Modern Manual Therapy Blog

This post… has been a long time coming. It’s needed. It will not be comfortable. And, it shouldn’t be! If you’ve read any of the below posts…
You know what I’m about, and, you know for the most part that I nigh annoyingly positive, constructively inclined, and inherently optimistic. Rarely, do I flat out say something needs to stop. Well… today is one of those rare days.

5 Things in Physical Therapy We CANNOT Ignore Anymore

1. The Debt

It isn’t just because there are, for the most part, daily online conversations about the tremendous student debt happening in the field of allied rehab therapy. It’s not just because I get regularly flooded by questions in my many inboxes on the matter of personal finance and career path. The reason we NEED to talk about the debt, isn’t even for the sake of student debt, itself.
I believe it was said best in a major highlight point in the Graham Sessions 2018 conference [click here for the recap] — The debt we are saddling our students with is unconscionable and threatens the health of our profession.”
There will be no profession, if professionals cannot afford to practice.
This is as much of a problem in the health of supply in new clinicians, as it is in the business practices en masse of our profession. If we have no supply, how can we suffice any demand…. not to mention, our historical desire to raise demand for Physical Therapists beyond the 7-10% marketshare for musculoskeletal health service delivery — a great segue to #2…!

2. The Atrocious Attitude Towards “Marketing”

For far too long, Physical Therapists along with our allied rehab therapy colleagues have taken this curious “step back” in accepting our station as “ancillary services” to the “primary” services, that of physicians. We’ve been happy enough — at the very least, happy enough not to change anything. Still, when it comes to being at the mercy of referring medical offices versus aggressively going after the market — we do a lot of talking, and not much action.
A market, mind you, which is WIDE OPEN. As mentioned, only 7-10% of the general population that medically qualifies to be seen by a Physical Therapist — ever does. AND, of that marketshare, the outpatient sector can boast a conservatively aged industry value estimate of $30 BILLION dollars [see here & here, “classic numbers”].
This attitude problem is furthered with so many practices “proud” of have a “zero marketing budget” or being 100% driven by referrals and word-of-mouth. What happens when referrals stop? What happens when people stop talk about your practice? What happens when the majority of healthcare consumers do what every other consumer group does… and, shifts their shopping behaviors online channels as they’ve ALREADY DONE?!
This “we don’t need to market because the excellence of our care will market for us” needs to go away… FOREVER.
Disney. Amazon. Apple. Google. Starbucks. Target. They are all pretty dang savvy at what they do. Do you see THEM bragging about their “zero marketing dollars spent???” HELL NO! These industry giants don’t measure their marketing success by how much money they DIDN’T SPEND; they measure their marketing success by the Return On Investment (ROI) by scale to which they DID INDEED SPEND! AND, many times… the more they spent, the more they gained!
Marketing isn’t a dirty word. Sales isn’t a dirty world. Public Relations isn’t a dirty word. Community Outreach isn’t a dirty word. Spending isn’t a dirty word.
If any of the words above made you uncomfortable, as if it’s not part of the clinician’s role… then it represent a naive outlook that if we are good enough, people will support us. WRONG! If we share the message of WHY we are the best choice they’ve ever made for their lives and their well being… THEN they will support us — which then leads us to…!

