Dr. Aaron Swanson, longtime Physio Answers contributor and recent contributor to The Manual Therapist with his amazing Monthly Hits list (April 2016 is here), had a great blog request.

He said after taking ISPI's course and reading Therapeutic Neuroscience Education - one of my highest recommended texts, btw, he finds himself using the same Pain Science metaphors, stories, and examples over and over. His request was for others to share theirs so he could spice it up a bit. 

1) Pain and Sunburns - via Dr. Kory Zimney

A simple pain metaphor I like to use with patients that can help them understand that our sensitivity to pain can change and sometimes it can be different from what we are used to. All too often patients
equate pain with injury, so after an injury when they still hurt they assume the injury is not healing and they are continually causing re-injury.
What “feels” dangerous might not actually “be” dangerous; or simply put by a patient of mine once: “So if I’m understanding what you are telling me, the pain I feel is not the pain I have.” 
I use the perspective of a sunburn to help teach what they feel may not be 100% accurate and that they might not always be re-injuring themselves when they feel pain. Almost everyone at one time has forgot to put on sunscreen and spent a bit too long in the warm sun only to experience the dreaded sunburn the next day. I’ll ask the patient to remember getting into the shower the next day and turning the water to a nice normal temperature and getting into the shower. What happened? This is the active part of the educational process with pain neuroscience education and let the patient answer. Usually you get the response about how the water is too hot and they have to turn the temperature of the water down. Then you can throw a bit of Socratic questioning at them, what do you think happened? Did someone sneak into your house overnight and turn up the hot water heater and mess up the temperature valve on your shower to make the water so hot? Let them ponder that a bit and then ask, so when you felt the “burning” hot water, were you really at risk for burning or injuring your skin? Sometimes what we “feel” is not actually what is happening to us, our body can make us more sensitive to things at times. What “feels” dangerous might not actually “be” dangerous; or simply put by a patient of mine once: “So if I’m understanding what you are telling me, the pain I feel is not the pain I have.”

This acute sensitivity is a good thing when we have had an injury to tell us to take it easy for a bit to allow a gradual return to activity. Because of this extra sensitivity we can bump into the pain safely and not cause further injury because our bodies alarm system has gotten super sensitive. Unfortunately, when pain turns chronic it is not so good. We know that around 1 in 4 times the pain system doesn’t reset back like it should. Often times they will ask the three most common questions: “How do you know that?”, “Why did it do that," and most importantly “What can I do about it?” These questions can lead into more educational opportunities for patients to understand why they hurt.

I have found this metaphor sometimes helps create that “ah-ha” moment for some patients in understanding that pain and injury are two different things. The more they understand with deep learning that the pain they are experiencing is not tied to injuring themselves further can be a key
turning point to help them get back on a gradual graded return to function.

2) Pain as an over-reactive protector via Dr. Greg Lehman

Pain is often helpful. It is meant to motivate us to do something when there is the potential for damage or the possible need of safety. However, pain is not proportional to damage and is quite often out of whack with the problem. Pain is also associated with a whole host of things that are also meant to protect us, might be unnecessary and might even cause more problems.

When in pain you might have muscle guarding, tentative movements or an increased stress response. When these persist they are often no longer helpful. The body has a number of responses that are similar to this type of over-reacting. In some ways, we are super-sensitive car alarms that go off with just a little contact. An example is a bee sting.
There can be a small physical or emotional stressor and BOOM! we can have pain, tightness, weakness and other symptoms of a flare up.
Most of us feel a little bit of pain when stung. It hurts, there is not much damage but in a few minutes we don't think much about it. But in some people that little string triggers a massive over-protective and non-helpful reaction. The reaction (or the immune response) is massively out of proportion to the insult. You might have swelling, redness, tingling, burning or even an anaphylactic reaction. These are often unhelpful and can be harmful.

Pain can be similar.

There can be a small physical or emotional stressor and BOOM! we can have pain, tightness, weakness and other symptoms of a flare up. What is unfortunate is that we can learn to have greater responses (i.e. greater flare ups) to smaller insults or stressors. Fortunately, treatment can desensitize us to these triggers. We can dampen our responses to these stressors. We can desensitize and ultimately build up our tolerance to all stressors. 

3) Pain is like the wind via Dr. Matt Dancigers

It can only be viewed by its interface with the environment.

We see the trees move, the leaves rustle, the flower petals quiver. We see the thick dust in the air, the yard furniture toppling in a pile by the fence, the branches dropping to the street.

Our skin turns alive with an unseen pressure. We are urged to move to the left by an unseen force from the right. It blew my hat off.

"I cannot take a picture of the wind. I can show you a picture of a windy day... but not the wind."
Now, since pain is a feeling, and not a thing, it does not show up on X-ray/MRI/CT. I cannot hand you some pain (reaching both of my cupped hands forward). 
It comes up in evaluations and interactions often. "The right knee has the tear in it, but the left one hurts more." or "The MRI showed nothing." I have a canned response since it comes up so much. "Well, you make an excellent point. Thank you for bringing that up. Now, since pain is a feeling, and not a thing, it does not show up on X-ray/MRI/CT. I cannot hand you some pain (reaching both of my cupped hands forward). There has never been a picture of feeling. There have been pictures of people wincing, or holding a body part, but since pain is a feeling, it will never show up on a picture."

I say this, generally the same way, while gauging understanding as best I can. This may be a good starting place, depending on the patient. Perhaps it's a good analogy to challenge a "seeing is believing" mindset. The wind is no less real.



Pain Wind Scale: "On a scale of 3 to 120 mph, how gusty is your pain today?" *image credit*

Now, the wind analogy is useful to look at the spectrum of what pain is in someone's life. It can blow your neighbors leaves into your yard. It can cool you down on a hot day. Pain serves a biological purpose as a threat/danger signal, but can also be a destructive force.

Not all the important things in life are made visible. 

4) Pain as a Home Alarm System via Dr. Andrew Rothschild

If your house gets broken into, you might want to call ADT and get a system installed with sensors on your front and back door, windows, etc. But then you might realize, if the alarm only goes off once someone breaks in and is inside the house, that might not be early enough warning to be able to protect your family, so you increase the sensitivity so the alarm gets triggered when someone comes up to the front door. 

