Modern Manual Therapy Blog

Part of my focus for the past few years has been expanding my knowledge base outside of traditional PT practice. Nutrition has been a big focus and getting people to focus on lifestyle changes is a great way of helping patients with a health problem that also just happens to have a persistent pain state or continuous re-injury.

5 Fundamental Key Points to Implementing Nutrition in PT

1) Knowing that Nutrition Impacts Rehabilitation Outcomes, Risk of  Developing Chronic Disease, and Quality of Life
  • Nutrition is essentially fuel, the energy and nutrients for the body to do work, to survive, and to recover. The quality of fuel intake will influence the body’s overall metabolic state and outcomes. 
2) Nutritional Screening
  • At the bare minimum a screen must be performed. Identifying if your  client/patient needs nutritional intervention or referral. If done right, this can be easily added to your traditional intake forms or merely be a conversation. 
3) Client/Patient Medical History
  • If your client/patient has a poorly controlled medical condition,  intervention may be beyond your skill set. You never want to provide nutritional intervention that targets a specific disease. 
4) Scope of Practice (Physical Therapy & Dietetics/Nutrition)
  • Every state is unique when it comes to the depth of intervention you as a physical therapist/physical therapist assistant can provide. If you are unsure, contact your state PT board or association for clarification and visit for nutritional laws.
5)Personal Scope of Practice (Knowledge & Comfort)
  • To speak on nutrition, you need to have a baseline knowledge of the essentials and stay current with the latest in high quality evidence. You also need to be comfortable addressing the multitude of factors that affect an individual’s eating pattern (beliefs, culture, preferences, socioeconomic status, etc.). 
Plus bonus 6th key point! If you are uncomfortable with this in a PT setting, knows the signs of when to refer out to a trusted RD or similar provider.

6) The Decision of Intervention or Referral
  • Taking into consider all of the key points above, will you as a healthcare provider give intervention yourself or refer to the appropriate professional?
via Dr. Patrick Berner, PT, DPT, RDN aka Fuel Physio

Interested? Check out Fuel Physio's Online Nutrition course! It includes a must have nutritional screen any clinician can implement for the clinical decision making for nutritional intervention.

Keeping it Eclectic...

This video discusses the use of Doppler Ultrasound to determine arterial pulse in a limb. In the Modern Strength Training course, we use a 8mHz probe as it has a shallower focus and will will only grab vascular sounds, both arterial and venous depending on where you place it.

Any clinician working in the neuromusculoskeletal field knows we have a big problem in describing conditions that we diagnosis and treat.  You get 10 PTs to examine a patient and you may get 10 different explanations.  A colleague’s work has even just eliminated all abbreviations across all of their clinics as we can’t get that right either!
Additionally, there has always been the multi-term description of a “joint problem”—somatic lesion, derangement, dysfunction, hypo mobile joint, hyper mobile joint, etc etc.  The trend is even getting less specific with conditions that have historically carried a diagnostic term.  Subacromial impingement is now being called anterior shoulder pain and patellofemoral pain syndrome is now being called anterior knee pain.
One of the main reasons for this discrepancy is that we have a challenging time correlating the actual source of nocioception from a clinical exam, and can be even less accurate with imaging exam for the above two conditions.  Even more, the purpose of a diagnosis is to lead to a sound treatment plan, but this depends on multiple variables.  Providing a clarification for our findings is challenging.
In the dizziness world, the subjective and variable explanation of symptoms makes the clarification of terminology even more challenging.
The current medical definitions of vertigo, dizziness, and imbalance are based on the recommendations made by the classification committee of the International Bárány Society for Neuro-Otology.
Vertigo is the sensation of self-motion when no self-motion is occurring; dizziness is the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion; and imbalance or unsteadiness is the feeling of being unstable while sitting, standing, or walking without a particular directional preference.
Additionally, dizziness may be described as feeling dizzy, lightheaded, giddy, faint, spacey, off-balance, rocky, spinning, or swaying (Newman-Toker DE & Edlow JA 2015).  Aren’t these descriptions all over the board?!
The definition of Cervicogenic Dizziness / Cervical Vertigo is even more muddy.  Here is a sample of dizziness descriptions from leading authors, alongside correlating them with neck positions/movements.  This is a small collection from my 300 page book (provided with course registration):
Non-rotary dizziness, imbalance, unsteadiness (Reid 2008/2012/2014/2015)
Vague sense of impaired orientation or disequilibrium (Al Saif 2011)
Non-specific sensation of altered orientation in space and disequilibrium (Furman/Cass 1996, Wrisley 2000)

For the most part, dizziness means different things to different people.

