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

Chronic Ankle Instability:

Strength Deficits
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INTRODUCTION: 
After ankle injury, some individuals develop chronic ankle instability and repetitively injure their ankle.
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This can be a frustrating and debilitating problem for many athletes.
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Understanding if specific strength deficits exist can guide and inform the rehab process to resolve chronic ankle instability.
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Khalaj et al. (2020), systematically reviewed the literature to determine whether impairments in lower limb muscle strength exist in individuals with chronic ankle instability (CAI) compared with uninjured controls.
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RESULTS: 
12,397 unique studies identified.
20 included.
16 eligible for meta-analysis. .
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Meta-analyses showed individuals with CAI (when compared to controls) had lower:
Eccentric evertor strength
Concentric evertor strength
Eccentric invertor strength
Concentric invertor strength
Concentric knee extensor strength .
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Ankle eccentric dorsiflexor strength was not different between groups. .
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Although pooling was not possible, data from three separate studies indicated individuals with CAI (when compared to controls) had lower::
Hip flexor.
Hip Abductor.
Hip External rotator strength.
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Hip adductor and extensor strength were not lower in individuals with CAI.
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CONCLUSION: 
Individuals with CAI have ankle inversion and eversion strength deficits. .

Differences exist between individuals with CAI and controls in hip and knee strength. .

These elements of the kinetic chain should be evaluated by clinicians who rehabilitate individuals with CAI.
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Thoughts? Questions? Comments?
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Write them below. .
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SOURCE:
Khalaj N, Vicenzino B, Heales LJ, et al. Is chronic ankle instability associated with impaired muscle strength? a systematic review with meta-analysis. BJSM. Online First: 14 January 2020.

Dalton Urrutia, MSc PT

Dalton is a Physical Therapist from Oregon, currently living and running the performance physiotherapy clinic he founded in London for Grapplers and Strength & Conditioning athletes. Dalton runs the popular instagram account @physicaltherapyresearch, where he posts easy summaries of current and relevant research on health, fitness, and rehab topics. 
Want to learn more or contact him?
Reach out online:
@Grapplersperformance
www.grapplersperformance.com

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🏃🏻‍♂️5 Exercises for Runners⤵️

This is one of my favorite old school manual therapy techniques I learned while in Fellowship with the University of St. Augustine.

Your body keeps the score of every bump, bruise, emotion, thought, situation and trauma together with your genes. It’s one continuous story.


It has take your whole life to get to where you are now. Everything that happens is brought forward, embodied and within our present expectations. The body keeps the score, is a phrase that I often use with people to help them understand their current experience of themselves within their world. I have borrowed it from a super book by Bessel van der Kolk, as it captures a reality.
When I meet people suffering persistent pain for the first time, I invite them to tell me their story. What is it like to be them at the moment? And how did they arrive at this point, in this particular way? Nothing happens in isolation and hence the ‘past medical history’ is far more than a list of other conditions and incidents. These life events make up the journey that brings the person to the room.

Resources and the person

Each person who arrives has been using their resources in the best way that they know. They have a range of coping strategies, some of which maybe helping. Overall though, the person seeks different and better results. This is why I am a proponent of the coaching approach, as it focuses on the person, their strengths and ways to get such results.
The body always participates. Whatever resources and strategies that the person is using, there it is, registering thoughts, feelings, emotions and emitting into conscious awareness an ever-changing range of bodily sensations.
The body always participates
How is this problem emerging in the person? And why it is happening this way, at this particular time? This is what we must consider, going upstream beyond a simple focus upon the location of pain. Most of the biology of pain is not where you feel it, is another phrase I use to help people understand the need for a whole person approach to persistent pain.
The biology of pain ~ arguably there is no biology of pain, instead mechanisms and behaviours of protection
For example, if I have on-going back pain, I will need a brain, a sensorimotor system, a peripheral nervous system, an immune system, an endocrine system, and an autonomic nervous system, most of which is not where I feel the pain. Pain also needs a context within which it arises in the person that is fundamentally part of the actual experience.
Why is pain persisting in this person, now, in this moment? This is a question in my mind as I gently enquire about their lived experience, seeing their strengths that they can use to move on.
Further…
What are their experiences that are being brought forward into the now?

Embodied

Underpinning the narrative is always the body in which our experiences are grounded. How my body is will determine my ability to move and hence impact upon my perception of the world — literally how I see it in terms of opportunities or affordances. We know that our worldly perceptions change when we are tired or suffering chronic pain. Within this, so too does our thinking and decision-making adapt to the state of the body. There is not much that we can achieve without movement — watch here.
This is the primary reason why movement is such a necessary part of getting better. We can’t think ourselves better without moving and seeking to move in the best possible way: balanced. Most people carry tensions in their body from all the life events to date as we have established. We then move according to these tensions that are now habits. Some of these will be protective and be happening entirely subconsciously. We are not doing it on purpose or even choosing to move in a guarded way. However, when we identify the pattern, we can make gentle changes to develop better body sense and movement. This creates evidence that we can move more efficiently as we take this expectation forward.