Your body's alarm system can work in the same way. Even if you've had an injury in the past, over time, we know that tissues heal. However you can store memories of that injury and the pain you had as a response. Your internal alarm system can sometimes become more sensitive and go overdrive into protect mode; when you adopt certain positions or do certain movements that were once painful or difficult, you can perceive them as being painful again, even when no tissue damage is occurring. 

5) Your Brain as a Police Station via Dr. Erson Religioso III

Think of your brain as a police station, it is routinely sending out patrols all over your body - this is part of it's job, to make sure you're safe. Once you are injured, do too much of a particular activity, or for apparently a reason you are not aware of (but your brain is), pain occurs. Think of this pain as that area that hurts calling 911. Not only will the patrol go to the painful area, but several extra squads, maybe firefighters, ambulance etc. These are all the body systems, like immune response, endocrine, etc responding to either a real or perceived emergency. These emergencies lower your pain and movement thresholds. The lower your threshold, the less movement and activity you can perform before another "911" call happens again.

For some people and reasons we do not know yet, pain persists. If the area is "broken into" or 911 is called enough times, regular patrols will be continuously sent to the area whether or not there is an actual emergency. This is a cycle that needs to be broken with novel movements, education like this analogy, and hands on techniques that make the brain feel safe. The safer the area is, eventually the patrols stop coming around so often and your pain and movement thresholds return to their normal levels.

I hope everyone got something novel out of this post, and thanks for the compilation idea Aaron! Comment below or on the facebook page with your favorite analogies, metaphors, or stories to help with Pain Science Education.


header image credit


Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...







Would you like to learn how to automate your practice? Thanks to my colleague and friend, Paul Gough, you can learn his automation strategies.

Luckily for my blog readers, Paul has allowed me to repost his entire 2 hour webinar on automation strategies. He actually has several thriving cash based practices in the UK - a country that has physio covered entirely by their health system. THAT is a feat!

You do not have to be a business owner to benefit from this
  • employees can feature this on an inservice - or watch it over a few lunches
  • students can also feature it on an inservice or use it in the future
What Paul and I have discovered is that business automation gives you more time for both your patients and more importantly, your loved ones.

Automate Your Practice So Your Business Grows Without You


Paul also has a 6 week course, with weekly LIVE seminars, click above to learn more! You have only 4 days to sign up for his latest cohort!



Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...









We already know I'm a big fan of podcasts. One of my most popular posts is about podcasts and I still update it every few weeks when I discover new ones. Which reminds me, it's been updated and re-posted. Here's the link: http://www.themanualtherapist.com/2016/04/are-you-listeningto-physio-podcasts.html

One thing I've noticed after listening to a wide variety of podcasts over the past few years, is that there appears a common thread with some of their marketing and promotional strategy that perhaps PT could learn from. 

Podcast hosts frequently have hosts of other podcasts on their show, which enables the guest to promote themselves and their own show and products. Very often, that guest will reciprocate and have the previous host on their show to do the same. And on it goes. I have myself discovered podcasts and books in this very way. 

Here are just two examples: In December of last year, Scott Iardella (@RdellaTraining) of the Rdella training podcast had on as a guest, Danny Matta (@dannymattapt) of the Doc and Jock podcast. Later that week, The Doc and Jock podcast hosted Scott Iardella and helped him promote his new book, The Edge of Strength. Scott was able to promote his book not only on his own platforms, but others as well, which enabled him to reach an even broader audience--brilliant. 

In November 2015, Mark Divine (@markdivine, @sealfit, @unbeatablemind), former Navy Seal Commander, author, founder of Sealfit.com, and host of the Unbeatable Mind Podcast had on Tom Bilyeu, CEO of Quest Nutrition (@tombilyeu, @insidequest). Just over a month later, Tom had Mark on as a guest on his show, Inside Quest. Even if there was already some overlap between the two tribes, members of each community were exposed not only to the thoughts and ideas of the other, but resources, products, and opportunities that they otherwise might not have known about. 

So, can physical therapy, specifically physical therapy private practices learn from this? Jeff Moore (@jeffmooredpt) seems to think so. In an episode of #PTonICE, Jeff discussed one strategy that involved encouraging multiple small practices in a town to join together for marketing efforts and even things like journal clubs or mentoring sessions to help raise the quality of care delivered by all the providers in the area. 

Jeff's thoughts on this strategy echoes what I heard Chad Madden (@MaddenPT), while a guest on the new PT Lanchpad podcast (@PTlaunchpad), refer to as "the abundance mindset." The abundance mindset basically is one that agrees that there are plenty of customers to go around. Jeff cited the recent Julie Fritz paper that noted only 7% of patients with acute LBP that presented to primary care were being referred for physical therapy. If we want to attract that other 93%, the efforts of just one PT practice in a town may not be enough. Perhaps working together to help promote the profession and educate the public is a good way to do it. 

"How you market anything is how you market everything"-- Paul Gough

Traditionally, private practice PT is often just that--private. We like to keep our methods secret. The internet and especially social media has changed all that. Our profession has people like Jerry Durham (@Jerry_DurhamPT), Paul Gough (@ThePaulGough), Chad Madden, Paul Potter (@paulpotterptcom), and Jarod Carter (@DrJarodCarter), who spend a large chunk of their time promoting physical therapy and providing services to help private practices get better and become more successful. 

As my colleague Eric Jorde (@EricJorde_DPT), says, "raising the level of all physical therapists helps raise the level of physical therapy everywhere." If all the groups in town that a physician refers to are good, the assumption by both the physician and the public might be that a large majority of us are good. And that can only help raise the profile of the value of PT. 

Many of us bemoan the fact that we are surrounded by competition, whether it be hospitals, POPTs, large corporate PT groups, and even other private practices. But using just the back pain referrals as a model, if we are all either succeeding or just getting by on that 7%, imagine what we could do simply by doubling that number. Finding more space and more qualified therapists would become our newest problem, and that's a good problem to have!

The even bigger picture is that it's not just about our practice or business success. It's the public that will benefit the most. The more the public knows about the value of PT and what it can do not only from a traditional rehabilitation model, but also from a health/wellness/performance standpoint, the better for everyone. We can enhance peoples lives in so many ways, and that's what we can sell. 

So maybe each practice doesn't have to be an island. We can help each other to help every-body. 

