Modern Manual Therapy Blog

An update on my chronic wrist pain which started insidiously June 2016. Every health care provider needs a swift kick in the behind to get some perspective on what their patients are going through. It's been a long road to recovery and here are 5 More Things I Learned on this journey. Here is my first video on what I learned if you need a refresher!

Thanks to everyone who has inquired online and live at seminars! Appreciate the concern!

5 More Things I Learned From Having Chronic Wrist Pain

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We often get the question: is pain neuroscience education the same as cognitive behavioral therapy? The literal answer is no. Cognitive behavioral therapy (CBT) is a psychosocial intervention that is based on a combination of basic principles from behavioral and cognitive psychology. It was originally designed to treat depression, but is now used for various mental disorders. To deliver CBT, one should receive specific training in the technique. With that in mind, does pain neuroscience education (PNE) contain components that are based on CBT principles? Our consensus is, yes.

In discussion with Jo Nijs, he agreed that PNE is probably mostly about the “C” of CBT. PNE is trying to change an individual’s perceptions about their injury/illness and beliefs about pain, aka the cognitive component. This is where understanding the neurophysiology of pain along with having the ability to change perceptions about various tissue variances that an individual in pain has is important. How one goes about this is through the various metaphors and stories to assist with the patient’s understanding. I like to make a point that knowing about pain science is not the same as treating a patient utilizing pain science. For me it is no different from knowing anatomy and biomechanics is not the same thing as treating a patient utilizing these principles. Sure, you need to have a sound knowledge of anatomy and biomechanics, but you need a lot more to be able to effectively treat a patient. I get concerned some clinicians may be content with knowing pain science, yet they have not been able to effectively use it within the treatment of individuals with pain. We recently finished an fMRI study that showed when we use PNE; we affect specific areas of the brain associated with the pain neuromatrix. These changes are different from when we used a control (non-PNE) educational process. The patient cognitively starts to think differently after they receive PNE. 

Put more simply: you cannot explain someone’s pain away.

Even if one is effective in delivering PNE the “C” portion of CBT, it is limited in its effectiveness. Our past research has shown that unless the PNE is followed up with the active behavior change, the “B” of CBT, it has limited effectiveness. Put more simply: you cannot explain someone’s pain away. For us in therapy we have been in the behavior change business since the start of our profession. The primary behaviors we work on are exercise, movement, relaxation, motor control, goal setting, graded exposure, etc. We can also do some behavior therapy in the areas of sleep hygiene, diet, meditation, etc. This should be in every good clinician’s wheelhouse to change behavior in our patients. While behavior change is hard, this is what we are trained to help with.

So why do you need to deliver PNE first then work on the behavior change? We know from our and other fMRI studies that PNE changes the “filter”, how the brain “scrutinizes” as Louis Gifford mentioned in his Mature Organism Model. A patient then needs to run the behavior through the new “filter”/cognitions in order to generate the output that becomes new inputs. It is the running of the behavior through the new filter repetitively over time that allows for changes eventually in pain and function. A new filter is worthless unless you run things through it to filter. Thus, PNE without the active behavior change activities is not very effective. The neat part about the filter of the brain is that exercise actually makes the filter get better over time as it releases BDNF, serotonin and other good chemicals to allow the filter to function better. Moreover, as we move the filter learns about the body better (sharpens the homunculus) with increased body awareness and thus learns through expectancy violation, that it can function without the production of pain in all situations. 

Therefore, while PNE is not CBT, it does use evidence-based principles of CBT by changing a person’s cognitions and then eventually using behavior change principles to make long-term changes to help an individual return to a level that they can function better again. What say you???

Chime in below or on the facebook page!

Via Kory Zimney, DPT

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Dear all,
Hope you're well. Welcome to tendinopathy blog 46 (subscribe here).
Another great guest blog from Eric Meira this week. This time on understanding hip pain in the young adult. Full of good info and practical tips as usual. Eric is over for a Hip and Knee course in Melbourne in August - limited spaces remaining.
Also, the Mastering lower limb tendinopathy courses in Wagga Wagga, Melbourne, Perth, Canberra and Adelaide are coming up. 
See you next time

