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.