Modern Manual Therapy Blog

Stop beating yourself with mobility balls, or doing painful pin and stretch techniques. Do they work, yes! Do they have to be painful, absolutely not! Isometrics are great modulators of pain and reduces the perception of stretch. After inhibiting the pec minor with light palpation and resisted isometric shoulder elevation, an anteriorly tipped scapula is often temporarily in a better set position at rest.

It wasn’t all that long ago that I was a casual kettlebell therapy blogger who was merely dabbling on Twitter and trying to find and otherwise connect with like minded people — ANY people… that didn’t see kettlebells as some type of severely dangerous, off the wall, voodoo exercise modality. 

Erson shares the story of helping another physio out after some spinal surgery. The patient's surgeon told him he could not possibly have a lumbar lateral shift after the fusion.

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...

Photo by Jaunathan Gagnon on Unsplash

How we conceptualize our body, our joints and tissues, affects how we react to situations that involve those tissues. Our joints and tissues represent, in the minds of most laypersons, a static entity. That is, “they are what they are”. They can often be viewed as the sum of all stresses, where stresses are responsible for “wearing out” the tissues. This analysis can be misleading. How we conceptualize our tissues dictates, or at least influences, how we behave. In essence, we act out in the real world what we believe to be true about our bodies.

The “wear and tear” model of joint structure, while intuitive and rational in terms of what we know about the world (we all are well aware discontinuity of all things that exist, aside change), has some misconceptions when applied to the living adaptable system that is our body. The main misconception involves the belief that tissue wear itself is irriversable tissue degeneration. In a world where tissue wear = degeneration = pain, the body can be viewed much like a car, in that based on amount of use (ie at 200k miles) it requires a replacement.

I can't remember the reference, but I once read of a tribe whom held the belief that a human has a finite number of heart beats before death. The tribe would act in accordance to this belief, and move very slowly, avoiding any increase in heart rate. They became fragile, soft and sloth like sedentary citizens, and their king existed in a near immobile state, spoon fed and manually transported. Yes, their hearts beat slowly. But at what cost was this belief? Was what they were acting out advancing the intentions of their belief, or to their detriment?

There is mounting evidence and exposure on the tenuous link between tissue and damage, and the more we can re-conceptualize our bodies as adaptive, the less likely we are to fall in line with the aforementioned tribe, mistaking cure for disease.

Bringing this to light can be of therapeutic value in many ways. If we can change what someone believes about their condition, then we can change what they act out, which has incremental returns. The job doesn’t end with just stating information about the body being adaptable. In order for a person to make an informed decision to change how they react to their pain, they need to find this new conceptualization of an adaptable system interesting. If it isn’t interesting, then there is likely no cognitive shift in understanding, and behavior would be unlikely to change.
The idiom “Wear and Tear” (a phrase also labeled by Butler/Moseley to be a particularly “sticky” neuro-tag in is roll-off-the-tongue ease) is usually somewhere in the mind of a patient. In reality, there is tear. There is breakdown. It is completely unavoidable. What can be missed though in the patient-physio interaction is the education that tissue “learns”, changes and responds. This is part and parcel of what Butler and Moseley are bringing to the rehab table. There are too many real interactions between the immune system, thoughts and beliefs, stress and sleep, behavior etc… to view pain in a purely isolated biological tissue mechanistic sense. That is, it isn’t exactly the painful joint (or the muscle or body part) but how that body part is acting in its environment. The “how it is acting” has implications both at the tissue state, and at the individual tissue owner’s state.

I am reminded of a recent PT visit of a woman in her 80’s that had severe scoliosis and it was affecting her gait. She wasn’t coming in because of pain, as she didn’t have any. She was just concerned about the way her walk looked, and her balance. Here is a great example of wear and tear, structural changes and tissue “dysfunction” over the course of an entire life without manifesting any mentionable pain level. But when we are under the influence of pain, it is much more difficult to zoom out and look at the big picture: there exists a present reminder of pain that can consistently confirm our beliefs that something is wrong, that we are at 200k on that tissue. It is difficult to imagine the educational messages of adaptation outweighing innate messages of pain (yes pain is output, but its output circles back around to a cognitive psychological input). But part of that depends on how relieved the patient is to find out the truth about their condition (this goes back to the interest). If for months you suspected a sneaking terminal cancer, awaking in the middle of the night dreading it and imagining and feeling symptoms that confirmed this daily, and finally getting to a specialist only to find that your symptoms were, all from say a gluten allergy, imagine your relief. Its not terminal cancer! Its just an allergy! A weight is lifted…this can change.