Understanding Hip Joint Pain in the Young Adult

I’m going to write a really quick overview of my understanding of the young adult hip joint (the joint itself, not the region). Why? Well I’m kind of considered an expert on it for some weird reason and you may find some value in it. I was the founder of the Hip Special Interest Group of the Sports Section of the American Physical Therapy Association. I’ve written a ton of articles/textbook chapters on the subject and am currently involved in several research projects trying to answer more questions regarding the hip, specifically in athletes. All this makes me an “authority”. Of course, if history has taught us anything, all of this makes me the LAST person you should listen to…
In this article, I’m going to give a bulleted list of my thought process. I’m not going to give you a bunch of citations for a few reasons:
1. This is a blog post which makes it cursory, unreviewed, and illegitimate.
2. I could say whatever the hell I want and find at least one citation to support it – means nothing.
3. None of these statements are controversial and I don’t feel like stringing out the 20 possible citations on each.
4. Here’s a reference list. Providing it means nothing since I could be misrepresenting it all.
5. Think critically about what I say no matter what. There is no way in hell that I’m 100% right.
If I feel that something might be a bit controversial, I’ll throw you a bone. Again, this is going to be pretty simple. Like a lot of things in in physical therapy, it doesn’t need to be that complicated.

Femoroacetabular Impingement (FAI) is a thing

FAI has to do with bony morphology. The femoral head and the acetabulum have a…uhhhh…let’s call it “an imperfect fit”. “Pincer” is when the acetabulum covers too much of the femoral head. In isolation, I really don’t care about a pincer since its ability to cause any real damage is limited. When we talk about a cam, it gets more complicated.

What is a cam?

A “normal” (whatever that means) femoral head is spherical in nature. Round peg (femoral head) and round hole (acetabulum) work really well together.  When there is a cam, you no longer have a spherical head, it is more egg or cam shaped. This offset can be measured via the “alpha angle” on frog-leg radiograph.
Screen Shot 2017-04-14 at 10.32.22 am.png
The term “cam” refers to a mechanical concept of an offset shape used for work. Mechanical cams can be useful. Due to its shape, a cam interfaces one way in one position, but another way in another position. For example, when rock climbing, a climber will put a cam-shaped device with a cable or webbing attached into a crack in the rock. When she pulls on the cable or webbing, the cam turns in the crack. The offset shape causes the cam to exert more force on the walls of the crack as it turns and “spreads”. The harder you pull, the more it binds inside creating a fixed anchor point for her rope. How do you remove it? Just turn the cam the other way and it slides right out.

Cams can be a “bad thing”

A cam shaped femoral head acts in the same way as the rock climbing example above. As the hip goes into flexion and/or internal rotation, the aspherical portion of the head slides into the joint. Just like in the crack of rock, that creates an increasing “spreading” force in the acetabulum. The greater the spread, the greater the shear force to the articular cartilage of the acetabulum. As we all know, articular cartilage handles compressive forces very well. Shear forces? Not so much. The damage associated with the presence of a cam is a delamination injury to the articular cartilage of the acetabulum right where the cam engages. There is a correlation between cam and OA but that doesn’t mean cams always cause OA. Definitely plausible, but, in general, lots of things are plausible.
Screen Shot 2017-04-14 at 10.27.53 am.png
The cam tends to present on the anterior femoral head-neck junction. They will not have a hard, bony stop during range of motion. When you take them into terminal flexion and/or internal rotation, they will have a progressive seizing sensation that will be described as “tight”. What do you think happens when you stretch this “tightness”? You ruin their day.
Screen Shot 2017-04-14 at 10.29.17 am.png

I don’t care so much about an acetabular labral tear

As in the shoulder, degenerative labral tears happen. FAI can cause them. Sure, when you go into a symptomatic hip arthroscopically, you will find FAI (most likely cam) and a labral tear. So what? In isolation, those two things do not correlate with joint pain. You heard me (or read me). What correlates most with hip joint pain is damage to the articular cartilage. Read this. Also, that pain will ALWAYS present in the front of the hip. Not the side or back (although they may ALSO have pain in those other areas from something else). Front. Got it? Good.

Let me summarize hip pain from cams in an oversimplified way

"The cam articulates with the acetabulum creating an increasing shear force to the articular cartilage of the acetabulum resulting in hip joint pain (perceived in the anterior hip region). Over time, a secondary labral tear can evolve. The bigger the cam, the earlier this can happen during the range of motion of the hip – the “good fit” happens in a smaller arc. More cam does correlate with more pain."
Surgical correction includes removing the cam via a femoroplasty (duh) and repairing or performing a debridement of the torn labrum (why the hell not?) but the reduction in hip joint pain most likely comes from decompressing that irritated acetabulum. Now, if you stop reading here, you are missing half the story about cams.