3. Acting As If Someone Else Will Advocate For Us

In the scope of physical therapy, we are a doctoring profession. That means Physical Therapists are doctoring providers; and, Physical Therapist Assistants are extenders of doctors. This isn’t about if we should be; this isn’t about how it came to be; this isn’t about how we should change; this isn’t even about how some of our colleagues missed the “D” in front of their “PT by mere months or handful of credit hours; this is about what is presently the situation for the Physical Therapy profession. And — we need to own this.
HOWEVER, what we are trained to do is ultimately trumped by how we are LEGALLY allowed to practice. It doesn’t matter how great our training gets, how advanced our schooling gets, or how backed by science our methodologies are — if our LICENSE doesn’t reflect those knowledge & skill sets… our hands are tied.
All these political and legislative battles are fought in another playing field — outside of the clinic walls, on top of another veritable treatment plinth. The victors of these battlefields are the true gatekeepers of supply. It is here, we must fight and win.
Speaking of… have you heard of the PT PAC? Any ideas what they do? Honestly, I didn’t while I was in school… I barely understood the significant even three years post grad… and, only recently have I had in depth discussions with the PAC on what they do — and, how simple things like: how APTA membership dues and lobbying dollars come and go in different buckets. Confused? Angry? Feeling like your dues should somehow lead to advocacy dollars for lobbyists? Well….. it’s a different story in this battlefield and we must be AWARE of the weapons if we are to be strategically involved in actionable game plans.
Tragically, this ever present lack of awareness to the importance, logistics, and flow of how advocacy works for our profession is crippling us. It’s beyond ridiculous to think a PROFESSION can care so little to act upon the very barriers and boundaries to which govern its ability to practice. Sadly, so much of this can be attributed to…!

4. The Lack Of Ownership Mindset

In the practice of physical therapy, clinicians are conditioned to be workers, not owners. You heard me, you read that correctly — Workers. And, regardless of if an individual professional is an equity owner or shareholder, it’s not so much about the title as much as it is the MINDSET. Our tendency as clinicians is to think and value only the clinical aspect of our profession — after all, someone else will take care of it, right?
Someone else will do marketing, someone else will cover billing and coding, someone else will do training, someone else will surely take care of the political battles on Capitol Hill… right??? Right? Please??? Somebody?!
This is a huge problem as the clinical practice is but once facet of the bigger picture; a bigger picture that includes things like business administration, marketing, healthcare administration, corporate compliance, human resources, billing, accounting, finance, business development, company culture, legislative and political advocacy, public relations, systems building, etc. etc. etc.
We need to stop thinking as clinicians, and start thinking as a profession.
Further on the ownership mindset: There are these weird and terrible myths we still circulate. Thoughts like it takes 5 years of experience before clinicians should think about opening up a practice. Or, that business is bad & corporations are greedy.
BUSINESS isn’t bad. Bad business, is bad.
If we continue to ignore all the other various facets of professional practice, we will only continue to pigeon hole ourselves as replaceable technicians.

5. Comfort Is The Enemy Of Progress

“Comfort is the enemy of progress” — P.T. Barnum
Competitive advantages don’t come from comfortable situations. Sadly, one of the highlighted “benefits” of the Physical Therapy profession as well as the Rehab Therapy Allied Industry at large… is that it’s comfortable! At WORST: You will always have a comfortable, recession proof, average middle-class American job and lifestyle.
I don’t know about you… but, for me… with the amount of training, sweat, blood, tears… oh, and of course… the aforementioned #1 thing we can no longer ignore… THE DEBT… “average.” is no where near good enough.
Average comfort is not good enough for me, for my profession, for my colleagues, for my stakeholders, for the patients we serve… it’s not good enough for a health-stricken society that NEEDS US to step up and be the doctors they deserve… the doctors we are supposed to be.
Comfort has left our feet, stuck in the mud, because all we’ve done is let rain water gather around us whilst we failed to prepare our crops for the coming seasons. And, while not taking any credit nor due recognition away from those who continue to fight for us, lead us, pioneer, suffer, and otherwise put themselves out there for public critique — we’re not talking about those already sacrificially leading the way on the bleeding edge….. we’re talking about our entire profession en masse. We need to stop being, feeling, and aiming to be comfortable.
We need to get comfortable being UNCOMFORTABLE.

