media palooza of cool videos and poses, it’s good to remember that the client in front of you needs a customized program tailored to their goals in order to have an efficient and successful relationship.

    Interactions between stress and vestibular compensation – a review by Yougan Saman, D. E. Bamiou, Michael Gleeson and Mayank B. Dutia (20 min)

  • “As discussed by Joels et al. (2006), a normal stress response within the context of a learning situation focuses attention and improves learning and memory, and this may be a significant role for the vestibular-evoked stress response in facilitating compensation. However for optimal learn- ing to occur the stressor must occur at the same time and act on the same neural circuits (Joels et al., 2006), so that if for example the vestibular stress response competes with an additional stressor such as anxiety, this may prevent vestibular compensation from occurring optimally.”

  • “Significantly, patients who recovered normally had higher scores on the resiliency and coherency questionnaires, suggesting that they displayed better coping mechanisms with regard to stress. Thus the longer-term outcomes of vestibular dysfunction or damage may be rather idiosyncratic, likely to be influenced not only by the nature of the associated stress response in each patient but also by the coping mechanisms that they are able to bring into play”

  • It should come to no surprise to someone who has worked with patients or have personally experienced symptoms of vestibular disorders that stress is often involved. Within vestibular rehabilitation, relearning and re-calibration of the vestibular system is crucial for the patient’s recovery. This article highlights the impact that stress can make on learning and memory and how managing stress with a patient with vestibular issues may be worthwhile.


Reading List: September

Reading List: September

You realize when you know how to think, it empowers you far beyond those who know only what to think.
— Neil deGrasse Tyson

As a growing therapist, I believe it's crucial to take advantage of what the internet has to offer in terms of having access to knowledge of experts around the world. Here is a compiled list of the articles I've read in the month. Feel free to share with me articles that you found insightful and useful for your development as a person and as a clinician!

Energy System Development and Load Management through the Rehabilitation and Return to Play Process by Scott Morrison, Patrick Ward, Greg R duManoir (25 min)

  • "As an athlete recovers, the emphasis progresses from protecting the injured tissue, to guiding the healing process, and finally into restoring the capacity of strength and energy systems. However, this restoration of strength and capacity may not be fully realized during the athlete’s rehabilitation.”

  • “team sport athletes require fitness levels sufficient to support metabolic requirements specific to their sport and position that spans the three main metabolic pathways.”

  • Thoroughly detailed article by Scott Morrison et al that polishes the return to play considerations for athletes in terms of manipulating their metabolic systems. This will require multiple reads for me, but the overall concept is that in order to assure that your athlete is truly cleared to return to play is beyond just strength testing and special tests. The client needs a program tailored to address the multiple metabolic demands of his/her sport.

Why Your Body Is A Hypocrite by Todd Hargrove (10 min)

  • “Sometimes our knowledge and conscious thought processes about the body will affect how a body part feels. If we think that a body part is broken, degenerated, falling apart, unstable, this can make pain worse. And if we think that our body is robust, strong, and capable, this can make us feel better.”

  • “But pain is unfortunately sometimes more like the checkerboard illusion - immune to logic. People often have pain in areas where there is no damage, and sometimes in areas where there aren't even body parts! Having conscious knowledge about these facts sometimes cannot affect perception.”

  • Todd Hargrove connects the phenomenon of pain and how it relates to the topics discussed in Robert Kurzban’s book Why Everyone Else is a Hypocrite. Citing examples of how consciousness dictates how we perceive things in terms of vision, Todd discusses how it can alter and also not alter our perception of pain. This is a great article that helps bring to reality that just speaking to our patients about pain can certainly be inadequate.

‘F*ck Your Dreams’ (And Other Painful Things You Have To Hear To Be Successful) by Ryan Holiday (10 min)

  • “I try to push past the resistance and deliver the truth as I see it.”

  • “Let’s not dance around the fact that a lot of dreams aren’t sacred, beautiful things. They are bullshit. The person who claims to want to be a writer, but doesn’t do any writing. The person who wants to be a singer but actually just wants to be famous. The person who sees other people making millions with a startup and assumes it’s easy.”

  • “Nobody grows by flattery. No one benefits from chasing down a flawed dream they are not suited for or can’t properly defend.’

  • A good friend of mine, David Ly Khim, sent me this article. Having multiple conversations about this and interacting with me, you’ll learn that I’m that person who is often excessively honest about my opinions on a topic. Catering to my bias, Ryan writes an article about success is founded upon criticism not flattery. Of course apply this into a PT standpoint, I think there is a fine line to have a discussion with your colleagues and students. With a growing number of millennial new-grad physical therapists (myself included), we need to be humbled and that our dreams of a 6 figure salary, autonomy, and mentorship aren’t guaranteed as we “dream” it (well delineated by Jarod Hall and Mark Powers).

When Chronic Pain Is Not “Chronic Pain”: Lessons From 3 Decades of Pain by Alan J Taylor, Roger Kerry (15 min)

  • “His own reflection was that every single practitioner he had seen appeared to have an inherent self-belief and convincing explanation (and solution) for his pain experience.”

  • “Interestingly, the patient’s belief that something “was actually wrong” had remained with him throughout the journey. “

  • “his case study has not been chosen for any other reason than for us to reflect on the profession and the trends that physical therapists have all seen and followed over the years. It does not suggest that we should all be so skeptical that we deny that any new theory or research has value. Nor does it claim that every patient who does not respond to our therapies will have a vascular origin to their pain presentation.”

  • “It is our contention that we should embrace the ever-changing landscape, yet learn to navigate it more cautiously. We should abandon our inherent, historical herd tendencies and step back to occupy the middle ground. We should use the best of the research to guide us, yet at the same time be able to recognize bias, con icts of interest, and fashionable trends when we see them.”

