Modern Manual Therapy Blog

What happens when you have a patient with a condition that you don't specialize in? Do you treat them? Refer them to someone else? Listen in to a story about what Jason did in this situation.

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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...

A lot of videos and experts out there will tell you using a mobility ball is a great way to decrease pain and increase mobility. They are not wrong about that. What could be better is the instruction itself. Like all manual techniques, you don't have to use a lot of force or make it uncomfortable to get rapid improvement.

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.

Subscribe on Google Play Music
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...