Modern Manual Therapy Blog

It is now well known through documented basic science research and clinical trials that a subtype of dizzines can occur from dysfunction of the afferent input to the vestibular nuclei arising from the cervical spine, particularly C0-3.  However, the treatment approaches do vary widely in the literature with many accounts showing benefit from therapeutic exercises, education, vestibular rehabilitation, acupuncture, massage, mobilizations and manipulations.
Spinal manipulation continues to be a heavily debated topic due to its possible adverse events & specifically the risk of causing undue stress on the vertebral arteries in the V3 segment with a rotational manuever.  However, it continues to be an effective procedure for cervical spine dysfunctions and may be more effective than massage or mobilizations.
In fact, the effective delivery of manipulation over mobilization/massage could make sense to the practitioner based off of clinical results (personal experience) but also basic science from the findings of Bolton and Budgell 2006, which suggest,
that manipulation provides an immediate and short-term stimulus to the intervertebral tissues and that it is unlikely that deep short intervertebral muscles would be similarly activated when manual therapy is applied to superficial tissues
The application of spinal manipulation, especially to the upper cervical spine, is still contentious.  Even with this disputable intervention, there are multiple accounts of the use of spinal manipulation in the literature for the treatment of cervicogenic dizziness (to name a few – Cote 1991, Uhlemann 1993, Bracher 2000Galm 1998)
In fact, Heikkila et al 2000 found when comparing acupuncture, NSAIDs and cervical manipulation that,
spinal manipulation may impact most efficiently on the complex process of proprioception and dizziness of cervical origin

However, the leading expert in cervicogenic dizziness, Dr. Timothy Hain, disagrees with the use of spinal manipulation with this quote:
we generally think that chiropractic treatment is not a good idea for vertigo of any type, including cervical vertigo
Granted, Hain is speaking of chiropractic but we all know this relates directly to manipulation.
Additionally, Fraix M et al 2013, an osteopathic physician and his group that has studied the effects of osteopathic manipulative therapy in a pilot study in 2010, then again in 2013 and Papa in 2017, purposely did not manipulate the upper cervical spine due to “possibly a pronounced effect on the vestibular system”.  Further, many clinicians note that non-thrust techniques may better serve the suboccipital region.
Thus, the literature is still pending on the use of spinal manipulation for the management of cervicogenic dizziness as it does not always seem logical (Duquesnoy & Catanzariti 2008).   Beyond the scope of this piece but very relevant is the type of manipulation in a patient with dizziness—such as, would it be more appropriate to perform a non-momentum induced thrust vs momentum induced thrust in someone with dizziness induced by head on neck positions?
The author of this manuscript considers spinal manipulation, but knows the effectiveness of other articular and non-articular methods of manual therapy.  It is not to say spinal manipulation isn’t safe, as it can be very safe if provided in the right context.  The application of one over the other entails many facets of patient management, including psychomotor skills, prior experience (patient and clinician) and a thorough assessment.

What are your thoughts?  What kind of experience do you have with this topic?

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You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the author and his wife, a Vestibular Specialist, teach a 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.  
If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at for prices and discounts.
Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    
Instructor: Cervicogenic Dizziness for Integrative Clinical ConceptsPhysical Therapist at In Touch Therapy, South Hill, VA
Danielle N. Vaughan, PT, DPT, Vestibular Specialist  
Instructor: Cervicogenic Dizziness for Integrative Clinical ConceptsVestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

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: 10:44

Listen in as Jason Shane rapidly loses the faith and interest of a patient who was so excited to see him as THE Guru she has been waiting for. We apologize for the quality of the audio in the next few episodes. It was a recording issue that we were not aware of until Jason and I recorded 3 entire episodes. You'll get the gyst of them and thanks for listening!

When active motion is limited, passive motion is not, but there is still pain or a sticking point, there is no physical barrier. There is a perception of pinch or pain, but it's neurologically limited. Often we find the most painful "hard end feel" and oscillate it or thrust through it. It usually improves upon re-test. Some patients will be too tender to use your go to mobilization or thrust techniques. Using manual resistance or agonist reversals gets your through a sticking point and often restores threat free end range. The goal is get the patient repeatedly loading the same motion to end range with passive overpressure repeatedly to keep the treatment effects going after you're done. All manual techniques should be applied with the goal of empowering the patient for self treatment. 