  • This is a great read in JOSPT by Taylor and Kerry that goes over a case study of a man labeled with chronic leg and back pain receiving physical therapy from therapists from many different schools of thought including manual therapy, core stability, mechanical diagnosis and therapy, and pain education. The authors just highlight how the pendulum will continue to swing back and forth, trends will come and go; however the educated clinician should be able to manage the gray area knowing that nothing is a 100% gold standard for treatment.  Highly worth scouring the internet for an downloading source to read this article.

Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain by Joel E Bialosky, Mark D Bishop, Joshua Cleland (20 min)

  • “Expectation is a pertinent factor in placebo analgesia and the placebo literature supports expectation as a causative factor in patient outcomes related to musculoskeletal pain conditions. The magnitude of the placebo effect is greater in studies of the mechanisms of the placebo effect rather than studies in which the placebo intervention serves as a control.”

  • “Conversely, expectation of a pain-intensifying effect (negative predicted expectation) has been found to worsen experimental pain sensitivity.”

  • “Furthermore, these studies suggest a prognostic value for expectation in the treatment of individuals experiencing musculoskeletal pain that may surpass the type of treatment provided. Specifically, the exact intervention may not be as important as the individual expectation for the intervention.”

  • “Predicted expectations (what the patient believes will happen) currently appear more reflective of clinical outcomes related to musculoskeletal pain and should be included as prognostic indicators.”

  • “Individual expectation for a given intervention for the conservative management of musculoskeletal pain conditions may provide a pertinent variable to assist clinicians in the identification of individuals likely to respond to a given intervention.”

  • “Clinicians also should be aware when a patient has unrealistic recovery expectations, as fulfillment of expectations is predictive of outcomes related to musculoskeletal pain. Subsequently, physical therapists should establish baseline expectations for recovery and provide direction should the expectations appear unrealistic.”

  • “Differentiating between ideal expectations and predicted expectation may allow the physical therapist to appropriately direct the patient to achieve goals that are medically feasible. The discrepancy between predicted expectations related to outcomes of treatment and ideal expectations related to outcomes may factor into continued health care use by patients with chronic pain and subsequent increased health care costs.”

  • This is probably one the most pivotal articles that I read about a year back that helped me realize my role as a physical therapist when working with a patient. The expectations of a patient is a crucial part of their rehabilitation process. Having a small sample of different patient education styles from different therapists, you can find a baseline truth in all of the successful approaches where they are able to manage the patient’s expectations. Bialosky et al delivers an evidence heavy article on why catering to a patient’s expectations plays a significant role in their treatment.

Manual Therapy: More than Elaborate Swordplay by Chris Allen, Bradley Wells, Jason Silvernail (10 min)

  • “Conceptualizing manual physical therapy narrowly as a simple application of manual technique does not adequately capture the entirety or the complexity of the approach.”

  • “As physical therapists, we su er from this perception held by much of the larger medical community. Many providers refer patients to physical therapy for an intervention rather than for evaluation and treatment by a physical therapist.”

  • The authors write in JOSPT’s Letter to the Editor in Chief section in response to an article written by Joel Bialosky et al article on manual therapy and the placebo effect. The Bialosky et al article provides healthy criticism on efforts of physical therapists spending their resources on learning manual therapy from various schools. Their article suggests that manual therapy is all more or less a placebo, so why spend the time and money on them? In this letter to the editor, the authors provide an excellent counter viewpoint about how manual therapy is more than just the intervention itself, but about the ‘elaborate swordplay’ in patient education, assessment, and intervention that helps the patient realize that they are in control of their rehabilitation capability. Highly worth scouring the internet for an downloading source to read this article.

Divided We Stand by Adam Meakins (10 min)

  • “Another key barrier that contributes to the academic/clinician divide is an often archaic, dogmatic, hierarchical system that traditionally places academics at the top and clinicians as subordinates. This can, at times, make it challenging and daunting for clinicians to question, discuss and debate with academics openly, freely and con dently.”

  • “The academic tends to work with populations and pathology, whereas the clinician works with individuals and disability”

  • “Adding to this communication barrier is the disparity in understanding of the basic scienti c principles that academics and clinicians have. Unfortunately many clinicians have poor understanding of the fundamentals of scientific investigation and processes, and tend to be unaware that their day-to-day observations and clinical expertise are prone to many cognitive biases and error.”

  • Adam Meakins reflects on the divide of clinicians and academics when it comes to healthcare. He writes about the different factors that creates this chasm between the two entities and how the marriage of two are necessary to further progress the field. Reading this as a new grad physical therapists helps bring to light that mentorship quality will be variable. It is extremely crucial to have a mentor that doesn’t tell you what you should do, but present different ways as how how you can navigate a specific case. The perpetuation of different schools of thought is simply through narrow minded clinicians spreading their gospel to their ever naive students.

Pain: everything works, but nothing is effective by Korey Zimney (10 min)

  • “I want to offer this thought for the readers to ponder: An apple a day keeps the doctor away. But you can keep the doctor away and never eat an apple your whole live. It is less about the apple and more about the principle the apple represents (healthy food). When we look at some of our interventions, we maybe need to see that at times it may be less about the specific intervention and more about what those interventions represent.”

  • “My hope is that our profession can continue to understand the principles of what we provide through being more psychologically informed. Someday we might be less concerned about the methods of what we do and focus more on the principles behind them. A mind that can grasp principles will develop the methods needed for the person in front of them (and most likely it will not be your treatment of choice, but more of the patient’s treatment of choice).”

  • Korey Zimney writes for Evidence in Motion about the constant turmoil that occurs within physical therapy where interventions are compared to other interventions losing sight of the main point that we want the patient to get better. It’s important to be able to master the art of treating the patient with different methods that deem appropriate.

Enough is Enough by Jason Silvernail (10 min)

  • “When will people realize the basic facts of pain perception and pain physiology? To treat painful problems, our target is and always has been the nervous system. Some days I just get so tired of people trying to convince each other of the supreme relevance of some connective tissue they are all excited about. Enough is enough already.”