Cams can be normal and perfectly fine

It is a well-known fact that elite soccer players have cams. So well-known that some are suggesting that playing soccer causes the cam. Maybe. People with cams really like to be externally rotated which may give them an advantage in soccer – the game may naturally select those with developing cams. Also, the older you are, the more likely you are to have a cam whether or not you play soccer. Let’s just say, keep playing soccer for now.
HAVING a cam is not a problem. ENGAGING a cam can be. As long as you don’t shove that cam deep into the acetabulum, everything is hunky-dory. If you discover a cam (even a labral tear) without pain in the front of the hip, then carry on. Just don’t push their range of motion…obvious right?
I have a cam. My favorite hip surgeon has a cam. Neither one of us is rushing to the operating room. It is a finding that correlates with pathology, but is not pathology itself. Cams are a spectrum from “more cam” to “less cam”. The cut-off point is very debatable.

A simple look at the hip that anyone can do

Here you go internet. Here is the most basic of hip joint assessments from a worldwide leader in hip pain™!

Do they complain of pain in the front of their hip as their chief complaint or during impingement tests?

If no, do not send to a hip surgeon at this point no matter what else you find. It is a waste of everyone’s time. It is unlikely that they have any hip joint problem. Look outside the joint (I’m not going open THAT can of worms in this post – there are some crazy ideas out there). If the answer to that question is yes, carry on with your evaluation.

Do they have less than 40 degrees of internal rotation?

If they have MORE than 40 degrees of internal rotation AND anterior hip pain with impingement tests, they likely have a symptomatic pincer at worst. Conservative management should take care of it (strengthen and coordinate glutes, keep them out of terminal/painful ranges as it calms down).
If they have LESS than 40 degrees and NO anterior hip pain, take note that they MAY have an asymptomatic cam (only frog-leg radiograph will tell for sure). Read this. A little education on not engaging that thing is probably all that they need. The less the IR range, the more education I provide. In my experience, I don’t start getting concerned at all until the range presents below at least 20 degrees. Even then, I’m concerned that some education is warranted, not treatment.
If they have LESS than 40 degrees AND anterior hip pain, take a step back. The likelihood of it being a symptomatic cam is increasing. The less the internal rotation, the higher the likelihood. Again, I use 20 degrees as my concern point but that’s anecdotal. Remember what is most likely causing that pain? Not the cam itself. Not a labral tear. The articular cartilage – most likely in a delaminating fashion. Not good. If they have been dealing with this for more than 6 months, I’ll work with them, but I will also recommend a surgical consult for a full workup of that joint. Diagnostic pain injection is the best tool to rule out the joint. It is the only way you can have confidence that the pain is coming from the hip joint. Never do surgery without one.

How do you treat a cam conservatively?

Look, I’m not going to tell you how to do your job but what is really the big problem here? An engaging cam creating shear forces across the joint right? So what should we try to do? Ok – stay with me here ‘cause it gets complicated.
"Teach them not to engage the cam to hopefully reduce the shear forces likely occurring."
Modify their squats and other activities to fit the cam. What motion is most likely to engage that cam? Hip flexion with internal rotation, right? Hey! That’s dynamic valgus – the boogeyman of the lower extremity! Teach them to activate their external rotators as they squat, land, jump, cut, etc. A “normal” movement for one person may not be “normal” for another. Again, “normal” hips come in all sorts of shapes and sizes. Find the position that works best for your patient. Could there be more going on here? Sure, but start here.
Should you try to gain hip mobility? Uh, how? If you reduce the irritation (unloading, rest, anti-inflammatories, time, or any voodoo you and the patient might think helps) you may gain some mobility secondarily, but otherwise there is a bone causing the limitation. You are saying that they NEED that hip mobility? Then you are saying that they NEED surgery because otherwise that cam will continue to engage in those positions. You can’t have it both ways.
The goal of any treatment, whether conservative or surgical, is to restore desired function within tolerable/manageable pain. The joint doesn’t have to be “normal” nor does its mobility.

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Download file | Play in new window | Duration: 5:23 | Size: 12.31M

This is a story you have to listen to, to believe. A patient experiencing TMJ issues only improves when she eats…ice cream! Check out Dr. E's The Ecelctic Approach to Temporomandibular Management here!

Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Another epidemic I see in the clinic, online, and in the gym is smashing or rolling out of trigger/tender points. Like ANY technique, this works to improve mobility and decrease discomfort, but can be entirely pain free. Here is how to use a mobility ball with some diaphragmatic breathing techniques in a quicker and often much more comfortable manner.

Mitch Starkman from The Movement Centre demonstrates with a upper trap variation in this video.

A Better Way to Use a Mobility Ball

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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They say life is a marathon, not a sprint. And, as endurance goes, keeping yourself motivated can be a challenge from time to time. There can be set backs, barriers, down turns, and many other things that may dampen your morale. Well, fear not! Here are…!

5 Effective Ways to Stay Motivated

1. Take a Break. What? Really? Already?! Yes. Take. A. Break! Many times, motivational burn out occurs because you haven’t balanced out your cognitive faculties. Banging your head against the same wall can get old quickly. Moreover, doing so can make you lose perspective as to why you are doing what you do. In fact, taking a break was an inside joke during graduate school for me. I always found a way to divert my attention away from my work and towards something else. However, I was very disciplined as to how I did this. Most of the time, I would take 15-20 minutes as a “pre-game break” to studying. After which, I would lock myself in a study room for hours and hammer out huge sections of material. Suffice to say, it works. And, it helps you to…
2. Remember the Why. Going back to your original passions, interests, and the heart of each reasons to why you began this journey in the first place is an honest way of introspective clarity. Remembering your first love or the reason for your drive when you began is a good way of recharging the batteries. It also helps you dig your mind out of the present clutter. Remembering the reasons behind what you do helps you take a step back to see the big picture. It gives a deeper meaning to what may seem like tasks and will place them in your mind’s eye as the stepping stones toward success.
3. Enjoy the view. As you take a step back, make sure you also appreciate the view. Take a good look at where you started as well as how far you’ve come. It’s tempting to get frustrated at the direct barrier in front of you. In the same way, it is easy to forget about how many accomplishments you’ve made and how many obstacles you’ve overcome just to get to this point. Whatever is stifling your motivation, it is but another obstacle which you will conquer. And, all the great things you’ve done, they are part of the story of your success to which you will add.
4. Go Exercise! Sometimes, the body and the brain need an entirely different source of stimulus. Exercise. Not only has the news media been regularly highlighting academic success in K-12 as it relates to physical activity in children, there is much to be said about how this affects us as adults. Personally, I view exercise as a keen and full-proof way of giving the brain the best chance it can have by pumping it full of fresh blood and fresh oxygen. There is something healing about exercise that allows so many systems of the body to recover faster than its sedentary self. Therefore, if you’ve already taken a mental break, maybe its time for you to take a physical one as well.
5. Help Someone. I find that generosity and altruism is a great source of motivation. There is always someone who is suffering worse, enduring more, and trying to bound over obstacles which would put your own worries to shame. Helping someone else, even for a small concern, is a wonderful way of reminding yourself that in all that you do, your success means most when it helps others. While helping someone may be slightly divergent to your immediate goals, it is a way to redeem a part of the human experience which goes beyond finishing the task. It brings back more than reason. It re-centers us on the meaning of what we do.

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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Spots still available! Mark your calendars for our next MMT Webinar on Wed Apr 26th, 8:30 pm EST! I'm excited to have Adam Wolf, PT, NY Times best selling author of Real Movement present the next webinar on Perspective on Integrated Motion and Motor Control.

What You're Going To Learn
  • Define and associate integrated movement, including concepts of drivers and transformational zones. 
  • Apply and demonstrate assessment strategies utilizing principles of integrated movement using fascial connections.  
  • Differentiate and identify between capsular versus soft tissue restrictions and different strategies for treatment

