Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews

5 Steps to Prove Your Therapy is Effective, Even When It Isn't - themanualtherapist.com


To add a little humor to the mix, this week goes over the steps needed to prove your therapy is effective, even when it’s not.

When you decide you want to create your own treatment method and want to maximize profits, these steps will guide you in showing others just how effective your treatments are despite them being full of bologna.

5 Steps To Prove Your Therapy is Effective, Even When it Isn't by Cameron Faller

👉Develop a Strong Allegiance - Create a following of eager clinicians and individuals who believe your claims developing testimonials and statements for why it has helped them.

👉Increase Patient Expectations - Utilize as many contextual effects as you can such as the way you dress, the words you use, the complexity of the intervention, etc. to increase preconceived patient expectations. Strengthening the beliefs of the treatment is more likely to result in a placebo response further enhancing the belief in the treatment.

👉Conduct Research with the Right Trials - It won’t be long before other clinicians claim “where is the research?” Luckily, you can design the right trial by including small sample size and comparing the intervention to a control group that is no treatment (DO NOT compare to an already existing treatment). Most often doing “something” always results better in doing “nothing”.

👉Utilize ‘Weak Spots’ In an RCT - There are several weak spots to take advantage of within your RCT such as failing to blind both assessors and patients, using selective randomization, failing to conceal allocation, and use multiple outcome measures with the hope that one shows significance.

👉Use the Right Publication Strategy - If your results are positive but you lack validity, there are still thousands of journals willing to accept without any peer-review process. Then you can boast your new method as an evidenced-based intervention.

On a more serious note, unfortunately, this process is exactly what several already existing poor quality interventions have done and continue to do claiming they are the “best.” When appraising any new treatment, or deciding to take a new course, make sure you don’t fall victim to these strategies and end up wasting a lot of your money and time.


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Untold Physio Stories Podcast - A Headache Differential Diagnosis - themanualtherapist.com


Did you know that you should get your eyes checked starting in your early 40s? Especially if you do not regularly go to an ophthalmologist. In this episode, Erson goes over a differential diagnosis for headaches and the importance of having your eyes checked.


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Can Botox help Cervicogenic Vertigo? - themanualtherapist.com


We recently read with interest a case report in 2020 by Dr. Odderson in the Journal of Clinical Neuroscience describing the resolution of Cervicogenic Vertigo using botulinum toxin (botox).

Albeit a short literary piece, Dr. Odderson provides sufficient information with cause/effect relationship of success using botox for Cervicogenic Vertigo after failed physical therapy, course of prednisone and two cervical epidural steroid injections.

Now before you go off and recommend botox for your dizzy and neck pain patients, let’s highlight 6 clinical characteristics about the patient as described in the study (in bold) and OUR impression (not bolded):

