If you want to assert a truth, first make sure it’s not just an opinion that you desperately want to be true.
— 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!


Paradigms

Why Do Muscles Feel Tight? (10-15 min read)

  • I really like how Todd Hargrove explains what tightness means to him. Since I began my journey of my own aches and pains, I’ve been notorious for having “tight” everything. I believe it’s easy for young clinicians, if not all clinicians, to harp on this perception of tightness and create a scenario that their hands are necessary and can fix the problem.

  • “For example, I have many clients tell me their hamstrings feel tight, but they can easily put their palms to the floor in a forward bend. I also have clients whose hamstrings don't feel tight at all, and they can barely get their hands past their knees. So the feeling of tightness is not an accurate measurement of range of motion.”

  • “So tension is not a threat, but the absence of adequate rest or blood flow is a threat, which could cause metabolic stress and activate chemical nociceptors. So the problem that a feeling of tightness is trying to warn us about is not the existence of tension, but the frequency of tension or the lack of blood flow (especially to nerves, which are very blood thirsty.)”

  • “But, as noted above, most people who suffer from chronic tightness have already tried and failed at this strategy [stretching], which suggests the issue is less about bad mechanics and more about increased sensitivity.”

  • “In fact, full range of motion strength training can increase flexibility, perhaps more than stretching. It creates local adaptations in muscle that may improve endurance and make them less likely to suffer metabolic distress. And exercise also has an analgesic effect and can lower levels of inflammation that cause nervous system sensitivity.”

Your Back Is Not Out of Alignment (30-45 min read)

  • This is one heck of an article by Paul Ingraham. He dives into a 4 part lengthy text about how the current field of physical therapy has this over emphasis of biomechanical models and alignment in treating pain. Providing great evidence, rationale, and clinical expertise, he explains why again it’s not as big of the pie as everyone else claims it to be when it comes to reasons for patients’ pains.

  • “To understand injuries and pain problems and to recover from them more effectively, both patients and professionals need to stop trying to think of the body as a machine that breaks down, and start thinking more in terms of squishy, messy physiology, especially neurology and biochemistry. Pain itself is much weirder and more useful to understand than the many mechanical glitches that supposedly cause it.”

  • ““The warning” is the most common way that structuralism can do harm. It is often a part of the sales pitch for a structural diagnosis. It simultaneously offers the client a pleasingly simplistic explanation for their pain, and yet it also manages to frighten patients into paying for therapy for the wrong reasons. Much worse, and ironically, it can probably frighten them right into real pain or pain chronicity, in some cases, via a nocebo effect — the opposite of a placebo.”

  • “It is difficult to get a therapist to understand that structural abnormality is rarely meaningful when his job depends on ignoring this data and actually emphasizing structure.”

The Conversation Placebo (5-10 min read)

  • Danielle Ofri of the New York Times published this nice article on her experiences as an MD dealing with pain. She talks about the power of placebo and how great bedside manners and communication skills can provide a therapeutic response that many interventions fail to do.

  • “This type of study provides hard evidence for what shamans, witch doctors and assorted mystics have known for millenniums: A substantial portion of “healing” comes from the communication and connection with the patient.”

A picture is not always worth a thousand words… (5-10 min read)

  • Adam Meakins discusses the impact of radiology and how images can negatively affect the patient in many ways. He provides references and great examples explaining how radiographic images provide just a snapshot and shouldn’t be as emphasized in the entire intervention process as it currently is for some clinicians.

  • “However there are also many times when a picture is NOT worth a thousand words and does NOT covey complex information very well. Instead some pictures over simplify, or add more confusion, or can just be just plain wrong and more harmful than helpful. For example images of doughnuts shooting jam out as we bend forward supposedly reminding us not to ‘slip a disc’ when we bend, which is simply nocebic, harmful, myth perpetuating crapola!”

  • “However, where modern medical imaging is failing patients and clinicians, and where it is often doing more harm than good is when it is being used hastily and incorrectly to explain why things hurt and recommend treatments including surgery for many musculoskeletal issues such as back, hip, knee, and shoulder pain. Unfortunately many patients and clinicians still think that pain and disability is as simple as structural irregularity or damage, that is when something misshapen, wonky torn, degenerative then it must be a source of problems.”

Diabetes, heart disease, and back pain dominate US health care spending (5-10 min read)

  • Institute for Health Metrics and Evaluation analyses the American health expenditures during 2013. What was pretty surprising from a physical therapist standpoint was that the amount spent on neck and back pathologies and pain were 3rd most on the list. It shows that there is an incredible demand for therapists who are able to work with this population, working age adults. On the other side of the coin, you could think that the expenditure would be significantly less if therapists were more efficient in treating neck/back pains. This is where you can conjecture that if there is still a large focus on biomechanical causes to these pains, maybe this shift to pain science education may be more efficient. The last sentence is not stated in the article, just a thought.