One thing I want to point out is that the description and definition of Cervicogenic Dizziness does notinvolve vertigo—which is definied as a “sense of spinning, surroundings seem to whirl such as feeling that you are dizzily turning about you”.  This is typically associated with BPPV (hence the “V”).  
In the literature on this topic, you may find  the phrases, “Cervical Vertigo (CV) , Cervicogenic Dizziness,  or Cervicogenic Vertigo” as you search across multiple discipline journals.  Considering vertigo is not a typical description or definition associated with dizziness associated with the cervical spine, I suggest abandoning the phrases, “Cervical Vertigo (CV) and Cervicogenic Vertigo”.
You will still find these other terms in overseas texts and articles, so do not abandon it completely in chasing down research, but we do need to continue a trend towards being consistent across our professions.  Therefore…

Let’s just stick with good ol’ Cervicogenic Dizziness.

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 for more information.


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

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...

How do you diagnose or treat frozen shoulder? Is there a "quick fix?" Listen in to find out more about this condition.

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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....

We've all been there, the seemingly simple evaluation on your schedule for post op total knee arthroplasty. Then see them having a hard time walking to the table with a very recognizable gait. They're missing 25 degrees of extension and have 70 degrees of flexion at best. What to do?

My favorite part of the initial evaluation is the history. That initial interaction, sets the stage for the subsequent visits. Many patients are nervous, especially if they received a lot of the standard gloom and doom from well meaning, but misinformed providers or loved ones.

Most of the patients walking through your door will respond rapidly even with "chronic pain." Only a small percentage are centrally sensitized or have an underlying disorder which slows down or prevents your current approach from working rapidly. Just because a patient had their function limited or pain for a certain time does not mean you won't be able to hit a home run in the first few visits. We've all had that patient with knee or back back for longer than they can remember yet, still feel 80% better after the first visit.

Some patients are convinced they're a mess, and they've been to so many other providers. For your own prescription and outlines of care, plus to alleviate their anxiety, here are 5 Ways to Tell If Your Patient is a Rapid Responder

1) Their Symptoms are Intermittent
  • just went over this in a MMT video, here's the link
  • the short of it is, intermittent Sx = times when the nervous system is not threatened, chances are they're a Rapid Responder
2) They have recovered from similar episodes with or without care
  • is the patient's entire ecosystem healthy enough so they recovery from other or similar episodes?
  • often they see clinician X, go for 20-30 visits, and they recovery - if it's been that long, was it really the clinician or just time? Tough to tell, but if they've recovered before, chances are, they can do it again
3) With previous flare-ups, "enter treatment here" really helped
  • I almost tune out to what a patient received as treatment when it comes to previous providers, it may be the best evidenced based care in the world, or terrible
  • I really care about two things
    • what were they taught for HEP, and overall education of their condition and recovery
    • did it help rapidly
  • patients will often say, manipulation, IASTM, Needling, etc all helped but only lasted 2-3 days
  • that's where I know it was a failure of the HEP, most likely in dosing
  • if whatever magical treatment they received improved their symptoms/function for hours or even days, all they have to do is dose the appropriate home program high enough to Keep the Window of Improvement Open
image credit
4) They have an open mind to your approach
  • we're all in sales, if the patient doesn't buy in to your treatment and overall approach, good luck!
  • being a Rapid Responder means their entire mental and physical ecosystem is open to suggestion and ready for changes
  • When I think back as to all the patients I had difficulty with, many of them were non-compliant, or we flat out didn't get along for whatever reason
  • pro-tip: if this is happening to you - refer to a trusted colleague or co-worker
    • I've swallowed my pride, referred a patient to a co-worker and his pathoanatomical approach was just was she needed
5) Their Symptoms Are Still Significantly Better on Visit 2
  • making huge changes on initial evaluation is always a thrill for both clinician and patient but that does neither of you any good if they are back at square 1 on follow up
  • if they have all of the above points, AND you gave them the appropriate HEP to maintain improvements between visits, the majority of the changes should remain
  • I used to tell patients I wanted "most" of the improvements in function, mobility, and pain to stay between visits
  • now that I treat people once every 2-3 weeks, all that self treatment, I expect most of them to be better, not just where I left them at the end of visit one
  • education and self treatment are the only things a patient can take home, no matter how much they want to take your "magic hands" 
  • emphasize the HEP, not the treatment
  • when a passive/manual approach makes rapid changes, frame it that "this was applied so that you can now perform your home program and loading strategies pain free." It's up to you to keep it!
The last bonus tip is that honestly, unless you work specifically with a certain population that are non or always slow responders, chances are, the patient in front of you is a Rapid Responder.