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Hi all,
Welcome to blog 45 (subscribe here).
In Sydney, this weekend for first sold out Mastering Lower Limb Tendinopathy Course of the year – other dates around Australia can be found here.
Also, Erics Meira’s Hip and Knee course in Melbourne in August is filling fast – limited spots left.
This week I focus on a study investigating a potential mechanism that may explain the link between foot pronation and Achilles tendinopathy. A sound study with interesting findings, but we also need to ask; 1) how strong is the link between foot pronation and Achilles tendinopathy; and 2) what do we know about the use of orthotic devices for prevention? 3) what do we know about the use of orthotic devices for treatment? Some interesting clinical questions to ponder.
Background: Although the Achilles tendon is the strongest and largest in the body, it is commonly injured. Most likely because it undergoes high and repetitive loading. Achilles tendinopathy is a common running injury, but it is also very common among people who do not run, as walking is a relatively high loading activity for the Achilles tendon. The authors argue in their intro that foot pronation is thought to be ‘strongly associated with Achilles tendon injuries’ (more on that later). Possibly the whipping or torsion of the tendon described by Clement way back in 1984 explains this. The authors aim was to test this hypothesis by measuring blood flow in the tendon pre and post running.
What they did: Healthy participants were asked to run barefoot for 10 minutes and then with neutral running shoes for 10 minutes. Three Achilles tendon blood flow measurements were taken, baseline, post barefoot and post shod running. Participants were asked to self-select running speed and this was monitored to ensure consistent through both trials. Blood flow was measured with an oxygen-to-see device which measures the perfusion and oxygenation of the subcutaneous tissue up to a depth of 8 mm using an optical fiber probe. To do this it used both white light spectroscopy (wavelengths of 500-800 nm) and the laser Doppler technique (830 nm and 30 mW). They used 4 synchronised high speed cameras to measure 2D kinematics (sagittal and frontal planes) during running on a 45-meter track. Kinematic variables related to ankle dorsiflexion and one of the components of pronation ie foot eversion (eversion excursion, dorsiflexion excursion, average and maximal velocities, and initial foot strike pattern). They investigated whether kinematic variables influenced Achilles blood flow after each running condition.
What they found: There was a significant increase in blood flow after both running conditions, more so after the shod condition (62% vs 43%), but this may have been because the shod condition followed the barefoot (ie they did not randomize or counterbalance order of tasks). The main finding was that people who displayed greater eversion excursion had a lower increase in blood flow following the shod condition (eversion excursion explained 11% of within participant change in blood flow following this task). The figure below shoes the potential differences between participants in eversion excursion. Dorsiflexion excursion or foot strike did not influence blood flow.
Screen Shot 2017-03-31 at 1.00.55 pm.png
Clinical interpretation: This is an interesting study in that the authors have identified a potential mechanism between foot eversion and Achilles tendon pain. The authors suggest antipronation measures such as taping, orthoses or foot intrinsic muscle exercises may reduce the risk of Achilles tendon pain onset. A strength of the study is they controlled for speed and considered the influence of foot strike.
Some clinical questions may help to provide some context in applying these findings…
1. How strong is the relationship between foot eversion and onset of Achilles pain? My current PhD student (Igor Sancho) is just completing a systematic review that includes this, and he found that there is conflicting evidence for a link between foot eversion and Achilles tendon pain. Listen out for more on that soon (I don’t want to steel Igor’s thunder).
Given the at best weak relationship, the issue with intervening with a blanket strategy for people who may display increased foot eversion and giving them foot orthotics is that you will be treating lot’s of people who although have this risk factor, may never develop the injury. You may run the risk of causing them harm or impairing performance. The other problem clinically is identifying excessive pronationor eversion accurately.
2. How strong is the association the authors have found in this study? Similar to the association between foot eversion and injury, the association with change in blood flow and pronation in this study is weak – see figure below.
Screen Shot 2017-03-31 at 12.31.55 pm.png
3. Further, can we prevent injury with shoe inserts? There are only very few studies that I am aware of that investigate the influence of shoe inserts on Achilles tendon pain onset. House et al. 2013 found that shock absorbing insoles reduced the incidence of Achilles tendinopathy during marine training. However, Larsen et al. 2002 found no effect of custom made shoe orthoses, again in a military population.
4. Lastly, what do we know about treating Achilles tendon pain with foot orthotics. The state of the art randomized controlled trial from Shannon Munteanu at La Trobe Uni from 2014 showed no benefit at 1, 3, 6, and 12 months for custom orthotics compared to sham orthotics when added to exercise in managing Achilles tendon pain.
Although I may not agree with the clinical implications of the study, there is not doubt this study is novel and very interesting, and gives a snapshot of load profile on the tendon with a specific kinematic pattern. The authors should be congratulated for this. Follow up prospective work (rare as Hens teeth in the tendinopathy aetiology literature) would be lovely to see!
See you next time

Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...