  1. This patient was also diagnosed with cervical dystonia by EMG. 
    • Anyone who has treated a patient with cervical dystonia knows it is not straightforward cervical case, especially if adding on 10 years following a traumatic event and multiple system involvement to cause dizziness.
    • I have actually recommended botox for cervical dystonia patients (which is also recommended in the literature) if no success with other conservative measures.  This pathology can be challenging and with it now in the literature, the typical signs and symptoms may not be as traditional as we first thought.  This takes us to other characteristics.
  2. She had onset of symptoms with full cervical rotation to the left
    • Over 2/3 of patients with Cervicogenic Dizziness have symptoms with cervical extension, which was not mentioned in this article.  Rotation is second most common, such as in this case and some of our cases too.
  3. She had symptom reproduction at times when lying in bed.
    • Cervicogenic Dizziness provocation is more positional, not positioning.  Meaning, positional movements (such as ROM as described above) brings on symptoms with minimal latency and fatigues if provocating maneuver is reduced.
    • Potentially, with the amount of stenosis as described in the case report, would create more of an upper cervical extension moment, placing undue compression on the upper cervical spine (and oblique capitis superior that was prominent in this case).  We see headaches and neck pain > dizziness arise with this position.
  4. The patient would, at times, have to lie down due to symptoms so bad it would make her nauseated.
    • It is a general rule that Cervicogenic Dizziness is not as “functionally limiting” or “severe” as a peripheral vestibular condition (such as BPPV).  Even Susan Reid’s 3 question clinical prediction rule helps us as clinicians consider symptoms that “keep the patient more at home” as NOT to be cervical in nature vs other causes.
    • Again with the cervical dystonia present, the amount of abnormal afferent information to the vestibular nucleus could have significantly altered postural control and head on neck awareness to make the patient this ill.
  5. The cervical vertigo presented with episodic bouts of dizziness, where the environment would move for her.
    1. It has been well-established in the literature (we have even written several posts on it too) that someone with dizziness arising from solely the cervical spine, or extra-cranial origin, is not described as the room spinning (i.e. vertigo).
      • I cannot say I am an expert at cervical dystonia, but possible the altered afferent proprioceptive projections from cervical and nuchal musculature (C1-4) is enhanced in this population and significantly overloads the signals to the vestibular nucleic complex.
    2. Anyone in neuromusculoskeletal physical medicine avoids “never and always” and again, this case could debunk our typical descriptors of dizziness in this population.
      • With this being said, we are moving away from descriptors and move towards timing and triggers for our dizziness diagnosis as we describe in our course.
  6. The patient “failed” physical therapy
    • Ah, as physical therapists, we hate this term!  It’s like saying, “doctoring failed” or “nutritioning failed”, etc You get the point.
      1. Yes, prednisone and cervical injections failed too — but we can all agree that there is a certain dosage, location (by mouth or location in spine) that is specific to these procedures, thereby, knowing its cause / effect action.
      2. We have a phenomenal profession don’t get me wrong, but we do know that not all physical therapy is created equal.  Questions arise, such as:
        • Did this patient receive manual therapy?
        • If so, what type of manual therapy?
        • Did this patient receive a more advanced clinical reasoning management approach or general stretching program to the upper trapezius? (Our most popular article…)
        • Was the therapist more of a “vestibular” therapist?
          • Many (but not all!) of vestibular therapists don’t really address the cervical spine.

Flexion Rotation Test, AA, C1-2, Cervicogenic Dizziness, Cervical Vertigo

Lots of questions remain for me for but overall a great case study here!  I really enjoy reading these as it helps professional allies come together to work mutually to help these patients.  I want my physical therapy colleagues to know about the positive effects of botox for certain patients and for my medical colleagues to realize these impressions (numbered 1-6 above) of how a physical therapist thinks!


You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 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 harrisonvaughanpt@gmail.com for more information.

AUTHORS

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts


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Happy Turkey Day (if you're in the US)

I hope everyone is staying safe and healthy during the holiday season.

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Thanks to everyone for supporting MMT Blog, listening to Untold Physio Stories, and your comments on social media.. The team and I are taking a break from blogging this week but we'll be back next week with more posts, videos, and podcasts!

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5 Reason Why Direct Access to Physical Therapy is Beneficial - themanualtherapist.com



🔥FRIDAY TOP 5🔥

To end this mini series on the topic of direct access, I have developed 5 reasons as to why it can be very beneficial. Each reason is paired with moderate-high quality evidence supporting it.

5 Reasons Direct Access to Physical Therapy is Beneficial by Cameron Faller

👉IT’S COST EFFECTIVE - Seeing a physical therapist first has resulted in decreased health care costs in a variety of studies. The most likely reason for the decreased costs include reduced imaging, medication prescriptions, and need to see a specialist.

👉REDUCES LONG-TERM OPIOID USE - A retrospective study found that individuals with low back pain who saw a physical therapist first were less likely to be associated with early and long-term opioid use.

👉IMPROVES HEALTH OUTCOMES AND LESSENS DISABILITY - A higher quality study analyzed the health outcomes and disability between individuals with sciatica who were referred to physical therapy early vs usual care (i.e. medications and advice) and found that seeing a PT initially significantly improved health outcomes and lessened the risk of disability after one year. 