If you've tried your best, and the patient is compliant, know your limits and refer out. I've had very grateful patients refer me a ton of their friends and family because I was the person who referred them to the clinician who finally was able to help them. Ask yourself, when was the last time I made a breakthrough 6 weeks into care? 

Learn these strategies and how to simplify your assessment and treatment approach at a #manualtherapyparty or click below to do it online with the MMT Premium Community!

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...

Persistent Football Injuries - first found on Specialist Pain Physio

Persisting football injuries are the scourge of the dressing room. Whilst everyone accepts that injury is ‘part of the game’ and part of sport, this does not necessarily make it any easier for the player, whatever the level, or the treating clinicians. A range of pressures and expectations exist, which impact upon the experience and the outcome. Managing these in the best way is one of the key components of a successful approach. Kieron Dyer, in his new book, describes the suffering he endured as a result of his recurring injuries and pain, which certainly had an impact upon the longevity of his career.
“Even though I knew I was injured, there was a lot going through my mind when I was celebrating with the fans…..I couldn’t cope with a career that had become a continuous cycle of hope and despair. If there were an end in sight to it, it would be different, but no one could seem to cure the problem” ~ Kieron Dyer
Addressing an acute injury is a well known and understood process: diagnose the problem, administer the right messages and treatment, start rehabilitation as soon as possible, build fitness and sport specific training with a gradual return to play. So why is it that some plays become besieged by persistent and recurring injuries and pain?
The broad brush answer is the same for any person experiencing chronic pain and injury. There are a number of vulnerabilities and contextual factors at play, meaning that protective measures rightly kick in, but do not necessarily ‘reset’ to an appropriate level of vigilance. As a consequence, this loss of differentiation means that more and more moments are perceived as potentially threatening. It only needs to be a possible threat for a protect state to be initiated, with the perception of pain being part of this state.
The first step of understanding, especially for the player, is that pain and injury are neither the same, nor well related. We have known this for many years:
“The period after injury is divided into the immediate, acute and chronic stages. In each stage it is shown that pain has only a weak connection to injury but a strong connection to the body state.”
  ~ Wall (1979) Co-founder of Textbook of Pain
To fully describe the complexities of an emergent chronic problem is beyond the scope of this blog — we cover many of the important dimensions in the Pain Coach Workshops. Chronic pain and injury is a specialist field requiring a broad knowledge of a number of areas together with experience of working with suffering individuals. These include science pertaining to pain and survival, philosophy, cognitive science, psychology, sociology, anatomy and physiology to name but a few. This knowledge then has to be applied phenomenologically with meaning and effect. We need a means to deliver treatment and provide practical tools that allow the person to pursue a purpose and achieve results. The means that I propose and offer is that of coaching, pain coaching, which is all about getting the best of an individual.
A brief insight into the vulnerabilities for developing chronic pain is useful. We are essentially on a timeline, which means that every episode in our lives is logged as an experience with a learning effect. Significant events in particular will shape us as we journey through the ups and downs. We know that early life stressors have a particular effect as the biology that protects us is evoked at a young age, at a time when the person is maturing and reliant upon others for safety and security. When this secure base is compromised, there is a vulnerability to suffering a range of complete person problems from depression to irritable bowel syndrome to chronic pain states. The sensitivity manifests in different ways in different people of course. In recent times we have heard about terrible situations, which will impact upon brain, body and behaviour ~ the 3 come as a unified package of course, the person. Dyer has bravely described his early experiences, which will have been a huge factor in how he subsequently sensed himself and the world.
