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.