Modern Manual Therapy Blog

@rehabscience on Instagram reviewed this great article showing 1 year of resistance training and it's effects on bone mineral density.

A rare win story, especially from new co-host, former guest and Modern Patient Education lead instructor, Andrew Rothschild. Listen as Andrew goes toe to toe with a local Sports Medicine Doc over a differential diagnosis.
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 Andrew Rothschild at Modern Patient Education.
Keeping it Eclectic...

Concussion has been a hot topic in the last few years and continues to grow in awareness, diagnostic and treatment options in the field of medicine.  Rehabilitation professionals, such as physical therapists, play a vital role in recovery from this injury and can be argued to be the best healthcare provider to aid in a progressive, graded exposure to return to sport/play.  Treating patients recovering from this injury can be challenging but our field offers us the training and ability to address the multiple dimensions of symptoms; including the oculomotor, vestibular, cervical and central impairments.
Even though concussion can be considered physiologically a “brain injury”, there is a plethora of data correlating the mechanism of injury and impulsive forces to whiplash mechanism, such as seen in a car wreck (Elkin et al 2016Alexander 2003Hynes & Dickey 2006, Morin 2016).  So not only could impulsive forces in concussion involve the head, but the neck as well (Marshall 2015Kennedy 2017).  This is not a new subject per say, but with the continued expression of “brain injury” and “central condition”; I want to express to my colleagues that symptoms of headache and dizziness could be generators of nocioception and/or alterered proprioception.  There have been some authors to go as far as suggesting concussion should be appropriately called the monikor craniocervical shaky syndrome (CCSS).
Instead of simply allowing the brain injury diagnosis sticker dampen the prognosis to allow healing to occur, it is recommended to consider the cervical spine a potential reason/cause for post-concussion persistent symptoms.  Considering dizziness after sport-related concussion is common and reported to be in 43-81% of cases (Alslaheen et al 2010Duhaime et al 2012Lau et al 2011), it is highly recommended to get the formal assessment, evidence and treatment for these patients.
Cervicogenic Dizziness Course - Integrative Clinical Concepts
Let’s move on together to aid in finding potential, pragmatic and VERY treatable region of the body.  It can be challenging to find which system is of particular importance in the driver of post-concussive symptoms, but if you think it is the cervical spine, we have the answers for you.

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 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist diagnostic approach of Cervicogenic Dizziness, which includes ruling out central and peripheral disorders to rule in the cervical spine as driver of proprioceptive dysfunction.
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 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. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

Keeping it Eclectic...

Eccentric heel drops are a great and evidenced way to treat achilles tendinopathy. However, many times, there is a mobility issue in ankle dorsiflexion, lateral tibial glide and/or tibial internal rotation.

Thanks to Dr. Tom Walters of Rehab Science on instagram for letting us repost his awesome videos! Make sure to follow him!

Listen in as new co-host Dr. Andrew Rothschild tells a great story about Pain Science Education going very well and simultaneously terribly!

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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 Andrew Rothschild at Modern Patient Education..

Keeping it Eclectic...

Pain is a conscious experience, so in order to understand pain, we have to dive into how consciousness works. That is one of the reasons consciousness has been given some time in past posts on noijam (here, here and here for example).

One way to think about consciousness is as a controlled hallucination.

Not in a pathological way. Just in a way that is so fundamental to our experience and how we perceive our environment that it feels all too normal. At least that is Anil Seth's argument in his recent TED talk called “Your Brain Hallucinates Your Conscious Reality.”

Here’s three things that I took from the talk and how they relate to pain.

1) Perception is Based on a Best Guess

Lorimer Moseley has touched on the topic of perception being a best guess in his book Painful Yarns. One of the ways he did so was by using vision as a base for understanding perception, then applying the same concepts to pain. Seth takes this concept to an even more fundamental level and argues that not only is perception based on a best guess, but that it is a brain’s only option.

Here’s how Seth Explains it.

“Imagine being a brain. You're locked inside a bony skull, trying to figure what's out there in the world. There's no lights inside the skull. There's no sound either. All you've got to go on is streams of electrical impulses which are only indirectly related to things in the world, whatever they may be. So perception -- figuring out what's there -- has to be a process of informed guesswork in which the brain combines these sensory signals with its prior expectations or beliefs about the way the world is to form its best guess of what caused those signals. The brain doesn't hear sound or see light. What we perceive is its best guess of what's out there in the world.”

Day to day living doesn’t make it seem as if we are a brain locked in a bony skull, but it’s hard to argue that that is not what’s happening. I also like the acknowledgement that the information from the outside world comes in streams of electrical impulses that are only indirectly related to the outside world.

2) Perception is Based on Many Inputs, Some from the Outside World, Many if Not More are Internal

In order to figure out what is going on outside the locked bony skull, it turns out that our brain relies on more than just the electrical impulses that are indirectly related to the outside world. Our brains also rely on electrical signals generated internally, like thoughts, past experiences, etc.

For our patients, this can be a very challenging, and sometimes threatening concept. Moseley also addressed this challenge by using visual illusion as a demonstration.

Seth did this as well and even used the exact same visual illusion, but he took it one step further with what I found to be a brilliant and compelling audio example. Listen to the clip below, which I pulled from the presentation.

Here’s Seth’s interpretation.

“OK, so what's going on here? The remarkable thing is the sensory information coming into the brain hasn't changed at all. All that's changed is your brain's best guess of the causes of that sensory information.

Instead of perception depending largely on signals coming into the brain from the outside world, it depends as much, if not more, on perceptual predictions flowing in the opposite direction.”

Once you hear the meaning of the audio change without any change in the signal it gets very hard to deny that perception is significantly molded by internal factors.

The funny thing to me is that once I got the extra cue, it was impossible for me to perceive that same sensory information the way that I did the first time around. It’s not dissimilar from trying to unsee a visual illusion. Perhaps this is one of the reasons why improving persistent pain is so challenging. Once you hear the cue, it is very difficult to “un-hear” it.

3) Perception isn’t Passively Experienced, but Actively Created

If you accept that perception is based on a best guess and that it is based on many inputs, then it is hard to disagree with this last point, which is essentially Seth’s thesis of the whole talk. In his words...

“We don't just passively perceive the world, we actively generate it. The world we experience comes as much, if not more, from the inside out as from the outside in.”

To me, this statement is very closely related to the fundamental goal of Explaining Pain, which is to “...shift one’s conceptualization of pain from that of a marker of tissue damage or disease to that of a marker of the perceived need to protect the body tissue.

To that end, I have been including the video as supporting material in my Explain Pain curriculum and have found it useful as a way to reinforce or even lay the foundation for concepts like neurotags, the orchestra in the brain, how heavily pain relies on context, and linear versus emergent thinking.

Sum Up

Pain is a conscious experience and therefore if you want to understand pain, you need to know a thing or two (or three!) about consciousness and perception. Anil Seth’s TED talk covers a lot of ground for being only 17 minutes long. Do yourself a favor and go watch the whole thing. I’ve only scratched the surface of it here, and there is a lot more including the rubber hand illusion, interoception and using virtual reality to simulate hallucinatory experiences.

Keeping it Eclectic...

One of the hardest parts about an efficient and comfortable thrust manipulation is developing speed. There are ways to make it more comfortable as well. Make sure you are comfortable, using good body mechanics AND the patient is relaxed as well. No point in manipulating through high tone or discomfort. When was the last time you were relaxed as someone was quickly stretching you? Think of it this way as a clinician, would you stretch a high tone CVA, TBI, or CP patient quickly?