An Easier Way to Mobilize the Cervical Spine

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Keeping it Eclectic...

Today, I’m pleased to present a guest post by Ryan Klepps of Strive Labs, a leader in the space of customer relationship management software. In the face of shifting economics, customer loyalty is a huge deal. We know of this from the 80/20 rule as it relates in business, management, brand loyalty, profitability, and so much more.
And, in the current climate of healthcare economics, the question begs: What do we DO, when are just aren’t getting paid like we used to be?
Today, Ryan answers that very question and then some. So, without more yammering from yours truly… take it away, Ryan!

5 Strategies to Combat Shrinking Reimbursement in Physical Therapy

If there’s one thing we can all agree on, it may be this: the profit margin in outpatient physical therapy is slim.  And, with the average rate of reimbursement either staying stagnant or decreasing, this trend doesn’t look like it’s going to be reversed any time soon.
The frustration that I hear echoed most often by clinic owners is their lack of control over what they are reimbursed by insurance companies.  Out of this widespread frustration comes advocacy, spearheaded by the APTA (especially the Private Practice Section).
The issue is, advocacy is a slow moving beast (and insurance companies may be even slower moving); it may take years before we see an identifiable change in any given area of our profession.
So, we have a long-term plan as a profession, but what about your plan as a clinic owner?  What are your strategies to combat the current trends in the profession and continue to direct your business on the path to success?
Obviously, calling up insurance companies and fighting to get your rates increased is as effective as banging your head against a brick wall.  So, like any entrepreneur, you have to be resourceful and find creative solutions.
To help you get started, I’ve listed 5 strategies that focus on the aspects of your business that you can control.  In the end, zeroing in on concepts such as patient retention, word-of-mouth referrals, and patient engagement can improve your clinic’s efficiency and start increasing those profit margins!

1. Objectify the Patient Experience

Even if you’re using an outcome tool to track objective progress, and even if that outcome tool measures patient satisfaction, you’re likely missing the boat on objectifying and acting upon the customer experience.
Imagine having the ability to identify unhappy customers at their third visit in order to perform a customer service rescue to create a satisfied lifelong client. Or the ability to identify your biggest fans at discharge in order to ask them to tell their friends and family about your services. This isn’t a dream – a tool exists that can help you create and retain loyal customers. This tool is the Net Promoter Score (NPS).
The Net Promoter Score was developed by Bain and Company in 2003 to help businesses measure and monitor customer loyalty. This tool is so powerful, in fact, that the Harvard Business Review has dubbed it The One Number You Need to Grow.
The NPS is more than a survey, and it’s more than a metric; it’s a way of doing business. Monitoring, understanding and acting upon the NPS forces companies to focus on delighting their customers. And in that process, it can drive growth, as NPS companies see:
  • Increases in their number of word-of-mouth referrals
  • Increases in their customer retention rate (decreased early patient dropout)
  • Increases in customer reactivation rate (getting past patients to come back)
  • Implementation of data-driven process changes across their organizations to improve the customer experience and systematically build patient loyalty
  • Utilization of NPS data to increase Search Engine Optimization (SEO) so that it is easier for potential customers to find them online.
And the best thing about the NPS is that it’s simple to deploy, analyze and act upon.
The NPS itself is a quick, one question survey that asks your customers:
How likely is it that you would recommend [Blank Physical Therapy] to a friend or colleague?
 Best practice for NPS collection also calls for optional open-ended feedback asking What is the most important reason for your score?
Depending on their score on the NPS, customers can fall into 3 categories:
  • Promoters: Responders who score a 9 or 10. These are your loyal customers; the lifeblood of any business.
  • Passives: Responders who score a 7 or 8. These people are passively satisfied with your services. While you may think satisfied customers is a good thing, this group isn’t brand loyal: they’d be quick to try out a competitor’s services next time around.
  • Detractors: Responders who score a 6 or lower. For these customers, a fundamental failure in service delivery occured. These people, aside from being angry, are the most likely culprits for negative word-of-mouth comments that hurt your business.
To calculate your company’s NPS you need to keep track of the percentage of your patients that are promoters, passives and detractors.
The calculation itself is is simple:
NPS Score = (% Promoters) – (% Detractors)
As an example, if 70% of your customers are promoters, 10% are passive, and 20% are detractors, your NPS is 50.