Thanks for reading,

-Andrew





Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...







Are physical therapists good at analyzing and prescribing heavy lifting?

That's the fundamental question we asked our guest Dr. Zach Long on this episode of Therapy Insiders podcast. You may know Zach a little better by his social media name, The Barbell Physio. He puts out a significant amount of content in the form of short form exercise videos, pictures and blogs. On this episode Zach shared his social media strategy as well as his lifting and training philosophies. So what do you think about the above question?
PS.
I will tell you the pink barbells I lift are heavy bro! - Dr. E (more like lifting multiple kids all day - they're often pink).
Therapy Insiders Podcast is proud to be sponsored by:
Therapy Insiders is sponsored by WebPT: The ultimate EMR for physical therapists. Not only does WebPT produce incredible EMR software, they also produce awesome content. Don’t believe me? Check out http://webpt.com/ptbilling for an upcoming webinar on top 5 billing secrets that payers don’t want you to know!!!Don’t miss out. Register now to attend this month’s special webinar on Thursday, May 19, 2016, at 10:00 AM PDT / 1:00 PM EDT. Can’t make the live event? Register anyway to receive the recording and handout. Want a free demo? Of course you do! Give them a call at 866-221-1870!
Therapy Insiders is also sponsored by IntakeQ, creating a digital intake experience. Do you want to improve the patient experience before they even walk into your clinic? Of course you do! IntakeQ allows you to create digital intake forms that are completely customizable and HIPAA compliant. Check it out for a free 2 week trial and 50% off your first month for Therapy Insiders listeners!


Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...







Pain is like the wind.
It can only be viewed by its interface with the environment. 
We see the trees move, the leaves rustle, the flower petals quiver. We see the thick dust in the air, the yard furniture toppling in a pile by the fence, the branches dropping to the street.  
Our skin turns alive with an unseen pressure. We are urged to move to the left by an unseen force from the right. It blew my hat off.
"I cannot take a picture of the wind. I can show you a picture of a windy day... but not the wind."
It comes up in evaluations and interactions often. "The right knee has the tear in it, but the left one hurts more." or "The MRI showed nothing." I have a canned response since it comes up so much. "Well, you make an excellent point. Thank you for  bringing that up. Now, since pain is a feeling, and not a thing, it does not show up on X-ray/MRI/CT. I cannot hand you some pain (reaching both of my cupped hands forward). There has never been a picture of feeling. There have been pictures of people wincing, or holding a body part, but since pain is a feeling, it will never show up on a picture."
I say this, generally the same way, while gauging understanding as best I can. This may be a good starting place, depending on the patient. Perhaps it's a good analogy to challenge a "seeing is believing" mindset. The wind is no less real.
Pain is like the wind
Pain Wind Scale: "On a scale of 3 to 120 mph, how gusty is your pain today?" *image credit*

Now, the wind analogy is useful to look at the spectrum of what pain is in someone's life. It can blow your neighbors leaves into your yard. It can cool you down on a hot day. Pain serves a biological purpose as a threat/danger signal, but can also be a destructive force. 
Not all the important things in life are made visible.
-Matt Dancigers, DPT
Header image credit 

*Yes there are biological structural processes to pain. Yes there is wind energy physics. 





Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...






Brought to you by Dr. Aaron Swanson, DPT

The Hits


This is just a collection of some of my favorite articles from the past month.  I bolded the numbers of the articles that I found most remarkable.  Of course, this is just my bias.  I think all the articles here have value.  I just realize that some readers may be looking for something more brief.

Also, I want to encourage any reader to share their favorite articles, books, or podcasts of the month in the comments below.  There’s only so much information that I can go through in a month.  I know there’s a ton of great stuff out there that isn’t on my radar.  It will not only help introduce me to new perspectives, but it will provide other readers this opportunity as well.

Epistemological Arrogance


1) “Epistemic Arrogance: measure the difference between what someone actually knows and how much he thinks he knows.  An excess will imply arrogance, a deficit in humility.  An epistemocrat is someone of epistemic humility, who holds his own knowledge in greatest suspicion.” -Nassim Nicholas Taleb

2) Complex does not mean complicated – “Complicated systems are usually built from design, and include cars, computers and buildings. Complex systems were not built but evolved, and include living things, ecologies and economic systems.”  Great piece by Todd Hargrove

3) Sometimes in the buffet style of information digestion that is the internet, there will be “gurus” out there who will claim “all health problems can be fixed with these “3 things you’re not doing”.  Or worse, they’ll take a “if your not doing ___ you’re missing the boat” approach.  

Those of us in clinical practice know it’s not this simple.  The problem is that ranting about a simple, secret solution to a complex problem gives people either false hope or it makes them feel bad as a clinician that they don’t know about the “secret answer”.  And I don’t think anyone in healthcare should be making clinicians feel bad or teaching through narcissistic ways.

My intention with this article is simply to put something out as a clinician that says it’s not simple.  There are no easy answers when it comes to treating the human species.  Each patient will be complex.  It’s a very intricate system with many parts.  It doesn’t work out all the time.  Some people don’t get better.  Sometimes they need a different approach or control parameter.

Clinical

  • “To understand is to perceive patterns” -Isaiah Berlin
4) It’s an honor to have one of my articles re-published on FunctionalMovement.com (FMS).

5) I’ve always thought people tend to get carried away with rolling patterns.  Especially when it comes to injuries distal from the core or people with ROM limitations.  You can’t roll your way out of a forefoot varus.  Emily Splichal apparently thinks the same way.  Here’s her article on the importance of the foot.

6) “The most common orthopedic surgery in America had it’s final epitaph written this month with a level-1 study showing that surgery for meniscus locking is no better than placebo.”

7) Erson shares 5 methods for improving your manual skills “you get more bang for your buck the more skin you contact – effecting greater portions of the homunculus”

8) “All movements are assessments. Not being able to do something gives you a lot more insight into what your weaknesses and vulnerabilities are.  This is where joint disassociation has it’s greatest benefit — increasing your awareness to which joints are lacking.  Mindfulness, then, leads to control.  If you can control something it gives any movement utilizing that joint more confidence.” -Christine Ruffolo

9) Some great thoracic mobility and stability exercises from Zach Long.  I haven’t seen most of these.  All of them are solid.  I really like the idea of side lying resisted open book.