  • “People, we don't need any of these things to be important. If we are talking about pain, we are talking about something that occurs in the brain, not in the spine, or the muscles, or the joints. The nervous system and the complexity of perception and processing of pain is more than adequate as an explanatory model to drive our treatments. Approaches that target the brain or nervous tissue first would seem most concordant with the existing science. Traditional types of manual therapy are perfectly aligned with modern science if they rely on patient response to drive treatment decisions rather than stories about joint positioning, alignment, or "restrictions" of some kind.”

  • This is a post from 2010 by Jason Silvernail venting on the ever flowing trends of manual therapy. He talks about joint-heads, to fascia-heads, to muscle-heads, and goes on to say how pointless it is to pinpoint everything around one part of the puzzle. 7 years later, everything he writes here is still relevant.

Why are strength gains specific? (and why does it matter?) by Chris Beardsley (15 min)

  • “Maximizing the effectiveness of a strength training program means designing it to fit the specific goal you want to achieve.”

  • “Both heavy and light loads can increase muscular strength, but the gains in maximum strength are almost always much greater when using heavy loads. Similarly, the gains in repetition strength (muscular endurance) are usually much greater when using lighter loads (Schoenfeld et al. 2015).”

  • “Partial range of motion exercises probably improve strength at short muscle lengths because of joint-angle specific increases in neural drive. In contrast, full range of motion exercises likely improve strength at long muscle lengths because of specific gains in regional hypertrophy.”

  • “Strength gains are specific to the type of stability used in training because the need to balance in any unstable environment affects the co-ordination patterns of muscles in multi-joint exercises, increasing both synergist and antagonist activation. Training in an unstable environment leads to reduced antagonist activation and increased synergist activation, as the more complex nature of the movement is learned. These changes leads to a more efficient pattern of muscular contractions for those exact conditions of stability.”

  • “Getting strong for sport means analyzing the requirements of a sporting movement, and figuring out how force is produced in terms of muscle action (eccentric or concentric), speed (high or low velocity), range of motion (point of peak contraction), load (maximum or repetition strength), and stability (stable or less stable).”

  • Great article by Chris Beardsley covering the mutlimodal approach to strength gain and how specificity is crucial to tailor strength gains to the athlete in front of you. He provides cornerstone research that has helped structure different approaches to strength gains and why each will have their specific effect on the client.

Here's What Placebos Can Heal—And What They Can't by Simon Worrall (15 min)

  • “Do placebos and the power of the mind work? What I’ve found is yes, but not with everything. There are rules and conditions in which healing can be incredibly effective. Parkinson’s, chronic pain, irritable bowel syndrome, depression, anxiety, certain types of asthma, and autoimmune deficiencies are all very placebo-responsive. But cancer is not. Christian Science, homeopathy, or other unproven alternative medicines may make someone feel better, but when it comes to curing a life-threatening tumor, that isn’t an appropriate place to be using these methods.”

  • “The message for doctors is the importance of being more empathetic and taking more time. You may be throwing away 30 percent of your cure just by having a poor bedside manner. If you do, you can’t be surprised if people go looking for other means of healing. The witch doctors, traditional Chinese medicine practitioners, and homeopaths I spoke to all understand this.”

  • Simon Worrall interviews Eric Vance author of Suggestible You: The Curious Science of Your Brain's Ability to Deceive, Transform, and Heal. They discuss placebos and how they are administered in health care. At the foundation of the article, they discuss how powerful placebos can be and then flow into a “whatever works for you” attitude. Though I understand patient’s expectations play a huge role in their recovery, I believe establishing the patient’s self-efficacy should be prioritized first. It’s easy to endorse another profession “if it works for them,” but who's to say that other practitioner you’re referring to won’t create a cycle of dependency. Healthcare is a team approach, and alternative medicine can play a role with placebo mechanisms, but I think there needs to be a line drawn somewhere whether it be essential oils, meridian points, or other integrative medical theories.

What Makes a Truly Skilled Manual Therapist? by Jarod Hall (10 min)

  • “Study after study continues to show that we have been tricking ourselves and falling prey to every logical fallacy in the book by telling ourselves we can use our hands to feel those ever so slight differences in our patients’ bodies.”

  • “This highlights the importance of a variety of other contextual factors that are constantly at play during the course of any patient-provider interaction, such as the environment, language used, the provider’s confidence, therapeutic alliance, patient beliefs, etc. It emphasizes the need to “make pain science the air we breathe, not the thing we do.””

  • “The skill in manual therapy comes less from proficiency in performing a specific technique and more from being able to skillfully HEAR what your patient is telling you. You must be able to adjust your treatment under an umbrella of the evidence, rational thought, and skilled setting of the environment.”

  • Jarod Hall delivers another great article examining manual therapy and how as clinicians we need to frame the intervention differently than we were traditionally taught. Manual therapy as an intervention has received a ton of flack over the past decade on it’s efficacy and having each guru-incited theory invalidated by research. Now there is a movement to identify how manual therapy is key to establishing therapeutic alliance that overall leads to better outcomes for the patient. I would encourage you to read more of his articles as he challenges current topics in PT without throwing the baby out with the bath water.

Injury Prevention and Variation of Movement by Erik Meira (10 min)

  • “What many people have interpreted from that research is that those faulty mechanics CAUSE the injury and that correcting them would PREVENT the injury. But that is not what that research says at all. As a matter of fact, by correcting the athlete’s DVJ all you have done is make that test no longer predictive of anything for that athlete. You have taught them how to pass the test but may not have corrected the underlying problem.”

  • “What many people have interpreted from that research is that those faulty mechanics CAUSE the injury and that correcting them would PREVENT the injury. But that is not what that research says at all. As a matter of fact, by correcting the athlete’s DVJ all you have done is make that test no longer predictive of anything for that athlete. You have taught them how to pass the test but may not have corrected the underlying problem.”