👉REDUCES THE UTILIZATION OF SPECIALTY REFERRALS, IMAGING, AND PHARMACEUTICALS - Similar to being more cost effective, seeing a PT first reduces the need for a variety of interventions or testing that could result in increased harm and having deleterious effects in self-management.

👉HAS BEEN CONSIDERED AS SAFE AS SEEING A GENERAL PRACTITIONER OR SPECIALIST FIRST - It has been proven time and time again that seeing a physical therapist first is completely safe. With most PTs having doctorate level education or over 15 years of experience, there has been data collected from the 1970s indicating that it is no more dangerous being able to see a PT first than it is your GP or a specialist.

Currently all 50 states are able to have some sort of direct access meaning that if you are dealing with pain you have the opportunity of seeing a PT quickly, bypassing the need to get a referral. Early management and understanding of your condition can be very beneficial towards your health as indicated by each of the reasons above.

Know someone who might find this helpful? Tag or share!

via Cameron Faller's instagram
"Movement is Medicine"


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Untold Physio Stories Podcast - Do You Misunderstand Me - themanualtherapist.com


In this episode, Erson goes over a recent case that is fixated on "knee alignment." After a lot of education and back and forth debate about it's not ruminating on joint position, scans, knee fat pads and more. It turns out the patient was really talking about dynamic alignment as in knee stability during movement, not just joint position. It was a great lesson as defining what certain obvious (to clinicians) terms might mean and verifying whether or not a patient has the same definition might prevent a big misunderstanding. 


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Could Meat Lower Heart Disease Risk? - themanualtherapist.com


By Dr. Sean M. Wells, DPT, PT, OCS, ATC/L, CSCS, NSCA-CPT, CNPT, Cert-DN

If you were reading the news last week then you might have seen an article that sounds something like: "Good News, Meat May Protect You from Heart Disease." While this sounds exciting and promising, many of the published media articles just don't dive into the science enough to give citizens and clinicians an educated viewpoints. Let's examine the new evidence, its science, and what impact it should have on physical therapy practice.

The Article

The main research paper the media is slinging around can be found in mSystems, an open access journal. The authors, Kivenson and Giovanni, published the paper title An Expanded Genetic Code Enables Trimethylamine Metabolism in Human Gut Bacteria, which full-text can be found here. Both Kivenson and Giovanni are researchers at Oregon State University and their primary focus is in microbiology.

mSystems is a relatively new journal. Overall it has an impact factor of 6.28 on Resurchify, which compares bleakly to JAMA's 14 and New England Journal's 37. Typically a score above 10 shows the journal has a major impact on Resurchify. Using Scimago Journal and Country Rank (SJR) website, they rank mSystems well below even our Physical Therapy and Journal of Orthopedic and Sport PT Journals. I guess this shouldn't come as a surprise given it is a young, online, open-access journal.

Setting aside the journal, the article itself is a quasi-review of published data sets. The authors take a "survey" approach to reviewing selected data sets to round out their research inquiry. Let's explore the science behind the article now.

The Science

The primary inquiry of the researchers focuses on animal meat and trimethylamine (TMA), a precursor of the proatherogenic compound trimethylamine-N-oxide (TMAO). PTs that have taken our courses know that TMAO is a known byproduct of animal consumption. Choline and carnitine, both amino acids found in high concentrations in animal products like meat and eggs, are converted in the liver to TMA. Gut bacteria often covert this TMA to TMAO, which is taken through the bloodstream and promotes cardiovascular disease. This is what the process looks like:

TMAO is just one of many reasons (including excessive heme iron, saturated fat, advanced glycation end products) most of our physical therapy patients should be eating a plant-based diet.

On the contrary, these researchers sought out to find a strain of bacteria in the gut that could process the TMA to not produce TMAO. They knew that eating meat increased certain bacteria, one of which is known as Bilophila wadsworthiaBilophila was first found in a appendix many years ago, is a known pathological bacteria, and has genes necessary for encoding pyrrolysine, which has been suggested to demethylate. Bilophila is associated with inflammatory bowel disease, hydrogen gas production, amongst other "bad" things. 