I know, I know… I’m just so positive on a usual day. This is a rather aggressive post for someone like me. Well, sometimes you have to draw a line and take a stand… sometimes, you can’t just promote what you love. SOMETIMES, there are barriers that get in the way. And, as much as I’m known as an advocate for building bridges, sometimes you have to knock down a few barriers first, before you can make meaningful progress in making those connective crossways.
These are five areas we just cannot ignore anymore. And, sure… there are probably way more. Starting here is a good place to begin planting the seeds for other concerns, such as narrowing the gap and tightening the confidence interval in our clinical excellence as a profession. Honestly, it shouldn’t be the case that going to one Physical Therapist while compared to the care of another, becomes a drastically different experience. Sure, stylistic uniqueness should remain; but, the amount of brand damage we receive from such variance between consumer experiences doesn’t help show how unique we are as practitioners. It only communicates to healthcare consumers that they can’t trust the consistency when “going to get physical therapy.” *barf*… #YouGetTheIdea…

Oh, if that bit on attitude towards marketing for you a bit fired up… here’s some light reading material on marketing that you can check out via our exclusive e-series “MARCH MARKETING MADNESS 2018.”

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Keeping it Eclectic...

This episode I discuss a recent systematic review that concluded that PRP is more efficacious than control injections for tendinopathy, but the plot thickens when we scratch the surface a little.
via Dr. Peter Malliaras, Tendinopathy Rehab

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 following three blogs are a review of the most recent clinical practice guidelines for pelvic girdle pain in the antepartum population. Published in 2017, and I believe one of the first of it's kind, particularly in the field of Women's health, this review looks a the body of knowledge prior to 2012. The article by Clinton et al (2017) is a comprehensive evaluation of the literature and provides assessment and treatment recommendations based on the strength of evidence available. What I felt was lacking from this CPG was a guide that would help clinicians improve their framework for assessment an treatment. The aim of this blog series therefore is to delve deeper into the papers behind this review, pull out the finer detail and hopefully provide further clarity to guide clinicians. 


Well this is a first for our blog, because classification codes are unique to Physical Therapy in the United States but also unfamiliar to me as a clinician before I moved here. The reason I have chosen to include this section is because one of the stronger arguments around why we are lacking strong evidence for this conditions is due to variability in nomenclature and terminology. Looking at the list of conditions accepted under this diagnosis below, you can easily see that we have not yet come to a firm conclusion about the language we should be using to identify patients with PGP and manage them. To my understanding, the Australian approach, is to broadly diagnose PGP during pregnancy and often use the terms reduced/excessive force or form closure according to the O’Sullivan classification. 
What the table below does represent well is how varied the symptoms are of this condition and the impact it has on the individual within the WHO-ICF framework. Often the name pelvic girdle pain can direct us to focus purely on the pain aspect of the condition and not how it affects the individual's activity levels and participation in daily activities. 
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The currently accepted definition for Pelvic Girdle Pain has been continued from the European guidelines published in 2008 and includes the following elements (Vleeming et al., 2008, p 797):
  • Pelvic girdle pain generally arises in relation to pregnancy, trauma, arthritis and osteoarthritis.
  • Pain is experienced between the posterior iliac crest and the gluteal fold, particularly in the vicinity of the SIJ.
  • The pain may radiate in the posterior thigh and can also occur in conjunction with/or separately in the symphysis.
  • The endurance capacity for standing, walking, and sitting is diminished.
  • The diagnosis of PGP can be reached after exclusion of lumbar causes.
  • The pain or functional disturbances in relation to PGP must be reproducible by specific clinical tests.
This same guideline also proposes a functional definition of joint stability (Vleeming, et al., 2009, p. 798):
  • ‘‘The effective accommodation of the joints to each specific load demand through an adequately tailored joint compression, as a function of gravity, coordinated muscle and ligament forces, to produce effective joint reaction forces under changing conditions’’. 
  • Optimal stability is achieved when the balance between performance (the level of stability) and effort is optimized.
  • Non-optimal joint stability implicates altered laxity/stiffness values leading to increased joint translations resulting in a new joint position and/or exaggerated/reduced joint compression, with a disturbed performance/effort ratio.