One

We are one. Whole. The idea of a separate body and mind is merely a convenient way to try and understand our experiences. It is wrong. We have just one experience, utterly unified. To try and simplify this by using silos of physical health and mental health takes the person away from reality.
Approaches to pain must be seen through the lens of oneness, the person first and the whole. There is no simplification.
The person suffering persistent pain is experiencing this state frequently in their life for there are unmet needs, often running deeply through their existence. Listen deeply and you will hear them. They are in a state of protect over and over with a narrow window of tolerance as they shift into hyper- and hypoarousal.
We seek to understand the person and help them to use their existing strengths and resources. We expand their choice of resources and widen their window of tolerance as they meet their needs and build wellness towards the real results that they want to achieve: their ideal self.
The body keeps the score. We can note posturing, guarded movements, limited actions, fearful responses and more as we study the embodied nature of the person’s experience. The more you look, the more you see. The more you listen, the more you hear. With this rich narrative and observation, we can then go about motivating positive actions, choose treatments that are helpful to ease symptoms and encourage the person to reach their potential.

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The New Year brings all sorts of new energy, renewed motivation, etc.; and, marketing is almost always on the forefront. However, excellence in marketing is the same as excellence in many things — you’ve got to play the long game. “Growth hacks” or any other short term tactic are just that… the effects tend to be unimpressive and you’ll find yourself very much close to where you started.
In the world of marketing, there are all sorts of traps: There are mindset traps. Shiny object traps. All the eggs in one basket traps. So… BE WEARY!
Just as patient’s benefit most from a consummate approach when the clinician considers the big picture, marketing works in the same fashion when a company invests in a strategy as a whole — an ecosystem approach. Today, we cover the top 5 traps in marketing for a practice’s growth in business and some thoughts on what you can do to find your true north.

1. Our Website “Is What It Is”

Year after year, survey after survey, we find that websites are a sticky point for many healthcare companies. Typically, the website isn’t regularly maintained or worse — is ancient and requires an entire overhaul. Yet still, there’s this mindset that “it is what it is” — that there isn’t the time, nor resources, nor inclination to fix the website, invest in a new one, or at the very least… keep it up to date.
The fact is, websites are enormously important. In the data we’ve seen, a good website is the difference between people finding you and selecting you as provider of choice; versus, finding you then moving on because your content is hard to browse, isn’t mobile friendly, is out-dated, is too small on a screen, or doesn’t quickly address a prospective patient’s questions and concerns.
How convincing is the data? Very. We’re talking improving a website’s efficiency to attract and convert new patients by over 300% and gaining over 50 new calls in a month after a website is revamped. On top of this, many times the return is greater due to the compounding effects a website has as the anchor point after online reviews, from browsing on social media, after a word of mouth referral is made… etc. It’s a big, big deal.
There’s another layer to this. “Free” websites.
Freemium platforms have been around for a long time. Blogger, Wix, WordPress.org, WordPress.com, SquareSpace, and hosting service native builders… they all have the same problem: building on builder is laying your company’s foundation on top of someone else’s roof. There are noticeable negative effects as it pertains to Search Engine Optimization (SEO) — ultimately hampering the way and ease that your prospective customers find you. There are also big gaps of functionality lacking — such as analytics, customer journey tracking, retargeting, and customized content experience… all of which are desired by consumers seeking answers to their health concerns with urgency.
We also see less efficiency with digital advertisements when it comes to inexpensive website designs as paid user acquisition tends to have a high bounce rate with leads being generated typically being of lower quality when compared to a site that is precisely designed to guide a prospective patient to the answer: Not only can you help… but, they can trust you.
The best platform to date for most practices, healthcare and education companies remains a true WordPress build (not a WordPress.org or dot come) for a website.
If attracting new customers, engaging repeat customers, having meaningful metrics, analytics, and a data driven way to measure how your marketing dollars are being spent is important to you — then the website should be of paramount concern for your practice’s marketing strategy in 2020.