10) I like the nervous system “wringing” (lumbar trunk rotation with contralateral cervical rotation).

11) 5 Things to Look at with Shoulder Post-Ops: why, t-spine, cervical sb, shoulder extension, and lat/teresmaj
12) “Perhaps its the ability to adapt to varied force distributions and striking patterns that makes you most resilient to injury. In a study published in 2015 in the Scandinavian Journal of Medicine & Science in Sport, authors Malisoux et al found that runners who rotated between different pairs of running shoes were 39% less likely to get injured versus those who ran in predominantly the same pair of shoes over 22 weeks. It’s possible that rotating between different shoes, and thus different strike patterns, minimizes the repetitive strain at each specific tissue structure and allows for more effective recovery and overall decrease in injury risk.” –Laurey

13) This might be one of the best explanations of mechanoreceptors and manipulation I’ve ever heard – stimulating type 2 joint mechanoreceptors causes pre-synaptic inhibition of pain

14) I’ve clinically seen a couple back injuries from lifters “burning out” their quads before deadlift or squat sessions.  #UprightAgainstGravity

15) You should do single leg seated calf raises for patients with achilles tendinopathies.

16) “The ability to inhibit unnecessary or excessive muscular tension is a true marker of self-regulation.” -Seth Oberst with a great article on how to improve your movement/self-regulation via play, slowing down, and detachment.

17) Brian Tiu with a shoulder course review.  Interesting perspective of rotator cuff being the cause of scapula instability.

18) The Gait Guys continue to teach the valuable lesson of torsions – “Because of the degree of external tibial torsion (14 to 21° considered normal), activity modification is imperative. A foot leveling orthotic with a modified UCB, also inverting the orthotic is helpful to bring her foot somewhat more to the midline (the orthotic pushes the knee further outside the sagittal plane and the patient internally rotate the need to compensate, thus giving a better alignment).” Here’s another great one with a video explanation.

19) Great Stuff From Peter Malliaris on Tendinopathies
“This doesn’t mean switching to midfoot strike is the only factor to consider – optimising leg stiffness, and training the muscle-tendon unit to maximise effectiveness of stretch-shorten cycle are also important, among other factors.”
“The authors own studies and others suggest that that less stiff tendons, particularly Achilles (Kubo et al. 2015 – in 5000m runners, Stafilidis et al. 2007 – in sprinters) may be advantageous for performance.”
“The muscle can work minimally to provide maximum efficiency or in a manner to generate optimal velocity for maximum power at ideal muscle lengths for maximal force generation’. Shorter/stiffer tendons with longer fascicles facilitates the latter (ie maximal force generation), like for example around the hip, as apposed to the longer/less stiff Achilles tendon that strains to allow the short calf fascicles to operate efficiently in an optimal range (see figure below – parts of the hamstrings have long fascicle lengths (FL) relative to muscle length (ML), whereas planterflexors have short FL relative to ML.”

20) I never thought about doing shoulder IR/ER from the knee.  Makes it very easy for patients.

21) Grip strength is important – “grip strength is a dependable predictor of overall health and wellness” #GetStrong #GoodForShoulders

22) Question: Jon Herting wants to know if anyone is using grip strength as a measurement for physical readiness? Great question and could be an easy assessment for all to implement.

23) “Clubfoot is usually not congenital”

24) Seth Oberst reminds us that as one progresses motor skills the degrees of freedom and available low-threshold patterns should increase, not decrease.  Someone with high-threshold, locked-out patterns is someone who has not reached the true autonomous stage of learning.  “Allow the nervous system to have a choice, mediated thru awareness, in making a more efficient movement output.”  See #71 for a research example of this fault.

25) Shoe tongue problems, lack of hip IR and ab/adductory twists – Gait Guys go over the mechanics of a common shoe problem.

26) “Gait appears most robust to weakness of hip and knee extensors, which can tolerate weakness well and without a substantial increase in muscle stress. In contrast, gait is most sensitive to weakness of plantarflexors, hip abductors, and hip flexors.” – van der Krogt (via Gait Guys)

From Greg Rose:
Restricted in 1 plane = TED
Restricted in all planes = JMD or Neuro-Locked
“It seems like the best way to coach is to let the learner tell you how to help them or let them coach themselves.”
“The real problem is our health care folks don’t look widely enough.”
“The body follows the eyes, not the neck.”
“The best constructs are inclusive and systematic and philosophical, and don’t simply tell you what to do.”
“Fascia answers a lot of the why and how to errors and successes in movement. The brain can’t control everything all the time, especially when movement is governed by the M1 reflex.”
“If you put a bunch of pieces of Swiss Cheese on top of each other, meaning you use multiple markers on a regular basis, the holes seem to get covered up.”

28) I’m not sure I understand the rationale for some of this, but there are some good points in this review of Greg Lehman’s course.

29) Quick Book Review
Why Zebras Don’t Get Ulcers – Robert Sapolsky
I thought it was just going to be another version of the Polyvagal Theory.  Instead, I was pleasantly surprised.  Sapolsky is a great writer, makes you laugh, and provides logical reasoning behind his detailed evidence.  He gives a detailed physiological argument for why stress is bad (glucocorticoids are the devil) and provides some profound solutions in the final chapter.

30) Great article on Anteromedial Ankle Impingement Syndrome – “The manipulation illustrated in Fig. 2A is particularly important in managing this condition because recent three-dimensional research confirms the medial cuneiform can dorsiflex as much as 10 degrees on the navicular. By maximizing the range of dorsiflexion available from the midfoot, the navicular / cuneiform joints may absorb motion that might otherwise be absorbed by the talotibial joint.”

31) Jill Cook is one of the best when it comes to treating tendinopathies.  Here in this post she gives you 10 things you should avoid doing.
Rest Completely, Have Passive Treatment, Have Injection Therapy, Ignoring Pain, Stretching Your Tendon, Massage Your Tendon, Be Worried About Imaging, Be Worried About A Rupture, Take Short Cuts in Rehab (it will take at least 3 months), Not Having An Understanding of Load Management (think speed too)

Important Healthcare Information

  • “The more income inequality there is in a society, the worse the health and mortality rates” -Robert Sapolsky
The decline of American health…

32) “Kapadia and his colleagues found that from 1995 to 2014, the average age of [heart attack] patients dropped from 64 to 60, and the prevalence of obesity increased from 31 percent to 40 percent.