  • “The conclusion of this for me is that we are better at telling people what they shouldn’t do (which again is pretty ugly), rather than what they should do. What is optimal for one athlete may not be what is optimal for another (especially true in elite athletes).”

  • As I’m learning more about dynamic systems, this article came up at a good time to help guide my understanding. Erik Meira writes about how physical therapy’s increasing role in injury prevention is founded upon faulty interpretation of the literature. He makes great points as to why clinicians have made assumptions that lead us to blame aberrant movement patterns for cause of injury. Good food for thought when you’re performing a movement screen on your patient.

Why a Runner's Flexibility is Overrated by Nathan Carlson (5 min)

  • “How flexible a muscle is, tells me nothing about how that runner's ability to produce force, hold a pace when fatigued, or make smart decisions in their training.”

  • “Although faster running requires a little more range of motion at the knee and hip, the best runners actually go through LESS ROM when running compared to novice runners.”

  • Nice quick article by Nathan Carlson who breaks down a common complaint and common scapegoat for running injuries. Using an impairment based model is great for physical therapists to hypothesize possible limitations to rehabilitation. However as one gets to understand the demands of the physical activity and movement of the patient that he/she wishes to return to, it’s great to have experts like Nathan to reveal the most pertinent knowledge for that individual and remove the artifact findings.

Cognitive Functional Therapy with Peter O’Sullivan by Joletta Belton (15 min)

  • “Through all of the doctors and therapists I saw over the years, not one had ever asked for my story. Sure, I’d been asked ‘tell me about your pain’ or ‘what brought you here today’ or ‘tell me about yourself’ – but as similar as they may seem they are WORLDS apart in my book.”

  • “Peter listened with such interest and attention to my every word, despite being in a large well-lit room in front of 60 some folks, that it surprised me. He didn’t interrupt me. He offered assurances and asked gentle, guided questions. I felt heard and validated, believed and cared for.”

  • “He told me it was understandable to go back there, how reasonable it was for my fears and worries to become so elevated when this new pain started. The pain in my right hip led to some really difficult times and tumultuous years, after all. To darkness and sadness and feelings of worthlessness and purposelessness.”

  • “He asked if he got it right. That, too, is IMMENSELY important. Because he might not have, but he did in my case. Even if he hadn’t, though, such a way of summarizing, reflecting and asking will let the individual say ‘heck no! Not at all!’ and help you get closer to what they meant.”

  • Joletta Belton provides the patient perspective when receiving Cognitive Functional Therapy from Peter O’Sullivan. This gives us that rare glimpse to understand the therapy session through the mind of the patient. The point is not so much about the specific intervention, but as a therapist being able to meet your patient where they are comfortable and connecting with them first before showering them with your clinical expertise. Plenty of gems in this article that sums up characteristics in communication I’ve observed in many great clinicians.

Stress, allostatic load, homeostasis, attention and pain by Joletta Belton (10 min)

  • “I have the capacity to do this right now. I’m able to give them my full attention because my bucket isn’t overflowing. Pain is barely on my radar these days, let alone sapping all my energy and attention as in years past. And I have strategies in place to help me manage what life dishes out now that I didn’t have back then.”

  • “Not all stress is bad, of course. Like with most things it falls along a continuum. Some stress is actually quite good for us. The kind of stress that allows us to grow, learn and adapt or to take chances on the things we want to do. Running is a good stress for me. So is writing.”

  • “Pain and stress aren’t two separate processes occurring independently of one another. I think it an error to look at anything going on in our human experience, not just pain, as being separate from every other part of our experience. It is all interrelated and all relevant (to varying degrees across time and across people, of course).”

  • “It took me years to stop planning my life around my pain and start living my life with pain.But pain was always there, whether I was living my life or not. And to live life, I knew I had to stop spending so much time, energy and resources on fighting pain and wishing for a different reality. Accepting what was and making space for pain afforded me ability to pursue strategies that have been shown to help alleviate the effects of toxic stress.”

  • Joletta Belton with another article updating her followers on how her progress is going. Again with the rare opportunity to understand a little about someone’s chronic pain experience, this post is loaded with great reflections on Jo's perception of pain. As clinicians find ourselves learning to talk AT patients and to blame patients for their lack of progress and stating “we’ve done everything we could for you.” But for a patient like Joletta, understanding that reconceptualizing views on pain and how it’s linked to more than a musculoskeletal “abnormality” helps empower the patient to cope with their pains. Her examination of her own toxic stress and managing her ‘cup’ reminds me of many wise words learned from Greg Lehman during his Reconciling Biomechanics with Pain Science course.


Reading List: August

Reading List: August

If anyone can refute me—show me I’m making a mistake or looking at things from the wrong perspective—I’ll gladly change. It’s the truth I’m after, and the truth never harmed anyone. What harms us is to persist in self-deceit and ignorance.
— Marcus Aurelius

As a growing therapist, I believe it's crucial to take advantage of what the internet has to offer in terms of having access to knowledge of experts around the world. Here is a compiled list of the articles I've read in the month. Feel free to share with me articles that you found insightful and useful for your development as a person and as a clinician!

The Repeated Bout Effect: A Defense of the Yellow TheraBand by Scott Morrison (15 min)

  • “When it comes to dealing with DOMS time seems to be the only good method available. Things like exercise, massage, ice, and etc don’t appear to be that beneficial. The single best way to reduce DOMS is to have previously trained at a level that prepared the body for the current workload.”

  • “In summary avoiding DOMS with our patients and athletes is likely to be a goal in majority of situations but occasionally it may be desired.”

  • “If the goal is to minimize the risk of DOMS via the RBE then  initiating rehab in the first session or two with a sub-threshold exercise dosage may be the most appropriate approach.”

  • Scott Morrison writes about the Repeated Bout Effect, and how it can be implemented with specific patient populations to optimize their strength gains in rehabilitation. He explains how each patient can be subgrouped into different levels of fear of pain, and that those with higher fears of pain could benefit from the avoidance of DOMs and the use of RBE to promote strengthening and discourage pain catastrophization.