The current CPG states that the "prevalence of PLBP and PGP is estimated to occur in 56% to 72%of the antepartum population, with 20% reporting severe symptoms during 20 to 30 weeks of gestation. In total, 33% to 50% of pregnant females report PGP before 20 weeks of gestation and the prevalence may reach 60% to 70% in late pregnancy.” (Clinton, et al., 2017, p. 107). 
This is an incredibly high prevalence!
I thought this number to be so high that I decided to look at two of the key references supporting this claim (Albert et al., 2002; Mens et al., 2012).
“The lack of definition together with a large variety of study designs have led to the fact that the reported incidence of pelvic and low back pain in pregnancy varies between 4% and 76.4%.”(Albert et al., 2002, p.2831). Albert et al (2002) conducted a epidemiological study and described 4 different groups of PGP: pelvic girdle syndrome, symphysiolysis, one-sided sacroiliac syndrome, and double-sided sacroiliac syndrome. They found that many studies did not provide specific detail of the location of pain and how participants were assessed. What Albert et al (2002) concluded was that the incidence of PGP at 33 weeks gestations was 20% and that 6% of pregnant women pelvic girdle syndrome. 
Mens et al (2012) reported a much higher number. “In the present study, about 60% of the women reported pain in the lower back and/or pelvis at that moment of examination or during the previous seven days. The severity of experienced pain and disability can be interpreted as mild and moderate in the majority of cases, and severe in about 20%. Women with LBP during pregnancy had more previous pregnancies, a higher BMI and more often had LBP in the past.”
Overall, while the prevalence stated in this CPG appears high, after reviewing some of the backing literature, it appears that the values have been summed together. The higher values are generally derived from studies with a less structured clinical assessment and ones where pregnant women report the presence of PGP based on self assessment and questionnaires. Regardless, PGP is a highly prevalent and varied condition


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Risk factors are an element all clinicians are curious about and yet we can't concretely make clinical judgements made purely around this area. But who is more at risk according to the current CPG? Those with(Clinton et al., 2017, p. 107):
  • A history of multiparity,
  • Joint hypermobility,
  • Periods of amenorrhea,
  • Increased BMI, 
  • Hip and/or lower extremity dysfunction including the presence of gluteus medius and pelvic floor muscle dysfunction.
  • A prior history of trauma to the pelvis or history of lower back pain,
  • Pain during previous pregnancies,
  • Work dissatisfaction, and
  • Lack of belief in improvement. 
One of the key articles referenced (Gutke, et al., 2008, p.304) was a Swedish study that explored the role of muscle function and dysfunction in its relation to pregnancy. Essentially, they wanted to find out if it was a case of the chicken or the egg? Do muscles become dysfunctional during pregnancy or are they pre-existing and contribute to the development of LBP and PGP; which is a similar research question to one asked in other sub-populations of LBP? 
The overall structure assessment of LBP and PGP is very similar to what I have been taught, except for the assessment of muscle strength. Gutke et al (2008) assessed muscle function of gait speed, hip extension strength with a dynomometer, back flexion strength with a sit up and back extension strength prone on the table lifting their legs. Some of these strength assessments are particularly hard to complete with a pregnant patient. What I use is single leg stance, side lying external rotation strength, side lying active straight leg raise, bridge strength, single or double leg sit to stand and gait. 
What they determined from their assessment is that women with PGP +/_ LBP demonstrated lower endurance on back flexion and extension strength, slower walking speeds and weaker hip extension strength. This weakness was seen early in pregnancy suggesting that it may be pre-existing. These findings strengthen the hypothesis that muscle weakness can contribute to reduced force closure and the development of PGP during pregnancy. From these findings other researchers have used exercises to promote force closure by strengthening these muscle groups with good outcomes. 
This was just one of the articles I read but the take home message is that many articles included had completely different assessment and screening processes. Therefore it is hard to know the exact weight each of these risk factors has on the condition and is likely to be based on the individual rather than being a hard rule.
When looking at a systematic review from 2009, Vleeming et al state that there are only 2 strong risk factors associated with pregnancy. “Risk factors for developing PGP during pregnancy are most probably: a history of previous low back pain (OR 1.8–2.2) and previous trauma to the pelvis(OR 2.8). (Vleeming, et al., 2009, p.801).