Also, the proportion of heart attack patients with diabetes rose from 24 percent to 31 percent. High blood pressure was reported in nearly four out of five cases, up from 55 percent. And COPD, usually the result of smoking, increased from 5 percent to 12 percent.”

33) Number of adults with diabetes reaches 422 million worldwide, with fastest increases in low and middle income countries

34) Here’s a thorough article on one of the factors of our poor health – Role of Low Energy Expenditure and Sitting in Obesity, Metabolic Syndrome, Type 2 Diabetes, and Cardiovascular Disease

35) Decreasing sedentary time is equal to increasing moderate-high intensity exercise time.  #DontHaveToBeAnAthlete #Move

Discuss or share this with your peers, friends, family, and patients.  Awareness is the first step in change.

The Life of a Physical Therapist Summed Up in One Gif


You would think it would be easy to motivate people to something that will decrease their pain, improve their quality of life, and help them live longer...
You would think it would be easy to motivate people to something that will decrease their pain, improve their quality of life, and help them live longer…

Pain, Neuroscience, & Psychology

  • “A diagnosis of psychogenic anything…is usually a diagnosis of exclusion” -Robert Sapolsky
37) “Systematic reviews concluded that the evidence for Explaining Pain in decreasing pain, increasing physical performance, decreasing perceived disability, and decreasing catastrophization was compelling…Critically, the state of the evidence does not suggest EP alone as a viable intervention to induce long-lasting improvements in pain and disability. However, EP is clinically intended to be combined with multimodal approaches.”

38) This ISPI Newsletter has some very useful pain stories to help educate and persuade your patients.  I love the New Zealand guy with the rod in his head.

39) Uncertainty can cause more stress than inevitable pain. #Expectations #Control

40) Great story about Steve Kerr and his chronic pain and headaches.  Makes me wonder if he saw a PT before surgery.  Makes me wonder if he’s seen a pain science specialist.  Makes me wonder about the cerebrospinal fluid.  Makes me wonder about his neurodynamics and myodural bridge.  Makes me wonder about his cranium.  Makes me wonder if maybe there’s something else missing that we don’t know about yet.

41) Mindfulness practice reduces pain.  “Our team has demonstrated across four separate studies that meditation, after a short training period, can reduce experimentally induced pain”

42) “The aim of Pain Neuroscience Education (PNE) is to teach patients more about the pain they’re experiencing from a biological AND physiological perspective, embracing a biopsychosocial approach.”

43) “Research looking at the link between listening music and pain tolerance suggests that it is not only effective in relieving acute and chronic pain but can also help patients manage anxiety and depression.  According to one study from 2012, two daily sessions of music listening helped a sample of chronic pain patients relieve symptoms related to conditions such fibromyalgia, inflammatory disease, or neurological conditions as well as the anxiety and depression linked to chronic pain.”

44) The rest of the healthcare world is starting to catch up to physical therapy. “The nation’s top federal health agency urged doctors to avoid prescribing powerful opiate painkillers for patients with chronic pain, saying the risks from such drugs far outweigh the benefits for most people.” #GetPT1st #PainScience

45) It’s not that there are bad people, it’s that there are prefrontal cortexes.  “Human brain mapping study suggests you might be hard-wired for altruism”

46) Elevation leads to happiness.

47) Interesting study on how the brain uses objects to help focus visual attention.  “Perception experts have long known that we see much less of the world than we think we do. A person creates a mental model of their surroundings by stitching together scraps of visual information gleaned while shifting attention from place to place. Counterintuitively, the very process that creates the illusion of a complete picture relies on filtering out most of what’s out there.”

48) “Rather, the findings provide support for the embodied social-communication model, suggesting that chemosignals act as a medium through which people can be “emotionally synchronized” outside of conscious awareness.”

49) Another perspective on the importance of expectations.  ““What we’re showing is that attention is not enough to ensure accurate memory,” said Wyble. “You need some kind of expectation that attributing certain features to the object is important.”  This indicates that much of what a person can remember is based on their expectation of the information they will need to recall.”

50) We should all take some LSD – “Dr Carhart-Harris explained: “Normally our brain consists of independent networks that perform separate specialised functions, such as vision, movement and hearing — as well as more complex things like attention. However, under LSD the separateness of these networks breaks down and instead you see a more integrated or unified brain…Our results suggest that this effect underlies the profound altered state of consciousness that people often describe during an LSD experience. It is also related to what people sometimes call ‘ego-dissolution’, which means the normal sense of self is broken down and replaced by a sense of reconnection with themselves, others and the natural world. This experience is sometimes framed in a religious or spiritual way — and seems to be associated with improvements in well-being after the drug’s effects have subsided.”

Cognitive Bias


51) “a failure to acknowledge cognitive bias is a failure to acknowledge the limits of human intuition”

52) Here’s a great infographic describing 20 cognitive biases

53) “It seems that researchers are less likely to scrutinise results that “align” with their theories, but when we’re faced with results that appear out of the ordinary, intuition tells us to take another look. Some will even re-analyse the data to find plausible explanations for the unexpected result.”  BodyInMind has had a great series of articles on cognitive biases.

54) For more on cognitive biases, check out Daniel Kahneman’s book

Training


55) Diagonal Side-Sit Unilateral Press from Perry Nickelston

56) Dan Pope teaches you how to do some handstand push-ups.

57) “High intensity interval training may not be healthy for untrained individual. Study finds it cuts mitochondria production in half. “

58) Eric Cressey gives many reasons why it’s important to train after surgeries/injuries.  I agree with all these points.  Great read.

59) If you force people to lift based on what you want it to look like rather than what it feels like, then you are going to have a bad time.  Dean Somerset agrees and writes a post on spinal angles and deadlift variations.  #RespectTheVariables #Individuals

60) Random Advice – If it’s extremely uncomfortable in the set-up, it’s going to be painful and potentially damaging during the lift.  Be a coach – plan, prep, modify, regress, use alternate exercises.

61) 5 Core Exercises from Mike Robertson – I like the dying bug with reach and kettlebell
62) Mike Robertson gives 27 random tips on training the core – “While we’re on the topic of PRI influence, just check out how much real estate the internal obliques and transverse abdominus on the pelvis. I’d say they’re kind of important if we want to control our pelvis, lower back and hips!”