Argument and the Ever-shifting Goalposts by Jason Eure (15 min)

  • “While we (sadly) can’t influence physical goalposts to this extent, this happens metaphorically during many arguments — evidential standards are arbitrarily altered in order to make a counter-argument inadequate or insufficient. This is an informal fallacy known as (wait for it) ... shifting the goalposts.”

  • “When cupping garnered national headlines, the conversations which inevitably followed closely mirrored those being had concerning topics such as manual therapy, therapeutic dry needling, taping, craniosacral therapy, or any other modality with varying levels of evidential support. This is because the current discussion is merely a proxy for the larger conversation often not being had — the differing opinions on how we are able to determine clinical efficacy, the validity of specific mechanisms behind treatment approaches, and/or how we value treatments which may only provide relief through non-specific mechanisms.”

  • “Importantly, this does not mean your values and beliefs are fragile and subject to change when confronted with any retort. Instead, as is consistent with Bayes theorem, you should weigh the quality of evidence provided and judge it against the pre-existing body of knowledge. This process allows our thoughts and opinions to be more nuanced and granulated rather than conforming to a simple dichotomy of right/wrong or yes/no. “

  • Jason Eure writes about the nature of controversies in the physical therapy profession. He breaks down why we have arguments over seemingly similar topics and suggests an extremely rational and responsible way of filtering and processing new evidence and information as more and more information is revealed.

Platonically irrational: How much did Plato know about behavioural economics and cognitive biases? Pretty much everything, it turns out.  by Nick Romeo (20 min)

  • “He depicts people believing what they want or what they are predisposed to believe (confirmation bias); asserting whatever comes most readily to mind (availability bias); reversing their opinions about identical propositions based on the language in which the propositions are presented (framing); refusing to relinquish current opinions simply because these happen to be the opinions they currently possess (a cognitive version of loss aversion); making false inferences based on the size and representativeness of a sample of a broader population (representativeness heuristic); and judging new information based on salient current information (a version of anchoring).”

  • “Only by rechecking arguments both for validity and soundness, and becoming acutely aware of our own susceptibility to certain forms of deception, are we likely to get closer to the truth.”

  • “Distinguishing relative and absolute magnitudes of objects outside the body is one thing, but what happens when we are judging the quantity of a sensation – perhaps represented as a number on a pain scale – that pervades our sensory awareness at every conscious moment? After experiencing terrible pain, for instance, the absence of that pain feels wonderful, just as the sudden absence of a sublime pleasure can be wrenchingly painful.”

  • “Intellectual humility and overconfidence can stem from purely cognitive processes, but they are also correctly understood as moral achievements or failings. Someone who always thinks that he is right about everything, however little he knows, is making a moral as well as a mental mistake.”

  • “While intelligence might provide some protection against the seductions of such words, a lack of pretentiousness would also be an asset. Like overconfidence, pretentiousness has a moral valence. Avoiding it is not only a matter of debugging some glitch in our mental software, it’s a moral achievement.”

  • This article is loaded with gems stemming from great philosophers of the past. My buddy Cameron has pushed a lot of philosophy onto me. Having read some works here and there, I’ve gained an appreciation for philosophy and how it applies to my clinical development and practice. Though it’s not for everyone, behavioral economics is the foundation as to why we do things, and understanding this can help you navigate a more ethical path in improving as a PT for yourself and your patients.

Does Excessive Sitting Shorten the Hip Flexors? by Todd Hargrove (10 min)

  • “It is well known that completely immobilizing a joint for an extended period of time can lead to loss of muscle sarcomeres and contracture and cross linking of connective tissue. However, it appears that one can fully prevent any negative effects of extended immobilization on tissue length with only short and infrequent bouts of movement. “

  • “Many people sleep on their sides with their hips flexed at ninety degrees for eight hour stretches. Hunter gatherers surely spend many hours a day sitting on the ground with flexed hips, and in a deep squat position, which involves far more hip flexion than sitting in a chair. Why would sitting in a chair tend to shorten the hip flexors any more than these completely natural uses of the limbs? Surely human joints evolved so they do not start to knit themselves together after a few hours in the same position.”

  • Todd Hargrove writes about the myths of shortened hip flexors and prolonged sitting positions. He provides thoughtful reasons as to why this theory is heavily flawed. Going along the idea of preventing negative patient beliefs, it may be a good idea to avoid hammering this myth into their beliefs.

A Systems Perspective on Motor Control, Part One by Todd Hargrove (20 min)

  • “For Thelen, this is a direct challenge to the idea that development has fixed rules or stages that infants must pass through. Instead, development is very individual, depends to a great extent on context, and has multiple pathways to success.”

  • “Humans are complex systems that have an amazing capacity to self-organize. If you give them the right motivation, environment, and task to perform, they will find good movement solutions, often with great speed and efficiency. The proper role of a coach is often not so much about telling people how to move, but creating the right conditions for learning and then getting out of the way.”

  • Todd Hargrove gives an introduction to dynamic systems theory (DST) in this article. He spends times introducing concepts that many therapists are intuitively implementing in their practice, but organizes these concepts into DST. What I take from this blog is the idea that we can change instruction to patients by simplifying external cues we give them. According to Todd, DST highlights natural movement patterns that can be elicited with specific environments using a “bottom-up” approach.

Can Pain Be A Tip With No Iceberg? by Todd Hargrove (10 min)

  • “According to Boorsboom, the problem is not some hidden X factor causing all the symptoms. Instead, it’s the way the symptoms mutually support one another in a network of relationships.”

  • “Practitioners with a more biomedical orientation might think this treatment plan will fail because it does not identify the underlying disease, the true prime mover for the pain.”

  • Todd Hargrove writes an article inspired by a facebook post from Diane Jacobs. Understanding that pain often can be a result of a complex web of factors, finding and addressing these factors should be the first step. Obsessing in finding the ONE linchpin that will fix the patient can be a waste of time and resources.