2. Turn 2’s and 3’s into 7’s and 8’s

Your patient Bill attended his IE, and scheduled a few follow-up visits.  You see him twice the following week, and all seems fine.  But, it dawns on you a week or two later that you haven’t seen Bill since his third visit.  This is an all-too-common occurrence, and unfortunately, Bill’s probably gone for good.
By analyzing the NPS data we’ve collected at Strive Labs, we’ve found that people who score on the low end of the scale (detractors) are more likely to drop out of care than their promoter counterparts. This is also supported by data collected by Bain & Company, who state that detractors are more likely to defect than promoters.
We also know that a large cohort of patients (about 20%) drop out of PT within the first 3 visits. This high customer drop out, or patient churn, can cripple your bottom line. The good news is, it can be managed by finding your detractors early and intervening appropriately.
If 20% of customers are dropping out in the first few visits, it makes the most sense to send the NPS within the first week of a patient starting care with you. You can have the patient complete the NPS in clinic, or send it via email with tools like Survey Monkey or StriveHub.
From there, have a plan in place to intervene when a low score comes across your desk. If you can set the wheels in motion early, you have the opportunity to improve the customer experience and decrease that patient’s likelihood of dropping out of care, as well as the possibility of creating a loyal customer through service recovery efforts.
You can also follow-up by sending another NPS at the date of discharge, and compare your scores at these two touch points.

3. Keep Track of Your Promoters, and Make it Easy for Them to Promote!

On the flip side, your promoters are the key to driving growth at your organization. Here’s what we know about the power of promoters:
  • Promoters account for 80-90 percent of a company’s word-of-mouth referrals.
  • Promoters require less sales, marketing, and advertising costs than other customers.
  • Promoters are less price sensitive than other customers (in the age of deductibles, this is an important statistic to be aware of).
  • Promoters have a substantially greater Lifetime Value than other customers. Meaning, they buy more in each transaction, and they come back more often.
  • Promoters are more interested in new offerings and brand extensions than other customers.
  • On average, an industry’s NPS leader outgrew its competitors by a factor greater than two times.
So it would only make sense to keep a running list of who these people are, because it makes the next step a whole lot easier.
Your promoters are ready-and-willing to talk about you. If you know who they are, it becomes much easier to give them a nudge in the right direction. Here are a few examples of how promoters can drive growth:
  • Drive social reviews: Follow up a few days after a customer scores highly with links to your Google Local page. Google Reviews improve your search engine rankings, and help prospective customers find you more easily.
  • Engage them with Post-Discharge Information: These are the people most likely to convert to wellness and gym programs. Make sure every one of them receives that information right around their date of discharge.
  • Run Reactivation Campaigns: Stay in contact with your promoters after they are discharged, and give them the opportunity to come back in for a free wellness screen or a new course of care 3, 6, or 12 months after discharge.

4. Close the Loop

The open-ended feedback that you’re collecting from your customers is a proverbial goldmine.  This feedback should be shared with the employee(s) most responsible for creating that customer’s experience.
Over time, this will give your team the ability to truly understand the voice of the customer and identify common trends that lead to a positive and negative customer experience. The end result: addressing and fixing common customer concerns as well as innovating with the goal of creating more promoters.

5. Make Sure Everyone on Your Staff is on the Same Page

This is absolutely necessary in order for above strategies to be successful; if you are considering implementing any of these strategies at your clinic, I’d suggest making sure you start here.
Any initiative’s success is heavily contingent upon your ability to develop a plan, articulate it to your staff, and get them to buy in. Everyone from front desk staff, to clinicians, to rehab aides should understand the plan, and their responsibilities in making the plan successful.
One of the most effective ways of unifying your staff is to focus in on a single metric.  Let’s say, for example, that your goal is to improve your clinic’s average visits-per-patient by 15% in the next 3 months (a good example of a SMART goal).  In this case, you should let your staff know that everyone’s performance, including your own, is going to be measured by whether or not this goal is met.
You can certainly identify particular areas that each staff member can work on to achieve the goal (e.g. front desk staff confirming appointments ahead of time, clinicians spending a set amount of one-on-one time with each patient, etc) and ask each team member for other suggestions.  But, ensuring that the staff knows that they are all working toward a common goal will promote accountability, teamwork, and help improve the probability that you will be successful.