The researchers then scoured the literature to find at least one human and one mouse data sets to begin their analysis. After surveying these data sets, the authors found that Bilophila appeared to be able to convert TMA to a safer compound known as DMA through demethylation and other processes. It looks something like this:

Got all that? Yikes! Continuing on, the authors cited "the fraction of TMA consumed via this bacterial metabolic process in the human gut microbiome remains uncertain, but expression data support the conclusion that this metabolic process is active." In short, the authors' diagrams and summaries all point to the fact that this bacteria could be utilized in some capacity to reduce TMAO, and heart disease, through the use of probiotics or other gut biome manipulations.

Physical Therapy Implications and Discussion

First, I think we should take this article for a grain of salt. It is an open-access journal that is new and with minimal impact. Secondly, the article design is survey-based with no actual manipulation of genes, proteins, etc by the authors. Thirdly, have the data sets used were from mice: human gut biomes varying dramatically from those of rodents.

Furthermore, I think we ought to take a logical step backwards. The researchers in their introductory paragraph cite that meat consumption often causes a spike in Bilophila. If this is the case, then meat consumption itself ought to promote more conversion of TMAO to TMA. A great drop in TMAO ought to translate into lower cardiovascular heart disease risk, right? This is what some of the media, Carnivore pundits, and want-to-be scientists were hoping to hear: eat more meat to boost this bacteria and cut your heart disease risk. 

Unfortunately it does not pan out with such logic. A high meat diet is associated with higher rates of mortality, cancer, heart disease, diabetes and obesity. This we know based on large epidemiology studies from various human data sets around the world. Hence why physios should be encouraging their patients to stick a predominantly plant-based diet. 

Putting aside these limitations, these researchers have opened the door to showing certain gut bacteria may be helpful in reducing heart disease. It should be stressed that the authors show a reduction in TMAO, not an elimination. How we manipulate the gut biome to yield higher Bilophila remains to be seen. In the future, the use of probiotics, possibly with certain antibiotics, may help a patient shift their gut bacteria to reduce their heart disease risk. This seems like more of a reality versus just eat more meat to get the higher Bilophila bacteria count. 

It's important to see that certain bacteria, viruses, and fungi interact with each other. Some supporting each other, while others attacking and dominate other strains. Understanding the complex interactions of the gut biome will be a monumental scientific feat similar to coding the human genome (if not more complex).

Physical therapy implications tied to the gut biome are many. From autoimmune diseases like rheumatoid arthritis and multiple sclerosis, inflammatory conditions like heart disease, to obesity and infections, the gut biome have certain implications in health and PT practice. Again, reducing TMAO through bacteria changes is one method, but we can nearly eliminate TMAO by making certain dietary changes...So, how can we help as clinicians? It's simple:

  1. Encourage clients to eat real, whole, plant-foods. Studies show that the human gut recognizes this food and it helps to build a stronger gut flora.
  2. Educate your patients to eat a variety of plant foods. More variety in foods equals a greater variety in bacteria, fungi, and viruses, all which can be helpful.
  3. Enjoy probiotic rich foods like kimchi, fermented drinks and plant-based yogurts, and miso. Probiotics themselves may be helpful, although we don't know exactly what strains are best for each client (yet).

In the end, PTs should look beyond the hype of the media, especially when it comes to hard science like microbiology and the gut biome. Simple dietary changes can make a big difference and is likely easier to implement at this time compared to complex probiotic changes and treatments. Enjoy your food!

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Top 5 Fridays! 5 Spiderman Mobility Progressions - themanualtherapist.com

🎯Spiderman Progressions ⤵️  reposted with permission from Matthew Ibrahim's Instagram

🧱 The Spiderman exercise has been around for quite some time and fits really well into the movement preparation/warm-up section of a training program. Additionally, it can also be used as a mobility "filler" drill in between your lifts and also on active recovery days for general health.