The Science Behind Why assessing and blaming Posture for Pain is BS by Ben Cormack (15 min)

  • “Way back in 1990 this was explored by Heino et al HERE and they found that the angle of someones pelvic tilt and their lumbar curve do not simply correlate! So looking at the position of the pelvis tells us very little about what is occurring at the lumbar spine, which is much harder to measure.”

  • “Anyway, back to the standing measurement paper HERE. The authors explored the variability in standing posture of 400 people, 332 without pain and 83 with low back pain, and they found that each time we stand we do it in a slightly different way.”

  • “The authors also suggest that scapular dyskinesis actually represents normal variability between humans! Perhaps if they assessed it multiple times it would throw up different measures each time?! It is important to remember we have no scientifically defined ‘good posture’ to base deviations from in the first place.”

  • Ben Cormack delivers a beautifully offensive article on the myth of pain and posture. Clearly reading this with my bias, I was excited to see the endless amounts of papers that he cites to back the claim that posture really doesn’t have as big effect on pain as most clinicians who deal with pain believe.

Tissue Changes and Pain: Explaining their Relevance by Greg Lehman (10 min)

  • “Kindling is not a fire. Its a precursor and before it can become a fire you need some accelerant or spark. We can view degenerative changes the same way. They aren't sufficient for pain but perhaps you need some sort of sensitizing agent to create that "spark' and the "fire" of pain.”

  • “Roughly, we can do two things: 1. We have to change the sensitizing agent and this can be done a number of ways. Or 2. we build our tolerance to the sensitizing agent or the structural change.”

  • Greg Lehman writes an article addressing the idea of degeneration in the spine and comparing it to wrinkles. It was great to see him teach this in his Reconciling Biomechanics with Pain Science course. I personally like his cup analogy and helping build people’s tolerance to multiple factors instead of trying to eliminate them.

Comprehensive Capacity: An Alternative to the Kinesiopathological Model for Shoulder Function by Greg Lehman (15 min)

  • “It is reasonable for a therapist to look at the correlation data and see that sometimes people with shoulder pain move differently.  A reasonable intervention would be to change their movement habits/behaviours.  But this is different than saying we have to change how their shoulder moves to the presumed ideal shoulder movement.”

  • “Since we can't say what is ideal movement we suggest that the shoulder joint, the scapula, the thorax and everything connected by functioning as best they can. Ideal function in this case being that every joint is maximizes all of its Biomotor abilities (strength, endurance, ROM, power etc).”

  • “If your patient consistently raises their arm with their shoulder blade down and back and this hurts then perhaps you teach them other ways to do it. Then look at the activities that your patient wants to do and slowly build up their capacity to tolerate those activities. You are choosing exercises based on what the joint is potentially capable of and what might need to tolerate in the future rather than nitpicking about timing and position.”

  • Greg Lehman breaks down the foundational myth of scapular dyskinesia and makes a strong argument that there isn’t one ideal movement pattern of the shoulder. Without strong evidence backing scapular dyskinesia, he breaks down strategies that he uses to treat patients with shoulder pains and provides great clinical frameworks to work off of.

This Is How We Roll: Getting the Most out of Your Foam Rolling Sessions by Kate Wason (5 min)

  • "Do whatever feels best.  Again, you cannot really make physiological changes to your tissue with a block of foam – the beneficial effects of foam rolling are mostly neural in nature."
  • Kate Wason echoes the identical spiel I give to patients about foam rolling. As the world becomes for fitness conscious, this question comes up from time to time with friends, family, and patients. People make pretty large claims about the significance of foam rolling, but you all should understand that it's just another way to relax tissue. Try it. Do if it helps, don't do it if it doesn't. 

How to allay the fear of rupture among patients with Achilles pain by Peter Malliaras (10 min)

  • “They showed that only 20% among 891 tendons that spontaneously ruptured were previously painful. They prospectively recruited ruptured tendons that presented for treatment. They also took biopsies from the torn tendon and showed that almost all (about 98%) would have had tendon pathology prior to rupture.”

  • Peter Malliaras writes about achilles tendon ruptures and their predisposing factors and prevalence. He reviewed a retrospective study that found that only 1/5th of the patients who had achilles tendon rupture had pain prior to it. Understanding the chances of a patient with achilles tendinopathy developing an achilles rupture is low. When treating patients with these fears, it’s good to have this information to help prevent some of the catastrophization that could occur.

2017 Hits : Vol. 1 : Clinical – Shock Absorption by Aaron Swanson (15 min)

  • “Sometimes we know why someone has pain when they run without even looking at them.  These are the patients we put on the treadmill and before we can even look it sounds like the Jurassic Park T-Rex scene… In other words, they’re not accepting force very gracefully.  Their ground reaction force is not being attenuated efficiently.  Their shock absorption sucks.”

  • “There are an infinite number of ways to compensate. Especially when fatigued.  Maybe one of them is to avoid the energy expense of shock absorption?  ITBS runners might be avoiding the global lower extremity pronation to avoid “wasting” energy on shock absorption.  “Regardless, In the runners with ITBS, fatigue was associated with a mean peak hip adduction angle that was 3° smaller than in the uninjured runners, which translated to an 18.5% difference between the groups”.”

  • Aaron Swanson has a fantastic website full of his thoughts on movement and rehabilitation. Scrolling through his huge list of articles in his “2017 Hits: Volume 1” catalogue, I started with this article. He breaks down the evidence that demonstrates the importance of shock absorption and what factors can affect it.

2017 Hits : Vol. 1 : Clinical Spine by Aaron Swanson (15 min)

  • “It’s more than a chin-tuck and lift.  “Elder women with cervicogenic headache had significantly reduced rCSAs of the rectus capitis posterior major and multifidus muscles compared to controls (p < 0.05). Larger amounts of fat infiltrates were also observed in the rectus capitis posterior major and minor and splenius capitis muscles in the cervicogenic headache group (p < 0.05). There were no changes in the size and fat infiltrate in the cervical flexor muscles (p > 0.05).””