“Vleeming et al (1990; 2008) developed the hypothesis of hormonal and biomechanical factors as potential contributors to PGP. Stabilization of the pelvis during load transfer is achieved by the 2 mechanisms of form closure and force closureForm closure is achieved when the wedge-shaped sacrum fits tightly between the ilia. This process is maximized by the force closure of the muscles, fascia, and ligaments to provide the joint stability. Changes in the ability to manage load transfers due to joint laxity may account for the development of PGP in this population. A change in adequate force and/or form closure of the pelvic girdle was previously postulated to occur by the presence of the hormone relaxin; however, current studies suggest no correlation between relaxin and PGP.” (Clinton, et al., 2017, p.110).
Alicia has previously written about the pathophysiology of PGP and discussed these hormonal changes in further depth. Many physiological changes occur during pregnancy. The most commonly discussed is the change in levels of the sex hormone relaxin. Earlier studies suggest these sex hormones have a role in altering collagen production affecting the ligamentous structures stabilising the pelvic girdle, however recent strong evidence indicates relaxin is not the cause of PGP (Aldabe et al, 2012; Kristiansson et al, 1999). Instead, O’Sullivan and Beales (2007a) propose the existence of other hormones in influencing pain modulation and the inflammatory process, possibly inducing heightened pain reception and prolonging the inflammatory response (Aloisi & Bonifazi, 2006). 
Another point to remember is that chronic injury is associated with psychological and cortical changes. O’Sullivan and Beales (2007a) specifically identify the presence of hyper-vigilance, fear avoidance behaviour, altered coping strategies, anxiety, pacing, depression and helplessness in pelvic girdle pain, among others. 
Many therapists have identified fear avoidance as a contributor in pelvic girdle pain, affecting the transfer of load through the pelvis. Although not a primary mechanism for the pain, it can cause secondary alterations in muscle activation and motor control, perpetuating the asymmetrical pelvic stability associated with pelvic girdle pain (Beales, O'Sullivan, & Briffa, 2010).
These psychosocial issues have an ability to drastically alter the patient’s outcome, while these factors are not the primary mechanism of pain, they have the capacity to sensitise or amplify pain receptors and disability (O'Sullivan & Beales, 2007a). A patient with poor coping strategies, in the presence of pelvic girdle pain, may experience increased anxiety levels, damaging beliefs, fear avoidance and catastrophising causing a heightened pain response through central sensitisation, further perpetuating the pain cycle (O'Sullivan & Beales, 2007a).


This is a topic everyone loves to talk about. Spoiler Alert! The results are similar to what we know about other conditions too...
  • The pain levels cannot be used as a predictor for the width of the pubic symphysis, indicating a relationship between width and pain is present but other pathophysiological processes are also occurring (Bjorklund et al., 2000).
  • Damen et al (2001) found a strong correlation between unilateral sacroiliac joint laxity and PGP during and following pregnancy, although this was not bilateral. It appears the laxity is a result of unilateral motor dyskinesis rather than global ligamentous change following pregnancy.
  • Hungerford et al (2003) found a delay in muscle activation of multifidus, internal obliquus and gluteus maximus on the stance leg when performing the Stork test, in individuals with sacroiliac joint pain, again proposing an altered stabilisation strategy on pelvic loading.
“The magnitude of postural changes during pregnancy was not indicative of the intensity of PLBP and PGP in the antepartum population.” (Franklin & Conner-Kerr., 1998, p. 137)
While there is ample literature that shows the increase in hormonal levels of relaxin during pregnancy, there is a very poor correlation between range of movement and the development of PGP. It is still poorly understood why PGP begins and why some women can adjust to the hormonal levels without issue, while others cannot (Vleeming, et al., 2009). Just be careful in placing causal blame on ligamentous laxity in the presence of PGP. 