2. Word of mouth has always worked.

This was our rallying cry for 2019 and echos still now in 2020. Word of mouth HAS always worked — it continues to work, but has changed because consumer behaviors have changed. If you’re skeptical and like hard numbers and facts, you can find them here.
In short, while some who are given a name and number will directly make a call to inquire (and hopefully, schedule), most prospective patients will search you out in a fair amount of detail; they will check you for reviews, they will explore your website, and many will screen your social media content just to see if you are active and engaged… perhaps to get a sense if you hold the style of care they seek. If word of mouth has always worked for you, that’s great! But, you’ve been warned… it has changed and has changed for quite some time — and, it will continue to change.
Just as with all phases, generations, and lifecycles of consumer behaviors… Word of Mouth used to literally be just that. With time, it progressed to various forms of telecommunication and now, to all things digital via screen access touch points. We are officially in a time where we should consider the effects of Word of Mouth 2.0… particularly if your practice has a history of growth due to positive reputation within your regional communities.
As noted in the State of Marketing Report, word of mouth is still very much relied upon in our industry and throughout healthcare at large. So, what is to be done that we can keep up with the changes in consumer behaviors? Well… there’s a blog coming up soon titled “3 Tip to Maximize Word of Mouth 2.0” — so stay tuned!

3. If I post it, they will see it.

This one reminds me of the Field of Dreams quote:
For those of you pop culture fans… my response is straight Jesse Pinkman’s “Fallacies.”
The reality of social media is that it’s crowded, it’s cluttered… and, many wish for a break from it all. This has been featured on Forbes and Psychology Today.
Now this doesn’t mean that social media is now irrelevant. Rather, this means you need to be relevant to your audience if you wish to be seen. Content marketing is a game of consistency, of understanding your customer’s journey, and producing written, visual, and video content that speaks directly to your customers by segment, buyer persona, avatars, and/or cameos — whatever your chosen terminology.
Most companies recognize the importance of being digitally visible — after all, visibility means discovery, and discovery means new customers. If you’re interested in learning more about how to do this, consider reading Standing Above The Social Media Content Clutter.

4. If I pay for it, they will see it.

Just as posting content isn’t a guarantee that they will be seen by the right people, or even seen at all in a meaningful way… paying for ads or promoted content doesn’t give a direct promise that results will come. Time and time again, we get asked questions about why a Facebook boost did nothing, or why Google Ads didn’t bring more patients, or why the paid listings on Yelp didn’t really glean any new patients.
It’s not just us saying so. We have industry agnostic marketing agencies saying the same thing — see 3 Myths About Boosting Facebook PostsDon’t Boost! Promote Facebook Posts Properly to Increase Reach, and Are Facebook Boost Posts Worth it?
Success with digital advertising is very much like Physical Therapy — it’s an art and a science.
As mentioned, we’ve seen a direct correlation for the success of online advertising and paid content positioning with that ecosystem approach we constantly talk about… where when online reviews are favorable and fresh, when a website is properly designed, when social media is leveraged, when a brand’s content is fresh, then and only then do we see repeated and consistent results in the play to play environment of digital ads.
If you want to play in this field, you need have the right stuff to be in the same league. Otherwise, you’re hampering your own efforts and very likely barely striking break-even on your ad-spend… or worse, just throwing dollars to the wind. This leads us to our final marketing trap to be watchful for in 2020….!