  • “The veins leaving the vertebral bodies are the only veins in the body that lack valves. They may act as hydraulic shock dampeners. Which is another reason why a healthy cardiovascular system is such an important variable in low back patients.”

  • “Just because it’s complex doesn’t mean we still can’t take care of the simple things while we try to solve the bigger problem. ‪Muscular endurance (back extension) may be protective against back pain‬.  And the balance of muscle endurance (flexion, extension, lateral) also seems to be important (here, here, here, here, here, here).  #GetThemExercising #Safely.”

  • “We’re currently in a time where lumbar flexion is in vogue and lumbar extension is a sign of the devil.  I’m definitely guilty of jumping on this bandwagon.  I even wrote an article 4 years ago on how we need to do a better job of controlling our anterior core to avoid excessive extension.  These concepts are still valid, but have we let the pendulum swing too far to the other side?  Are we losing our ability to extend?  Are we ignoring back endurance and strength because we’re too worried about extension?  Being weak and fatigued is never a good plan of care.”

  • Aaron Swanson publishes his bullet points of clinical gems related to the spine in this article. These are points that you’d expect to learn when you have the opportunity to shadow or observe a master clinician. Give this list a read, digest it and don’t get offended. There is a lot more to learn about and as he put it “Maybe instead of swinging back and forth with the trends we should embrace it all and focus on better identifying what the patient in front of us needs.”


Reading List: July

Reading List: July

To improve is to change; to be perfect is to change often.
— Winston Churchill

As a growing therapist, I believe it's crucial to take advantage of what the internet has to offer in terms of having access to knowledge of experts around the world. Here is a compiled list of the articles I've read in the month. Feel free to share with me articles that you found insightful and useful for your development as a person and as a clinician!


The Wellness Epidemic: Why are so many privileged people feeling so sick? Luckily, there’s no shortage of cures. (20 min)

  • “Four decades later, wellness is not only a word you hear every day; it’s a global industry worth billions — one that includes wellness tourism, alternative medicine, and anti-aging treatments.”

  • “Spend a little time in the wellness world, and it seems like everyone has an official diagnosis.”

  • This lengthy article touches upon different ways “wellness” has flourished. As a physical therapist, I believe the concepts of wellness is so important; however in a world of people addicted to looking better, looking younger, and feeling more healthy, the wellness industry looks to capitalize off of everyone. It’s too bad that there is so much distraction from the truth and the facts of what people can actually do to make improvements in their lives without the BS alternative supplemental products.

Flush Your Stool Down The Funnel (10 min)

  • “EBM is another epistemology. Those three concepts are NOT equal components that are weighed individually. They are a series of epistemological principles to guide the provider to the most accurate objective information regarding the patient in front of them. The patient’s values and circumstances are then applied for final decision making.”

  • “Now that you have all that evidence you must make sense of it collectively. As I mentioned before, you can find evidence to support anything. The goal isn’t to find support for an idea but to find the most accurate understanding. The most accurate understanding will stand up to all of the evidence.”

  • Erik Meira breaks down the problem with current EBM from the point of view of physical therapy. As I am about to become licensed PT, I’m aware that there will be biases in every clinic I work for. I understand that “it works for me” will almost always take priority over any other rational thinking. I also understand that these are people just trying to do their job, lead happy lives, provide for a family, etc. Aiming to be a leader in the field, I aim to do my best to keep my practice updated based off the current evidence and hoping that I can positively influence other PTs.

Burnout lessons from a Navy SEAL (15 min)

  • “They don’t fight against the way their brain is wired — they build their lives around it. They play offense, not defense.”

  • “But when I reframed hard work from causing burnout to giving me more energy, it started a snowball effect on how I prioritized, and everything changed.”

  • Ramit Sethi is one of the most influential thought leaders that has written books and blogs inspiring individuals to be smart with their money and also help shape them into better thinkers. In this blog he talks about burnout and how he reframes his perception of hard work. I believe over the past years, I’ve been able to recalibrate what hard work means to me and understands that it doesn’t have to equal exhaustion, negativity, or harm. 

Placebo effects are weak: regression to the mean is the main reason ineffective treatments appear to work (20 min)

  • “So the placebo effect, though a real phenomenon, seems to be quite small. In most cases it is so small that it would be barely perceptible to most patients. Most of the reason why so many people think that medicines work when they don’t isn’t a result of the placebo response, but it’s the result of a statistical artifact.”

  • Great article explaining the concept of “regression to the mean” and how it can apply in healthcare. Understanding that most of the time the patients will get better over time is a very important thing to keep in mind. Patients will come to us as clinicians looking for help when they are at their worse. It is likely whatever we do to them will result in a decrease of symptoms simply because the body’s way of adaptation and healing itself. We are not gods of movement. We just spent extra time in school understanding it a little better than the average human.

I’m just a physio… (10 min)

  • “Unfortunately most physios seem to think if they are not doing something to someone then they are not true physios. It appears that most physios suffer with inadequacy issues, inferiority complexes, or small person syndrome. Many physio’s feel the need to exaggerate and inflate what they do to make themselves feels more important and more worthwhile in the eyes of their patients, their peers, and other healthcare colleagues. Most physios do not see the value in good, simple, honest, education and exercise.”

  • Adam Meakins reminds us what our primary goals are as physical therapists. Despite his strong stances on many controversial topics in PT, I believe he is a solid example of how physical therapists should be. At the end of the day we are physical therapists. Patients can call us whatever they want, but we need to remember that we’re just a bunch of sherpas helping people get better. Our basic skills and knowledge of movement and exercise is plenty enough to help someone get back to what they love doing.

The Devil Is In The Dosage (15 min)

  • “We want to be the ones to “fix” patients instead of helping them realize it will be the patients who ultimately heal themselves. The best we can do is shift the odds of an outcome in the most favorable direction.”