In terms of pain, as a perception in the face of a perceived threat, the responses and actions become increasingly prevalent as the range of threats increases. For the player, these threats come in the form of their own thoughts (inner dialogue) like any other person, but also from the pressures of performing, from the club, from the fans, from not understanding their pain and why it persists, as well as other day to day influences. Peak performance emerges from a focused approach, from having energy, from being in flow and from minimising distractions. It is the inner dialogue that forms the greatest distraction.
Players must understand pain as the first step. It is their pain, and they can be given knowledge and tools to manage and overcome the problem. They understand that the experience is also affected by distractions that come in the form of old beliefs about pain and injury together with the aforementioned pressures. As Dyer realised, “So I hadn’t been pulling my hamstring at all. It just felt like it. Fans and others see an injury prone player but do not know the reality of pain”.
“So I hadn’t been pulling my hamstring at all. It just felt like it. Fans and others see an injury prone player but do not know the reality of pain” ~ Kieron Dyer
For anyone to manage and overcome a pain problem, an encouraging environment must be created in which the knowledge and skills are put into practice. This would include alleviating the pressures in the best way so that the focus can be on recovery within a realistic time frame. This time frame may not suit everyone, but the risks of ignoring this for the sake of a hasty return are high. A player clearly has the strengths of focus and perseverance to enable him or her to reach the professional level. They will also have overcome a number of challenges and set backs along the way. Drawing out examples of these helps the player establish the characteristics they hold, which they can use to address the current challenge of pain and injury. Maintaining a focus upon the right steps and managing the consequences of drifting off course is the route to success, encouraged and enabled by skilful clinicians who share the picture of the desired outcome. This is no different to clarifying where you are sailing your boat, setting sail in that direction and using skills and strengths to maintain course, manage the boat in tricky waters and get back on course as quickly as possible.
A programme to address persistent pain and injury (the two are different as you will know) must be complete. The clinician establishes the full story, the back story, the context and the circumstances before confirming with the player where he or she is going. This is why knowing your players is vital, and being able to have open conversations that are more likely when we practice deep listening and create an encouraging, compassionate environment. The biopsychosocial model is one that offers a framework to consider all of the factors, but of course it is how they all come together as the experience of the person that is important. It is the person who feels pain, not the body part, and hence ‘how the person is’ becomes highly relevant together with their approach to life and challenges. This style of doing life, possibility or problem, opportunity or obstacle, will often play out when it comes to pain. And this is where we deliver new choices that are the basis for moving onwards.
There are many challenges to managing and treating a complex, chronic and persistent pain and injury problem in football, especially in the professional game. Dyer describes the experience from the player perspective, delivering a stark insight. Players at the top level may receive vast rewards for their abilities, yet they are under a range of pressures that have a huge impact on pain and injury that need to be understood and addressed skilfully, to maximise the potential for recovery and return to play. This is always the goal.

Richmond delivers The Pain Coach Workshop for Football ~ a 1 day workshop for medical teams who want to build on their skills to be able to effectively manage the range of factors that need addressing in persistent and chronic cases of pain and injury. The Pain Coach Workshop for Sport is a more general experience for problem pain in sports. Call us now to book your workshop t. 07518 445493

Keeping it Eclectic...

Have you ever had a sales agent come into your clinic to try to sell you a product? Listen in to an experience Dr. E had with a cold laser salesperson.

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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...