About Today’s Contributor:
ryan pic
Ryan Klepps is a physical therapist and COO of Strive Labs, a software company that helps physical therapists create and retain happy, loyal customers.  Ryan is also on the Board of Directors for the APTA of Massachusetts, serving as their Membership Chair.

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 51 (subscribe here).
Here are some dates for remaining Mastering Lower Limb Tendinopathy course dates for 2017 in Perth, Brisbane and Adelaide.
This week we focus on biological therapies in tendinopthy. This basically includes platelet rich plasma (PRP) and stem cells. They are often wrapped up with many promises from enthusiastic clinicians but what does the evidence show and should we be recommending them? I wrote a similar blog focusing on PRP a while ago, this one extends the discussion into stem cells.

That elusive biological magic bullet for tendinopathy

I have wanted to write this blog for a while, mainly for the benefit of patients wondering about these treatments. For 11 years now I have worked in clinics were we only see tendinopathy patients who have tried (and obviously failed as otherwise they would not be there) basically every treatment. This commonly includes PRP. So yes, I am biased, but I admit people also commonly fail exercise and other evidence based treatments. So just because someone fails a treatment does not mean it is bad. We need to consider scientific first principles (biological plausibility) and the evidence. With this in mind, what do we know about biologic therapies in tendinopathy?
What is a biologic therapy?
Biologic therapies are produced by living organisms (This recent narrative review by Andia and Maffulli provides a detailed and balanced position and was the motivation for this blog). The aim of biologic therapies is to harness the potential of growth factors, cells and other biological factors to be used towards tissue healing. One of the issues is this aim, i.e. tissue healing. Although, an admirable aim, in a clinical context we often try and influence pain and function. It is far from clear whether tissue healing is necessary to achieve this. And even whether it is a realistic aim. We’ll explore this below.
Platelet Rich plasma (PRP)
The most commonly used biological therapy in tendinopathy is no doubt PRP injections. Blood is spun (centrifuged) to concentrate the platelets. Growth factors (GF) (eg platelet-derived epidermal GF, platelet-derived GF, transforming GF, insulin-like GF) and cytokines ‘with tissue healing potential’ from your own blood are injected into your own tendon. The growth factors have a role in tissue-repair, cell proliferation, and other processes, and that sound impressive. This is in my opinion one of the biggest issues with PRP. It comes from your body, it must be doing good. The story is so damn easy to sell.
But does it work? It depends on the study you read. As highlighted in the Andia review, ‘a moderate amount of basic science work shows that the approach may work, and a sizeable amount of animal work shows that biological interventions seem to have some effect.’ But does it work on humans? We know from imaging studies that improvement in tendon structure in imaging either does not occur or occurs partially, for most people, after PRP injections (e.g. Abate et al. 2014de Vos et al. 2011). And in any case, Drew et al. 2012 showed that structural change on imaging is not necessary for clinical improvements. Although this may be because structural changes on imaging are not sensitive enough to microstructural tendon adaptations. 
So, if the promise of better healing is not reality, can PRP at least improve pain and function? If you look at high quality trials, there does not even appear to be much benefit over placebo (e.g. de Vos et al. 2010, de Vos et al. 2014). A brief side note here. A recent RCT that I was involved with has challenged this. It was led by colleagues in Denmark including Anders Boesen and Henning Langberg and published in the American Journal of Sports Medicine. There were three groups. They all received eccentric exercise for 12 weeks, and two groups also had either PRP (4 injections) or high volume injection (HVI – 1 active and 3 placebo injections). Even the exercise only group received 4 placebo injections. We were able to blind patients and outcome assessors to the injection received. The findings were surprising – see the graph below for self-reported pain and function (VISA) outcome. The HVI was superior in the short term, but at 6 months PRP and HVI were equivalent and both superior to placebo control (exercise only). When I lecture about this I admit I am not an advocate of PRP but am an author on the only high quality study that shows it is more effective than placebo. It still does not change the overall evidence message. Of four Achilles trials, three show no benefit of PRP or blood products over placebo and only one shows benefit. Our finding may be explained by very poor execution and progression of the exercises.
Screen Shot 2017-07-09 at 8.51.02 pm.png
You might ask then, why is PRP so popular? As a doctor, you may see improvement in some of your patients and base your opinion on these cases (confirmation bias), and as a patient you may have a friend who had a great outcome (anecdotal evidence). This distortion of evidence is no doubt coloured by financial rewards for clinicians and the promise of a quick fix for patients. Andia and Maffulli suggest the biologic therapy/regenerative medicine industry will be worth US$8 billion by 2020.
Stem cells
The new kid on the block, sexy as hell, are the cell biologic therapies including stem cells. The mechanisms of healing related to tendon stem cell therapies are not known but may involve restoring homeostatic conditions and modulating the inflammatory response. Similar situation to PRP in that there is evidence they may be beneficial in lab and animal studies but translation to humans is very limited.
In the Andia review they identified nine studies that have used cell therapies to manage tendinopathy and only one was a randomized controlled trial. The remaining were case series which cannot tell us about the efficacy of these therapies. The one trial by Clarke et al 2011 showed marginal benefit for stem cell injections compared with PRP when added to eccentric exercise for patellar tendinopathy. The difference between groups in VISA change (i.e. 8 points) was well below minimally clinically important difference.
There is no doubt that these technologies will develop and this story may change in the future. For example, with PRP there is ongoing debate about the number of injections required, the optimal type of PRP preparation (e.g. leukocyte rich vs poor PRP), etc, etc. However, I struggle to get passed the underlying rationale of healing, given that it is conceivable that you can have a biological therapy that heals your tendon but does nothing for your tendon pain, and certainly nothing for function. So what are you trying to 'fix' or address?
Here are some take home messages:
1. Biological therapies are damn sexy
2. They promise a quick fix and the potential for healing
3. Cell and animal studies support this potential for healing
4. BUT this has not translated well to human studies
5. AND clinical outcomes from these outcomes may be no different to placebo
6. YET PRP is one of the most popular treatments for tendinopathy
7. What the?? This defies logic
8. Until you consider clinician financial incentives and patients desire for a ‘fix’
Peter Malliaras
Tendinopathy Rehabilitation