  • “The most expensive condition, diabetes, totaled $101 billion in diagnoses and treatments, growing 36 times faster than the cost of ischemic heart disease, the number-one cause of death, over the past 18 years. While these two conditions typically affect individuals 65 and older, low back and neck pain, the third-most expensive condition, primarily strikes adults of working age.”

THE DECLINE AND FALL OF THE TRIGGER POINT EMPIRE (15-30 min read)

  • Great discussion on myofascial trigger points by John Quintner. He spends a great deal reply to a response of one of his landmark articles refuting the existence of myofascial trigger points. Trigger points are a hot topic in PT, and probably won’t be going away in the next couple of decades due to the “I feel therefore, I believe” notion. It’s good to know what is actually supported by evidence and to stay vigilant with questioning of any theory. This article is a bit dense. I still need to re-read this a couple more times to grasp many of the concepts he brings up.

  • “We do not doubt that nociceptor fibres innervate muscles and that they can be activated by a variety of noxious stimuli. We agree that central mechanisms are important in explaining the phenomena of referred pain. However, it has yet to be demonstrated that a hypothetical “painful lesion” residing in “myofascial” tissues can be responsible for initiating and maintaining a state of central hypersensitivity.”

Tell Me a Story: The Importance of Listening vs. Hearing (5-10 min read)

  • Jennifer Stone talks about a very simple concept that we all probably come across at some point of our PT career. In case you missed your mentors muttering the same words, here is a full article on just how important it is to maintain the idea that each patient is an n=1 and shouldn’t just be categorized and dumped into a cookie cutter evaluation and treatment protocol.

  • “Even if this is your 452nd low back pain patient this year, this is the one and only back that Mary Sue has ever had-and maybe her first experience where a provider has sat and listened carefully and attentively to her symptoms.”

Orthopedic, Strength & Conditioning

Scraping Away the Narratives of IASTM (5-10 min)

  • Michael Ray writes an article for The Logic of Rehab blog providing a definitive article as to why IASTM lacks efficacy. As someone who has taken a course on it, I am actually glad to find this article. Patient education is the utmost important thing for the patient, and we should not lie to them with theories not backed by research. The dialogue that Mike Reinold and Erson Religioso provide during their online seminar for IASTM seemed to steer away from the previously understood dogma, and accepted the tool for what it is, a placebo providing intervention. With that being said, I’d use it in cases where I find some sort of mechanical modulation may help with symptom modification to help with therapeutic exercise. As other therapists use manual therapy to display to the patient how perception of pain and “tightness” can be readily changed, I feel that IASTM can do something similar. I don’t plan on lying to my patient.

  • “Keep in mind the body is constantly fighting for homeostasis i.e. regression to the mean, and since we can’t expedite the healing process we can simply foster it while ensuring patients remain calm.  Preventing catastrophizing and altering patients’ beliefs are some of the biggest components of our jobs.”

  • “Without valid understanding of the intervention’s premise and capabilities to treat a patient’s issue, the clinician is left stabbing in the dark with their IASTM tool of choice all the while increasing patient cost for treatment while possibly driving a nocebo effect and unnecessary dependency on an inefficacious modality.  We can do better.”

The Problem with a (Entirely) Structural Based Approach to Low Back Pain (10-15 min read)

  • Derek Miles and Michael Ray of The Logic of Rehab write a superb article citing multiple references as to why the focus on biomechanical reasons for low back pain needs to shift. There were too many great quotes in this read, so I just show a couple.

  • “If it truly were just raw strength that leads to a healthy back none of us who lift heavy weights should ever have back issues. It may not be a question of strength but more of a question of “are you strong enough to do what you are trying to do?” To further muddy the water, the 2011 study by Niemelainen  states “Substantial asymmetry in paraspinal muscle cross-sectional area in healthy adults questions its value as a marker of low back pain and pathology.” This would seem to place a big knock against the striving for symmetry camp. An interesting study alluding to the asymmetrical nature of some sports would also state that an asymmetry can prove advantageous at times.”

  • [Setting Patient’s Expectation] “There is something to be said for Ryan Holiday’s quote “The obstacle is the way.” Pain and structural abnormalities can be framed as either a threat/something that will hinder progress or as a challenge from which to learn. We would have never learned how to build bridges if there were no spans that needed crossing.”

  • “This one I’m adding even though classical conditioning has been shown to work (see Peerdeman). If we set expectations and condition patients that a modality is what cures them, then we never really help patients achieve independence. Sometimes we get so caught up trying to set ourselves apart as clinicians that we forget it is ultimately about the patient achieving their goals. “

  • “What we see may not be all there is, what we listen to may have the greatest influence on long term outcomes.”

Comprehensive Capacity: An Alternative to the Kinesiopathological Model for the Shoulder (5-10 min read)

  • Greg Lehman provides his case as to why pain might not necessarily be connected with the ideal kinesiologic movement of the shoulder. I think it is easy for a young clinician, let alone any clinician, to fixate on the movement of the shoulder and attribute the patient’s pain to his/her poor shoulder mechanics or “dyskinesia.” This is an interesting article that points out research and clinical experience revealing that it may not be as important as many make it to be.

