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

  • http://www.smertespecialisterne.dk/?p=813

  • http://www.smertespecialisterne.dk/?p=1203

  • 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.