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...

The latest MMT Webinar is now up for registration! Eric Dinkins of Motion Guidance LLC is back after his very popular Motor Control of the Lumbar Spine. His current topic is Motor Control Deficits of the Shoulder and you can register here. The webinar is scheduled for Wed 26th, 8:30 pm EST

You will learn
  • An overview of motor control principles and systems
  • A literature review of motor control deficits that are present in the shoulder
  • A review of motor control learning and retention strategies including external focus and visual feedback 
  • Rehabilitation strategies and considerations for proprioceptive and motor control deficits at the shoulder complex
  • Adding visual feedback utilizing the Motion Guidance system into rehabilitation regimens (videos and photos included)

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: 4:47

Could back pain be "all in one's head." The patient in this week's episode had persistent back pain for 4 years that resolved in 6 weeks. Listen in to find out how. Also, this is Jason Shane, one of the co-hosts of this podcast first solo episode.

Patient having some shoulder mobility, motor control, or impingement like complaints? Sometimes they need a little PNF to help them restore motor control and proprioceptive awareness to their scapula. 

In this case, the DC student was unable to do push ups without shoulder pain. After restoring her ability to load right cervical retraction and SB, with IASTM and then repeated motions, her scapula stability immediately improved in a push up position. However, resetting an area and eliminating pain may improve function, but it does not improve capacity. She still lacked endurance of her scapular stabilizers and needed some PNF cuing to help facilitate her mid/lower traps on the involved (right side).

PNF For Scapular Stabilization

The entire 12 min mini-case, including regression, progression, and stability exercise for HEP can be found on Modern Manual Therapy Premium!

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...