Now that we have sufficiently discussed what our knowledge is about PGP, why it can be limited by strong evidence and what we don't yet know concretely, here are some great facts about the clinical course of PGP that we do know:
  1. “The most common time period for PGP to occur is between 14 and 30 weeks of gestation.” (Clinton, et al., 2017, p.110).
  2. “Other factors that also have a high predictive value include a positive posterior PPPT in the first trimester, an increase in the sum scores of compression, distraction, Flexion Abduction External Rotation (FABER) test, and provocative palpation, along with an increase in distress and disability ratings.” (Clinton et al., 2017, p.110).
  3. The rate of PGP often drops to 7% post-partum (Vleeming, et al, 2009). This review suggest 7-25%, which again is a large variation in range. 
  4. “The incidence of DRA in the antepartum population in the third trimester is 66%, with the occurrence in the postpartum population at 39% after 7 weeks to several years.” (Clinton, et al., 2017, p.110). 
  5. Vollestad & Stuge (2009, p.718) found that scores on the ASLR test and beliefs in improvement (measured on the Oswestry disability index) were predictive regarding the prognosis of PGP post partum. More specifically, “ASLR score <4 predicted 10 points lower ODI and 19 points lower evening pain compared with having ASLR score of at least 4.” 
The key points to take from this blog and include in the next step (assessment and diagnosis) are that:
  1. Pregnancy-related pelvic girdle pain (PGP) is difficult to define as the aetiology and pathoanatomical source of the pain are challenging to localise, with various clinical presentations causing similar pain patterns.
  2. The is discrepancy in the language used to diagnose lower back pain and SIJ pain during pregnancy.
  3. Location of pain is very important in assisting diagnosis. 
  4. It is such a highly prevalent conditions, with a complicated etiology and varied clinical course. 
  5. We need to take a thorough history and perform a clinical examination to understand best treatment because generally, the pathogenesis behind PGP is poorly understood. 
Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor. 
instagram @siansmale_SF