63) Eric Cressey shares 5 core exercises for 5 different planes of motion.

64) Solid research on split training vs. whole body training.  Conclusion = not that big of a difference, WBT has more benefits for lean-mass.  I enjoyed the graph showing the dramatic difference in cortisol in the two groups (WBT had significantly lower).  And then there’s this gem – “Although there are some indications that full body training may be better than a split routine for even some well-trained individuals (Schoenfeld et al. 2015), total training volume seems to make more difference than training structure.”

65) Dean Somerset couples proper spinal mechanics in a plank position on a physioball and adds in abanded pull-down motion to groove the proper spinal mechanic position for pull-ups.

66) “I’ve been fortunate to visit a lot of different strength and conditioning facilities in the private, collegiate, and professional sector. Without fail, the most successful facilities are the ones with an awesome culture.” -Eric Cressey

Exercise of the Month



Everything is better with a kettlebell.

This exercise helps to level the pelvis, stabilize the trunk in the frontal plane, improve shoulder stability, and can help to reduce a trendelenburg gait pattern.
You’ll get a completely different muscle activation pattern depending on which side you put the kettlebell on.
Keep in mind you may need to raise the kettlebell to avoid too much lateral flexion in some patients.
It’s pretty much this thought process, but it removes the ankle – so most people lose their compensation strategy.

Research

  • “If you want to know if an elephant has a stomach ache don’t ask the veterinarian.  Ask the cage cleaner.”
67) I have no idea what these insoles look like, but on a fundamental level this shows the importance of the sole of the foot in all human movement.  “Sensory enhancing insoles improve athletic performance during a hexagonal agility task”

68) “These findings demonstrate that a short program in mindfulness meditation produces demonstrable effects on brain and immune function. These findings suggest that meditation may change brain and immune function in positive ways and underscore the need for additional research.” #Mindfulness

69) The Hip Thrust is good in many ways – “The barbell hip thrust activates the gluteus maximus and biceps femoris to a greater degree than the back squat when using estimated 10RM loads.”  Here’s why you should use it in the clinic.

70) “The results suggest that patients with chronic neck pain have gait disturbances. This supports the notion that assessment of gait should be addressed in patients with persistent neck pain.”

71) If you stiffen your body…your body will stiffen.  “Abdominal Bracing resulted in significantly reduced knee and hip flexion and increased peak vGRF during landing. No differences in lumbar multifidus EMG or lumbar spine kinematics were observed.”  Drop landing is not a simple tasks = external cues preferred.  #Principles #HighThresholdError

72) I first learned about it in undergrad psychology class with the pencil and cartoon study.  Then Amy Cuddy’s TED talk reminded me about it and brought it to gross postures.  Now this quick 60-second research review brings it to gait.  Sensory input can change your brain.  Change your gait, change your state.  

73) An attempt at feed-forward protection?  ”Increased Gmin motion during swing-phase and earlier Gmin and superficial Gmed motion in individuals with hip pain suggest an overall increase of muscle activity.”

74) “This study suggests that postural cueing to increase lumbar lordosis during trunk stabilization exercises may better promote multifidus activation than traditional stabilization exercises alone.”

75) “Following a first-time lateral ankle sprain, a patient who was unable to complete the single-leg drop landing and drop vertical jump at 2 weeks post injury was more likely to be classified as having chronic ankle instability.”  Do people really have their patients perform a single-leg drop landing 2 weeks after the initial injury?

76) “Cognitive flexibility, heart rate variability, and resilience predict fine-grained regulation of arousal during prolonged threat.” (via Jennifer Pilotti)

77) It’s a dynamic system.  It’s all connected.  This is well known for those that study the human species, but may offer other traditional or old school practitioners a new perspective – “treatment for depression resulted in a decreased level of cardiovascular risk”  #TheWholeIsGreaterThanTheSumOfItsParts

78) Get a dog!  “Dr. Andrea Beetz and colleagues at Rostock University, in a comprehensive survey of research on the relationship between exposure to animals and immune function, found strong evidence that owning dogs or other pets: Reduces levels of stress hormones such as cortisol that depress immune function Increases circulating levels of oxytocin, which promotes a sense of well being and had been linked to improved immune response Increases parasympathetic function (relaxation response), which has also been linked to elevated immune function (parasympathetic neurons directly innervate, and stimulate components of the immune system such as spleen and bone marrow)”

79) “Experimental measurements of humans showed that normal arm swinging required minimal shoulder torque, while volitionally holding the arms still required 12 per cent more metabolic energy. Among measures of gait mechanics, vertical ground reaction moment was most affected by arm swinging and increased by 63 per cent without it. Walking with opposite-to-normal arm phasing required minimal shoulder effort but magnified the ground reaction moment, causing metabolic rate to increase by 26 per cent.“ #ArmSwingMatters

Bring Back the 10 Minute Arm Ergometer Warm-Up!


