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.”