Albert, H., Godskesen, M., & Westergaard, J. (2000). Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain. European Spine Journal, 9(2), 161-166.
Albert, H. B., Godskesen, M., & Westergaard, J. G. (2002). Incidence of four syndromes of pregnancy-related pelvic joint pain. Spine, 27(24), 2831-2834.
Bjorklund, K., Bergstrom, S., Nordstrom, M. L., & Ulmsten, U. (2000). Symphyseal distention in relation to serum relaxin levels and pelvic pain in pregnancy. Acta obstetricia et gynecologica Scandinavica, 79(4), 269-275.
Clinton, S. C., Newell, A., Downey, P. A., & Ferreira, K. (2017). Pelvic Girdle Pain in the Antepartum Population: Physical Therapy Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability, and Health From the Section on Women's Health and the Orthopaedic Section of the American Physical Therapy Association. Journal of Women's Health Physical Therapy, 41(2), 102-125.
Cook, C., Massa, L., Harm-Ernandes, I., Segneri, R., Adcock, J., Kennedy, C., & Figuers, C. (2007). Interrater reliability and diagnostic accuracy of pelvic girdle pain classification. Journal of Manipulative & Physiological Therapeutics, 30(4), 252-258.
Franklin, M. E., & Conner-Kerr, T. (1998). An analysis of posture and back pain in the first and third trimesters of pregnancy. Journal of Orthopaedic & Sports Physical Therapy, 28(3), 133-138.
Gutke, A., Östgaard, H. C., & Öberg, B. (2008). Association between muscle function and low back pain in relation to pregnancy. Journal of rehabilitation medicine, 40(4), 304-311.
Hungerford, B., Gilleard, W., & Hodges, P. (2003). Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine, 28(14), 1593-1600.
Hungerford, B., Gilleard, W., & Lee, D. (2004). Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers. Clinical biomechanics (Bristol, Avon), 19(5), 456-464.
Mens, J. M., Pool-Goudzwaard, A., & Stam, H. J. (2009). Mobility of the pelvic joints in pregnancy-related lumbopelvic pain: a systematic review. Obstetrical & gynecological survey, 64(3), 200-208.
Mens, J. M., Huis, Y. H., & Pool-Goudzwaard, A. (2012). Severity of signs and symptoms in lumbopelvic pain during pregnancy. Manual therapy, 17(2), 175-179.
Mens, J. M., Vleeming, A., Snijders, C. J., Koes, B. W., & Stam, H. J. (2001). Reliability and validity of the active straight leg raise test in posterior pelvic pain since pregnancy. Spine, 26(10), 1167-1171.
Mens, J. M., Vleeming, A., Snijders, C. J., Koes, B. W., & Stam, H. J. (2002). Validity of the active straight leg raise test for measuring disease severity in patients with posterior pelvic pain after pregnancy. Spine, 27(2), 196-200.
Mens, J. M. A., Snijders, C. J., & Stam, H. J. (2000). Diagonal trunk muscle exercises in peripartum pelvic pain: a randomized clinical trial. Physical therapy, 80(12), 1164-1173.
Nascimento, S. L., Surita, F. G., & Cecatti, J. G. (2012). Physical exercise during pregnancy: a systematic review. Current Opinion in Obstetrics and Gynecology, 24(6), 387-394.
O’Sullivan, P. B., Beales, D. J., Beetham, J. A., Cripps, J., Graf, F., Lin, I. B., ... & Avery, A. (2002). Altered motor control strategies in subjects with sacroiliac joint pain during the active straight-leg-raise test. Spine, 27(1), E1-E8.
O'Sullivan, P., & Beales, D. (2007a). Diagnosis and classification of pelvic girdle pain disorders--Part 1: a mechanism based approach within a biopsychosocial framework. Manual therapy, 12(2), 86-97.
O'Sullivan, P., & Beales, D. (2007b). Diagnosis and classification of pelvic girdle pain disorders, Part 2: illustration of the utility of a classification system via case studies. Manual therapy, 12(2), e1-12.
Vleeming, A., Albert, H. B., Östgaard, H. C., Sturesson, B., & Stuge, B. (2008). European guidelines for the diagnosis and treatment of pelvic girdle pain. European Spine Journal, 17(6), 794-819.
Vleeming, A., Schuenke, M. D., Masi, A. T., Carreiro, J. E., Danneels, L., & Willard, F. H. (2012). The sacroiliac joint: an overview of its anatomy, function and potential clinical implications. Journal of anatomy, 221(6), 537-567.
Vleeming, A., Stoeckart, R., Volkers, A. C., & Snijders, C. J. (1990). Relation between form and function in the sacroiliac joint. Part I: Clinical anatomical aspects. Spine, 15(2), 130-132. 
Vøllestad, N. K., & Stuge, B. (2009). Prognostic factors for recovery from postpartum pelvic girdle pain. European spine journal, 18(5), 718-726.

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...

Listen in to a followup to our previous episode about size of rotator cuff tears. In this episode co-host Dr. Erson Religioso has a patient with MRI confirmed SMALL rotator cuff tears but a LARGE loss of function.

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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.

Keeping it Eclectic...

In the Eval, Reset, and Stabilize paradigm, you can use extension in standing and SFMA like breakouts to see which hip may be lacking in extension mobility. 

If you don't follow my UpDoc Media Colleagues over @rechargexfit on instagram you are missing out! Gene and Ryan post all kinds of fun movement and fitness challenges.