“Physical exercise facilitates long-term potentiation (LTP)-like plasticity in M1 (Singh et al., 2014b) and increases the level of learning-related neurotrophins (Rojas Vega et al., 2006). These and other mechanisms of physical exercise are discussed to potentially modulate motor learning (Fabel et al., 2009; McHughen et al., 2010; Cantarero et al., 2013).”
“In humans, neurophysiological studies showed that motor learning (i) requires LTP-like plasticity in M1 (Cantarero et al., 2013), (ii) increases the size of the movement representation of trained limbs in M1 (Pascual-Leone et al., 2005) and (iii) enhances motor corticospinal excitability (Muellbacher et al., 2002), although the relationship between cortico-spinal excitability and motor learning is complex (Tunovic et al., 2014).”
“Taken together, these studies provide evidence that exercise at low, moderate or even high intensities rapidly reduces intracortical inhibition and that this effect is not limited to the exercised limbs. This may be beneficial for online motor learning.”
“acute exercise induces facilitative effects on early neuroplasticity (within the first hour after exercise)”
“endurance exercise does likely not lead to neuronal adaptations (except of neurogenesis in the hippocampus) but exercise-induced vascular changes might contribute to subsequent learning-related neuroplasticity”
“Besides the changes in neurochemicals, exercise influences the energy supply of the brain. For example, recent investigations highlighted that lactate, elevated in response to exercise-induced anaerobiosis in the muscle cells (Robergs et al., 2004), is increasingly used as energy source for the brain and becomes the preferred fuel if arterial lactate values exceed the lactate values in the brain (Dalsgaard et al., 2004Kemppainen et al., 2005Boumezbeur et al., 2010).”
“An intriguing finding of Skriver’s study is the significant correlation of lactate with better skill retention at all measurement points”
Don’t over fatigue on the warm up : “To sum up, evidence indicates that acute exercise improves motor skill learning but further research is required to disentangle the effector-specificity of this improvement. Based on the existing evidence, a negative effect on motor skill performance and learning might be expected if warm-up exercise is potentially fatiguing and involves at the same time the main effectors that are important for the execution of the skill to be practiced in succession.”
“As mentioned in the previous section, Roig et al. (2012) showed that acute high-intensity exercise immediately after skill acquisition facilitates long-term motor memory.”
Post-skill practice: “exercise contributed to the emergence of an off-line performance gain in the retention test session despite of task interference”
“At the molecular level, skeletal muscles can act as endocrine organs capable of secreting molecules relevant for neuroplasticity”
Skill acquisition use before.  Skill retention use after.
Taubert, Marco, Arno Villringer, and Nico Lehmann. "Endurance Exercise as an “Endogenous” Neuro-enhancement Strategy to Facilitate Motor Learning." Frontiers in Human Neuroscience Front. Hum. Neurosci. 9 (2015): n. pag. Web.
Taubert, Marco, Arno Villringer, and Nico Lehmann. “Endurance Exercise as an “Endogenous” Neuro-enhancement Strategy to Facilitate Motor Learning.” Frontiers in Human Neuroscience Front. Hum. Neurosci. 9 (2015): n. pag. Web.

Other Good Stuff

  • “The sun doesn’t discriminate; the sun shines on all equally. We don’t get the light and warmth because we deserve it; we get it because we are. It’s the same with the heart’s compassion.” – Cheri Huber
81) “Tool use meant we didn’t need as big teeth and jaws as earlier hominins. This may then have increased evolutionary pressure to spend less energy developing teeth, making our teeth smaller.”

82) Seth Oberst told me to listen to this podcast with Josh Waitzkin. Tons of great stuff – flow, growth mindset, mindfulness, thematic learning/interconnectedness. I like the idea of interval training as a back door for teaching mindfulness to the skeptics. For example, put someone on a bike for intervals. Use high intervals to spike their heart rate (140-170), then on the low interval have them focus on their breathing for “recovery”. Show them how it helps lower their heart rate for the sale transaction.

83) Magic?  Higher levels of consciousness?  Different epistemology?  A Hoax?  You decide – 6 people withsuperpowers that science can’t explain.

84) “There are many kinds of toxic coworkers, but two that can do the most damage are those who won’t listen to others (egomaniacs) and those who suck the energy from a team (naysayers).”  Learn how to deal with these guys in this post.

85) 3 Mistakes Parents Make With Technology That Hurt Their Kids #PreventAddiction
1.Not Setting Limits on Technology
2.Not Having Enough Family Activities without Technology
3.Parents are also Tech Addicts  

86) “A programme to teach young children the basics of philosophical thinking in UK schools has been shown to help them progress in maths and reading.”

87) “We potentially can affect our epigenetics by living a healthy lifestyle and providing our body with the necessary building blocks for these epigenetic flags.”

88) Interesting article on anxiety.  “Problems in a Delayed Return Environment can rarely be solved right now in the present moment…Our brains didn’t evolve in a Delayed Return Environment, but that’s where we find ourselves today. My hope is that by measuring the things that are important to you and shifting your worry to daily practices that pay off in the long-run, you can reduce some of the uncertainty and chronic stress that is inherent in modern society.”

89) From 4 Rituals to Become an Expert by Eric Barker –
“What sets expert performers apart from everyone else is the quality and quantity of their mental representations. Through years of practice, they develop highly complex and sophisticated representations of the various situations they are likely to encounter in their fields… These representations allow them to make faster, more accurate decisions and respond more quickly and effectively in a given situation. This, more than anything else, explains the difference in performance between novices and experts.”
“Dan Coyle says you only want to be succeeding in 50-80% of your attempts. Less than that and you’ll get frustrated. More than that and you’re not pushing yourself.”
“Get outside your comfort zone but do it in a focused way, with clear goals, a plan for reaching those goals, and a way to monitor your progress.”

90) “Cato didn’t have Caesar’s military skill, or Cicero’s eloquence, or Pompey’s boyish good looks. But he had something even more formidable: a determination to hold himself, and those around him, to an insanely high standard. He asked to be measured by a standard higher than winning and losing in Roman politics, and that’s why he still matters long after ancient Rome went to ruins.” #Stoicism

Social


91) Great article summarizing the importance of social ties on overall health and well-being.

92) “A much more important barometer of long term health and well-being is the strength of your relationships with family, friends and spouses.”

93) Why are we becoming more narcissistic?  What is causing it?  How has our society changed to let this happen?  This article answers many of these questions.

94) “The latest scientific research shows that making eye contact and interpreting eye movements is paramount to forming strong social bonds.”

95) Relationships are a significant indicator of health and happiness
1) Relationships = health: Three times as powerful as exercise.
2) Online relationships don’t count: Don’t substitute Facebook for face-to-face. Use tech to arrange relationships, not replace them.
3) Be part of a community: Be a Sardinian and be engaged with groups of like-minded people who care.
4) Work relationships matter: Take breaks with your friends and give’em a hug.

96) Want better relationships? Study on social anxiety says don’t hide your personal weaknesses.

Diet


97) Great article with 3 easy, concise protocols for intermittent fasting.

98) I’m obsessed with coffee.  So I love articles that talk about how good caffeine is for performance.

99) Not only are flavored coffee lovers philistines, but they’re also ingesting propylene glycol (used as an airplane de-icing compound).

100) “The Learning Gardens provide essential education around food. The industrial food system has encouraged less education because the less you know, the more likely you’re going to eat their food. It’s not even food. We need to come up with a term for it. It’s calories, but it’s not food.”