  • “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”

  • “You are changing the movement as a temporary reprieve and then the person can go back to moving that way without pain.”

Most Personal Trainers Shouldn’t do Assessments (How to Collaborate) (5-10 min read)

  • Jonathan Goodman and Mike Reinold provide their respective perspectives, personal trainer and physical therapist, on each other’s professional roles when treating a client. This is a good article to acknowledge that there are certain lines drawn in the sand for both professions and that the collaboration of the two professions can be beneficial for the orthopedic patient or training athlete.

  • “A weekend or even week long course is not enough for us to tell our client that they are dysfunctional””and it’s definitely not enough for us to tell our client that they have an imbalance that needs corrective exercise.”

  • “Nobody comes into a gym saying that they want to improve their straight leg raise or inline lunge. They might say that they want to improve their posture, but more often than not they don’t really know why. They probably believe that an improved posture will reduce pain, which may or may not be true. Point is, posture improvement isn’t the goal, pain reduction is””so you should be measuring and tracking pain, not posture.”

The long and short of… Leg Length Differences (5-10 min read)

  • Adam Meakins dives into the topic of leg length discrepancies. As an individual who used to “reset” his pelvis everyday to relieve “SI joint pain”, this article came to me equipped with some convincing evidence that my understanding of LLD may be misled. Though it may actually be a factor of back pain, evidence on LLD points to the fact that there are many people who are asymptomatic with LLD. This notion that therapists look for the first thing to scapegoat is something I’m realizing my previous physical therapists followed.

  • “In my opinion LLD is a nice, easy, and convenient scapegoat for many therapists to blame as a cause or source of pain, often with most of those blaming LLD not really taking into account that humans are asymmetrical and the remarkable and amazing capacity for us to adapt to asymmetry.”

  • “So a therapist who suddenly finds a LLD in a patient one Wednesday afternoon, that’s been with the patient all their life, and blames it as the cause of their back, knee, hip pain just doesn’t make any sense to me.”

“Foot orthoses and biomechanics” Up to Date – July/August: Jade and Dan’s Top 3 (5-10 min read)

  • Jade Tan from this group at La Trobe University provides 3 up-to-date articles on common issues you’d treat in the clinic for runners. She does a great job summarizing the articles and linking you to more resources. Overall, I just discovered this website and it seems to provide a lot of great content and references.

Pain

Do we Really Know how Exercise Works for Pain? (5-10 min read)

  • Ben McCormack saliently writes an article challenging how we explain our clinical-reasoning to patients, and how it really does make a difference when using different interventions. I really like the emphasis on working with patient expectation and past experiences. Reframing how the patient perceives passed failures may be one of the strongest weapons a clinician can have in his “tool kit.”

  • “The predicted outcome does seem to be a HUGE factor in the success of a treatment, in part because it may affect the process of that treatment and this would be no different for ANY intervention, exercise included. If someone has had a previous failed experience with exercise, and this could be unrelated to pain, this might affect their perception of your chosen intervention REGARDLESS of the effectiveness shown by all those research papers you have diligently read’

  • “We might find that someone’s locus of control changes, moving from being externally focused, a sense of having little control over their current situation including pain levels, to being more internally focused and able to influence what is happening to them. This could also lead to increased self-efficacy meaning that completing tasks and reaching goals is now perceived as being within someone’s reach.”

Everybody wants a piece of the pain pie (5-10 min read)

  • Paul Lagerman talks about how pain science education is becoming a more popular thing with the therapy communities, but questions the professions’ readiness to administer and provide salient explanations of pain without butchering the message.

  • “It appears that many clinicians are familiar with the term multi-dimensional in that many factors make up a pain experience. Yet the difficulty is actually identifying how those factors fit in to why the patient presents to you at that time and that presentation is not a constant, it is highly variable! Clinicians that truly want to embrace the multi-dimensional nature of pain have to understand that a uni-dimensional approach is not sufficient. Unsurprisingly, Synnott et al (2015) highlighted this exact reason identifying that physiotherapy training did not instill the confidence in successfully addressing the multi-dimensional nature of low back pain (LBP).”

The Perils of Explaining Pain (5-10 min read)

  • By now, you can imagine I’m a student who is very seduced by this idea of pain science. It all started with Explain Pain by David Butler and Lorimer Mosely. What I’ve heard is that this “pain science thing” dies down after you get into the routine of treating patients daily and that it is actually ineffective. Fortunately for me, I was able to implement a lot of the principles with my patients the past clinical affiliation I had, so it looks like I’m here for the ride. In this article David Butler writes about how Explain Pain got bastardized into an abridged version that eventually lead to the idea that “pain is in your brain.”

  • “Dumbed down versions of Explain Pain are all the rage – as if a simple 5 minute video clip, on its own, is enough to alter deeply held pain concepts, or prescriptive treatments that assume pain is a universal experience for all, with a minute on this and two minutes on that.”

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