5. “Set and Forget” = Spend and Fail

This is a FATAL error when it comes to anything related to email marketing, marketing automation, and digital ads such as Google Ads, Facebook Ads, Instagram Ads, etc. Unfortunately, this is a very easy trap to fall into because once you (or, someone in your marketing department) has done all the work of writing out copy, targeting factors, test scripts, landing pages, automation sequences, workflows, triggers, etc. etc. etc. — after all of that… it’s easy to just sit back and “wait for the automation to do all the work.”
Consumers are smart, and patients very intelligent. They know when they are getting spammed. They know that the first one or two search returns are paid for. They know that they are getting hit up for reactivation, repurchasing, reviews, and to refer their family and friends. THEY KNOW.
And, that’s the “easy part.” The ugly truth is that while setting targeting factors, budget limits, and ad sets are all well and good — algorithms change. In fact, ads algorithms constantly change. Even automation software have occasional updates that can turn workflows askew… they’ve been happening a lot more as of late, and, we use a lot of different platforms…. it’s happening everywhere. In fact, we had a recent client alarmed at a region they were self managing for online ads… algorithms shuffled and suddenly, they had no clicks, no calls, and a massive ad-spend that lead to absolutely zero new patients. Yikes.
So… if the algorithms are changing and our customers are hyper aware, what can be done? Be Authentic.
What we’ve appreciated about marketing efforts that are highly automatable is that automation means nothing if it doesn’t come across as an authentic customer touch point. What constitutes authenticity? Genuine interest and care for the patient’s well-being and benefit. This comes across in copywriting. This comes across in mixing and matching ad sets with demographics and targeting factors. This comes across in tremendous ways with timing, messaging, and brand narratives. All of it matters. To further delve into this topic of authenticity is our own Therapy Insiders podcast host, Gene Shirokobrod with “The Authenticity Paradox.”
Ultimately, this trap of “Set and Forget” is solved with setting a regular schedule to audit your ads, audit your automation, and create customer check points to test, inquire, discern, and decide if your current settings are in fact optimal. If they aren’t, adjust & re-test… if they are, mark your calendar reminders to ping you again at regular intervals to ensure that you ARE NOT on track to spend and fail. And, Yes… it is very much time intensive and we can go into the nuance as well as conflict of interests within alternate methodologies and agency schemas if you’d like 😉 — you can schedule a call HERE.
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It is well known that vestibular rehabilitation is an effective program for many patient profiles that can walk into a physical therapist office.  A well-planned and adjusted program based off of symptoms is the basis behind strategies to improve Chronic Unilateral Vestibular Hypofunctions, Bilateral Vestibular Hypofunctions, mTBI and post-concussion syndrome.
Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness
It can be individualized through a tailored, progressive program to the patient for effective outcomes. Improvement is typically gradual as the system adapts and includes a home exercise program.
Classical signs and symptoms of vestibular dysfunction that would warrant vestibular rehabilitation include dizzinessvertigodisequilibrium, nausea, and visual impairment.  With the ongoing scientific research showing neurological connections via several reflexes and mismatch theories of afferent information, a healthcare provider should also consider vestibular rehabilitation for chronic neck pain.
Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness
In fact, I would bet majority of the patients whom are seeking out vestibular rehabilitation has either cervical pain and/or limitations in cervical function (i.e. altered active/passive range of motion, strength and endurance of deep cervical flexors/extensor, cervical kinesthetic sensibility, greater joint position error, pressure pain sensitivity).
Not just me making this comment, but Knapstad and colleagues in 2019 made the following conclusion in a cross-sectional study in Disability and Rehabilitation Journal:
Neck pain was equally prevalent in patients diagnosed with dizziness of vestibular and non-vestibular origin. This indicates that neck pain is a common complaint in dizzy patients regardless of diagnosis.
Additionally, Thompson-Harvey & Hain in 2019 documented that symptoms endorsed by subjects with cervical vertigo, migraine, and vestibular vertigo overlap.  Therefore, neck limitations, due to pain, stiffness or even abnormal imaging findings with both local neck origin, as well as a double entity of vestibular or central origin, can manifest an exaggerated proprioceptive response and translation into subjective symptoms of dizziness, lightheadiness and imbalance.
The basis behind Cervicogenic Dizziness treatments is that the patient has dizziness originating from the cervical spine, but couldn’t it be plausible that the dizziness could be coming from another source (i.e. peripheral) but compensatory strategies over time make it appropriate and quite reasonable to also address changes in the cervical spine due to altered head on neck orientation?
The basis behind mechanisms of manual therapy has been changed away from just local, biomechanical changes to the tissues to a more complex peripheral and central mechanisms.  Majority of the clinical effects are now known to be neurophysiological in nature.  Therefore, considering these patients have a head on neck disorientation that does warrant vestibular rehabilitation, could we get faster results, more buy in and ease of any nocioception that may hinder clinical outcomes.Cervicogenic Dizziness, Cervical Vertigo, Neck Dizziness
It is plausible that manual therapies can immediately enhance proprioception and may be a reasonable treatment approach to prepare a patient for exercise interventions.
The study quoted above examined Cervicocephalic Kiniesthetic Sensibility, Widespread Pressure Pain Sensitivity and Neck pain following spinal manipulation to the cervical spine.  Even if you do not believe in spinal manipulation or do not feel comfortable performing it on patients, it is wise to seek out some type of manual therapies that focus on high content from the muscle spindle and proprioceptive areas that is time-efficient, straightforward and effective.
This is why our Physio Blend incorporates your past knowledge and skill set with manual therapies without providing such “systems” as if you would feel like you need to learn before application.  Our Physio Blend for Cervicogenic Dizziness includes both joint and soft tissue/muscle manual intervention.  And trust us, treating the neck is MUCH more than prescribing ROM and upper trapezius stretching. 
So even if your patient is not having neck pain (so therefore, may not actually be able to be classified as Cervicogenic Dizziness), a vestibular/neuro therapist should consider manual therapies to the cervical spine due to its effects on proprioception, pain and cervical kinaesthetic sense.
I’ll end this post with another quote from Knapstead in 2019:
The relationship between neck pain, general and dizziness-related quality of life should make medical practitioners aware of these patients regardless of whether or not a vestibular disorder has been diagnosed.

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
Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

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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. 
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  • Live cases
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  • over 600 videos - hundreds of techniques and more! 
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