  • “The emphasis on diagnosis in our education leads us to think we can have more influence over long term outcomes than has been shown to be the case in the literature. Unfortunately, this has created a situation where efficacy of treatment methods and physiology are sorely lacking in clinician education.”

  • “To tell an athlete that we can prevent injury is a lie, and that lie is told far too often in the training and rehabilitation community. We are not fortune tellers, but risk managers”

  • The team at The Logic of Rehab lay down a nice article about our role as clinicians working with patients, clients, and athletes. They do a great job breaking down as to why we can’t necessarily “prevent” injuries and reframing our role with the rehabilitation of those who come to us.

Orthopedic/Strength & Conditioning

The corrective exercise trap (5 min)

  • “Corrective exercise is built on wishful thinking. Screening for movement dysfunctions has been failing one fair scientific test after another. The importance of posture has been wildly exaggerated. The importance of anatomical variation has been virtually ignored.”

  • “The practical implications of this are that the fitness professional should not immediately qualify a movement pattern as a dysfunction just because it does not fit within certain standards of a given corrective exercise evaluation, and that fitness professionals can better appreciate that exercise in general is far more valuable from a therapeutic perspective than is often thought in corrective exercise belief circles.”

  • Paul Ingraham gives a brief summary of the work of Nick Tumminello’s and Jason Silvernail’s recent work with the NCSA. They break down the myths and misleading dogma of corrective exercises and functional movement screens that has been plaguing the fitness and rehab fields. Each of these authors are incredibly respectable individuals, and I plan on reading the full text via the NCSA soon. 

6 Keys to Shoulder Instability Rehabilitation (10 min)

  • “Conversely, a patient presenting with atraumatic instability often presents with a history of repetitive injuries and symptomatic complaints. Often the patient does not complain of a single instability episode but rather a feeling of shoulder laxity or an inability to perform specific tasks. Rehabilitation for this patient should focus on early proprioception training, dynamic stabilization drills, neuromuscular control, scapular muscle exercises and muscle strengthening exercises to enhance dynamic stability due to the unique characteristic of excessive capsular laxity and capsular redundancy in this type of patient.”

  • “If the patient frequently performs an overhead motion or sporting activities such as a tennis, volleyball or a throwing sport, then the rehabilitation program should include sport specific dynamic stabilization exercises, neuromuscular control drills and plyometric exercises in the overhead position once full, pain free ROM and adequate strength has been achieved.”

  • Heading into my last affiliation in an outpatient orthopedic setting, I had to review the basics. Mike Reinold is always a great resource providing straight shooting information on how to treat the orthopedic patient.

Rehabilitation, Restoration, and Reconditioning with Doug Kechijian (15 min)

  • “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.”

  • “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.”

  • “This story is worth telling because extreme aversion to imaging is just as egregious as its overutilization.”

  • Freelap does an interview with Doug Kechijian who goes into different topics covering physical therapists vs personal trainers, pain science, and imaging. It seems that the therapists who really get it are those who don’t swing the pendulum too far in one direction. He notes multiple times of the current understanding and trends in the field and really recognizes it is important to be aware of the biases that come forth with those beliefs.

Isometrics for tendon pain - is the hype justified? (10 min)

  • “probably the best thing to do is experiment with load (regardless of contraction type) and find the ‘entry point’ to achieve a positive response from an individual. Some patients need a softly softly approach, others you can escalate load sharply, others need lots of reassurance/education. Be prepared to play and try things! For example, some of my patellar tendon patients may spend 15-20 minutes gently developing load intensity to allow a positive response from load.”

  • Peter Malliarias is reviews an article on the effects of isometrics and it’s temporary benefits. What I liked about this post is that he spends time finding related research to form the idea that there isn’t one way to do something, and in this case isometrics doesn’t have to be this panacea. His last point that I highlighted in the quote above really just shows how he recognizes the limitations to research and the importance of clinical expertise. It’s always humbling to see someone like Peter who takes time to be humble and transparent about his practice and show how much he’s still looking to learn.

Pain Science

Elicit a Prediction (10 min)

  • “The point is for us to use our skills of interaction to assist the patient in coming to an idea that will be helpful to them.”

  • Cory Blickenstaff writes a 3 part series on interacting with the patient to help them overcome their own biases and expectations. In this first installment he discusses how it’s important to listen to the patient thoroughly, but also guide them to a specific conclusion about their aches and pains that can proven wrong in order for them to change their understanding of their pain.

Set up an Experiment (10 min)

  • “I have also long argued that our role as therapists is not that of one who makes the change for the patient. We don’t take pain away or heal pain. Instead, we set up the scenario in which the patient comes to their own conclusions and makes their own changes. We are context architects.  We don’t perform the experiment. We set up the lab for the patient to run their own experiments. We are Alfred, not Batman.”

  • The concepts covered in this blog are one of the first things I’ve learned from Cory. In the second part of his series, he talks about about how after you establish a specific understanding of the patient’s pains, work to create activities that will challenge that notion. When I say challenge, I don’t mean to put them into pain, but more so to give them different positions in which the specific motions that hurt them don’t. Context architects largely defines what we do as physical therapists.

Build Confidence (10 min)

  • “First is that the prediction is not staying static. It gets updated based on the new information. We have a role here in continuing to elicit the changes in the predictions in a measurable way.”

  • “What is very cool is that we can teach this process of “predict -> test -> repeat” as a skill to our patients. We can help them use their creativity to come up with ways to test and progress on their own.”

  • Pulling from the Craske paper on maximizing exposure therapy, Cory talks about the driving home factor of his 3 step process: refuting expectation. It’s important to instill new confidence in the patient, and show them through movement that their idea of what causes pain may not be as accurate as they think it. As movement specialists, I think this is our bread and butter of our intervention. Strengthening and conditioning of course is a huge component to what we do, but if we cannot get them to take that first step because of pain-avoidant behavior, we are rendered useless in their recovery.