Here is Dr. Ryan Smith performing 5 Dynamic Plank Variations

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 Toll of Persistent Injury
Rugby player Dave Attwood talked about the toll of persistent injury in The Guardian today. This is likely to be one of the greatest fears of any sports person, particularly for professionals with a career at stake, and who identify with their game.
The physical nature of the training and the sport itself, particularly considering the extent of contact in rugby, both present a risk of injury. This would be accepted by players, with pain being part of the deal. It is expected and perhaps even revered as a demonstration of commitment. No pain, no gain continues as a philosophy.
Then we have pain that persists, which gradually begins to intrude into the player’s attention at inappropriate times. Thinking about pain rather than the game will inevitably affect performance and outcome. Beyond the white lines, the pain seeping into day to day life takes the suffering to a new level. This is a typical story for chronic pain. A sequence of priming events akin to a kindling fire, building and building along a timeline.
Not only does the player need to deal with the pain itself and the day to day rehabilitation, he or she also has to cope with a shift in their role. All of the above are ample causes of suffering, which can take its toll on anyone. We are all vulnerable to a greater or lesser degree. And this is why the modern understanding of pain and injury is so important across society, including professional sport. The biomedical model does not provide any long-term solutions to persistent pain, yet it continues to predominate in both arenas. This must change.
In sport, acute care is usually very good. However, identifying players who could be at higher risk of developing chronic symptoms should be a routine part of screening. Medical teams in sport need to be armed with knowledge allowing them to identify the factors the pre-exist but also be aware of characteristics of the acute injury that may heighten the risks; early, uncontrolled pain for example.

Dave Attwood: ‘Compulsory counselling for long-term injuries will stop stigma’ 

Attwood suggests that counselling should be compulsory. He acknowledges that not everyone will persist with this kind of input, however relevant it might be for that person. The opportunity to talk about the effects of an on-going injury would offer a non-judgmental arena of safety for players to express fears and worries. If players were also educated about persistent pain and injury, they would realise that a change in emotional state and thinking is typical, thereby reducing the stigma. Of course, the stigma arises from the existing culture that is misinformed when it comes to pain. Much of the education enabling pain to be understood would be very similar in content to that of a modern pain management programme.
To see a high profile player speaking out about the issue of persistent injury will hopefully encourage others to seek the right kind of help. Dealing effectively with on-going pain is a specialist area that requires a comprehensive approach that addresses all aspects of the experience. Medical teams may need to call upon external specialists to work with them for particular players. This is something that I have done and it works very well, particularly because professional clubs typically have great facilities and staff who you work with to cover all angles: strength and conditioning, diet, sports doctors, physios, massage therapists etc. But, it all starts with understanding pain.

‘Pain and injury are not the same and they are not well related’

To understand pain means that you know what you must focus upon, without fear, to achieve results. In managing painful moments and seeking to overall overcome the pain problem, it takes dedicated practice, encouraged by positive coaching. The content of the practice varies according to the nature of the problem and the necessary approach. That is for the specialist to decide and communicate with the player and medical team.  The Pain Coach Programme that I designed is commonly a blend of sensorimotor training, mobilisations of different types, skills of being well, and practices that bolster resilience, focus and hence performance. This sits in with input from other fields, very much embracing teamwork with the player’s best interests at the heart. A typical aim is to achieve greater than pre-injury performance.
The coverage of on-going injuries is typically negative from the press, fans, the team and the club. Instead there must be understanding, compassion and encouragement. The right conditions for recovery must be created, easing the pressure off the player so that he or she can truly focus on their job of the moment, getting better. So, well done Dave Attwood and The Guardian for raising the issue, another example of chronic pain in society. It is time for change.

  • Pain Coach Programme — for players suffering persistent or recurring injuries and pain
  • Pain Coach Mentoring & Workshops for clinicians and therapists who want to build their skills and knowledge in chronic pain
  • Pain Coach Workshops for medical teams
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Blended with my clinical work and workshops is the Understand Pain social enterprise that has the purpose of driving social change with regards pain, the number one global health burden.

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