101) “Scientists have shown that diet-induced obesity and diabetes can be epigenetically inherited by the offspring via both the oocytes and the sperm.”

102) “Children whose parents consume a high-fat diet are more likely to develop obesity and diabetes, according to research published in Nature Genetics” #EpigeneticInheritance

103) A great way to educate the public – The ANDI Score
“ANDI stands for “Aggregate Nutrient Density Index,” a scoring system that rates foods on a scale from 1 to 1000 based on nutrient content. ANDI scores are calculated by evaluating an extensive range of micronutrients, including vitamins, minerals, phytochemicals and antioxidant capacities.”

104) “Overweight and obese adults who are losing weight with a high-protein diet are more likely to sleep better, according to new research from Purdue University.” #BaconBeforeBed

105) DRINK MORE BEER!
“Scientists have been working on harnessing the anti-inflammatory and anticancer properties of beer hops….”
“Along with their purpose of balancing flavors, hops have been known to contain antibacterial and anti-fungal properties”
“Recently, studies have also found that hops may fight dementia: They contain antioxidants that prevent oxidative stress and cognitive decline.”
“One 2014 study argued that a flavonoid supplement found in hops could boost cognitive function. Not to mention all the health benefits that have been associated with drinking beer in general — including areduced risk of heart attack in women and lowered risk of kidney stones.”
“In the latest study, the researchers note that there are two compounds in hops that are promising from a medical standpoint: humulones, which are alpha acids with anti-inflammatory and anticancer features; and lupulones, beta acids that may also have some healthy properties”

Insulin, Glycemic & Insulin Index


There are many differences between NYC and the South (pizza, BBQ, accents, pace of life, interactions, etc.), but one of the startling differences in in weight.  The South is much more overweight and obese.  This is difficult to be around as a healthcare professional, let alone when it’s your family and friends that are struggling with weight control.  So I’ve started to dig a little deeper into diet and nutrition.  I still am trying to refer many people to Dieticians, but I figured a baseline knowledge of the mechanisms would help.  One of the foundations of diet, nutrition, and weight loss is insulin.  Here’s a few sources that I’ve found.  



109) The amount of sugar our country consumes is a MAJOR problem

110) “Administration of exogenous insulin increases fat mass.   Reducing insulin, by a variety of means, burns fat and spares lean mass.”

111) “Fat blunts the insulin response to meals; even if the additional calories aren’t accounted for.  In the Collier study, 50 grams of carbs (200 kcal) induced more insulin than 50 grams carbs + 50 grams fat (650 kcal).”

112) “There is strong and consistent evidence that a single exercise session can acutely reduce triglycerides and increase high-density lipoprotein (HDL) cholesterol (HDL-C), reduce blood pressure, and improve insulin sensitivity and glucose homeostasis.”

113) “Exercise blunts insulin secretion; meal timing matters…Exercising after the meal nearly cut the insulin spike in half.”

114) “Postprandial walking may be more effective at lowering the glycemic impact of the evening meal in individuals with type 2 diabetes compared with pre-meal or no exercise and may be an effective means to blunt postprandial glycemic excursions.”

Nutrient Timing


115) “The researchers say their findings may explain why people who sleep and eat out of phase with their body clocks are more likely to become overweight and obese and develop chronic diseases, such as diabetes and metabolic syndrome.”

116) “New proposed model, incorporating the circadian regulation of metabolism in adipose tissue:
AM: high muscle insulin sensitivity, low adipose insulin sensitivity; carbs now are OK, and exercise is better (but not necessary, unless goal is muscle growth)…?
PM: insulin sensitivity low in muscle, high in adipose insulin; carb-loading nowrequires exercise to increase muscle insulin sensitivity and offset the high adipose insulin sensitivity by improving nutrient partitioning.”

117) “Exercise blunts insulin secretion; meal timing matters…Exercising after the meal nearly cut the insulin spike in half.”

118) “How the “energy in” is handled is critically important.  With regard to an energy excess, dessert before bedtime is stored as fat but the same amount of calories from protein before exercise are invested into muscle.”

119) “Any protein is better than no protein (C & H, 2006), and protein immediately after is superior to 2 hours later (Esmark, 2001; Tipton, 2001).  I am proposing that protein prior to exercise is superior to protein after after.”

120) “eat more when the tissue-specific circadian regulation of insulin sensitivity is high in muscle and low in adipose = earlier in the day

121) “These data suggest that the daily addition of a breakfast, particularly one rich in protein, might be an important dietary strategy to reduce food cravings and potentially modulate the underlying substrates that control food hedonics/reward in overweight/obese young people.”

122) “For elite athletes, nutrient timing may provide an important competitive advantage.  However, the current research doesn’t support the importance of nutrient timing for most people who are simply trying to lose weight, gain muscle or improve health.  Instead, focus your efforts on consistency, daily calorie intake, food quality and sustainability.”

It’s important to keep in mind that the obesity epidemic is a complex process that involves psychology, education, society, the microbiome, and health habits.  It’s not as easy as calories in vs. calories out.  It’s not as easy as telling people to stop eating so much.  Instead, we need to have empathy and try to help in whatever ways we can.

Reform the World


I’m reading Robert Pirsig’s Zen and the Art of Motorcycle Maintenance.  It’s a very powerful and useful book in many ways.  Here’s a quote I think everyone should read, especially in the crazy political landscape of our country at this time.
  • “I think that if we are going to reform the world, and make it a better place to live in, the way to do it is not with talk about relationships of a political nature, which are inevitably dualistic, full of subjects and objects and their relationship to one another; or with programs full of things for other people to do.  I think that kind of approach starts it at the end and presumes the end is the beginning.  Programs of a political nature are important end products of social quality that can be effective only if the underlying structure of social values is right.  The social values are right only if the individual values are right.  The place to improve the world is first in one’s own heart and head and hands, and then work outward from there.”
The main reason I do this blog is to share knowledge and to help people become better clinicians/coaches. I want our profession to grow and for our patients to have better outcomes. Regardless of your specific title (PT, Chiro, Trainer, Coach, etc.), we all have the same goal of trying to empower people to fix their problems through movement. I hope the content of this website helps you in doing so.
If you enjoyed it and found it helpful, please share it with your peers. And if you are feeling generous, please make a donation to help me run this website. Any amount you can afford is greatly appreciated.



Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...