Can we shift our views, in a similar sense, when we think about low back pain, neck pain or knee pain? Are our pains conformation of a static and irreversibly damaged tissue? Or could they be a feared cancer without any relevant diagnosis? What would lift the weight of our concerns? Part of this is education. The other part is learned through experience, when the person starts to behave differently and treat the tissue based on what they may have learned through the education. We act out what we believe (we hobble on a joint we believe to be fragile, we move carefully and slow when expecting pain, we change what we do if we are afraid that activity will cause damage, we tense up with pain, and we avoid positions and loads that our tissues have disliked in the past). These behaviors can have their place, but their protection can often quickly become unwarranted.

Back to wear and tear, lets take a metaphor. Imagine a small cabin in the forest of Alaska. In that cabin lives a particularly industrious jack-of-all trades woodsman. His goal is survival, and to survive he keeps his cabin fortified. He learns how to properly fortify his cabin based on what he experiences over the years; wet falls, heavy winters, bears in the summer clawing their way in…you might liken that cabin to your body, where its under constant surveillance of your nervouse system and brain. The tissues are constantly being monitored, and changing in small ways based on what they experience. In a simple mechanical sense, these could be stress, strain, and all things detected by “mechanoreceptors”. In an immunological sense, these could be chemical changes, cellular response, and all things “chemoreceptor”. The cabin does eventually break down over 100 years. Tissue will always eventually degenerate. But, it also gets fixed up along the way, making areas of weakness more robust, and adding support where it is most needed. In a living system, there is adaptation.

Disk degeneration, or “DDD” is a common term brought up by patients with back pain. One argument against some of the medical overemphasis on disc loading strategy is disk research is conducted in-vitro to “non-living” tissue, and doesn’t respond the same to actual living tissue. But even then, disc degeneration doesn’t necessarily have anything to do with pain (back to the woman with severe scoliosis, and all sorts of disc degeneration). There are many angles we can help address where the body is working for the bothersome tissue, not against it. This may come in the form of load management, sleep education, graded exposure to reduce sensitivity, getting stronger globally to support the painful area, increasing cardio for improved blood flow (this could be an arm bike for a person with knee pain, or a leg bike for a person with neck pain… just something to globally improve vascularity).

Not only is the term “wear and tear” misleading (as it should be more something like “wear/load, and create adaptations to best/better tolerate future wear/load”), it also isn’t strongly correlated with pain, which is almost always the primary complaint. Take knee OA for example. Researchers are now referring to this condition as “symptomatic knee OA” (and more and more conditions are allowing this discriminating preamble) because radiographic knee OA does not equate pain.

The consensus is clear that as age and OA findings have a linear relationship, which does not come as a surprise. But remember, OA does not equal pain. The Framingham Osteoarthritis Study found that 10% of people aged 63 years and over had symptomatic knee OA (pain) in the presence of radiographic changes (1). In people with severe OA, it seems about half report pain (2). Although some studies find the link of reported pain and OA severity less clear, some large scale studies (4000 subjects) finds a clear relations between the roughly 40% of persons with radiographic OA and pain (3). Even in these studies, 60% of the persons with radiographic OA did not have pain. Further, can the 40% improve? If so, their “radiographic” OA isn’t changing….

Back to the education component. A study I like to reference is a recent “JOSPT perspective for patients.” (4) The important part to get across is, the more you load the tissue doesn’t necessarily mean the worse off the tissue is. Again, the structural life of tissue is not a ticking clock that only that only counts down to zero. People that don’t jump around, load and move (sedentary individuals) have a higher chance of radiographic knee OA than recreational runners. And people that are obsessive about running (over 57 miles/week runners) only have slight more signs of usage than sedentary people! The take home point is that, to a large level, tissue adapts and becomes more robust, depending what it is introduced to and how it is introduced (ie graded VS overworked). I also like to bring up the fact that people can train themselves to run 26 miles, without their body reacting to that load with severe pain and inflammation. If a runner runs 15 miles in the first month, they may be hobbling in pain for a few weeks. If they train, running 3, 2, 5, 4, 8, 3, 3, 8, 4, 10 miles and so on, they can undergo the same “wear and tear” load, with a totally different response. The response is different not because the person is just stronger or more fit (even though that may be part) but because the body gets familiar with the jolts and pounding of running, and has time to adjust to this and not be alarmed by it. If it (the brain) isn’t alarmed, then the alarm signals (pain) are not present. I also like to reference the Moseley / Butler diagram of “twin peaks” (5). This illustrates that the alarm is going to be set at a lower threshold after injury (even though the actual tissue tolerance can be still robust, especially after proper healing time).

I like tangible examples that don’t get too deep in the physiology of pain. We don't want to move into a completely mechanistic explanation of neurophysiology to replace a mechanistic explanation of structure. There are a lot of simple examples out there that can be used to open up a conversation about the pain in question and how it relates to structure. There is growing evidence that many things influence pain, and how we understand the issue may dictate how we then interact with the world. Not only do we need to change beliefs through our rhetorical explanations, we need to disconfirm beliefs (a term used by Peter O’sullivan in his CFT workshop) in a physical, real body activity and movement sense.

There will always be cases where structure wins, where structure truly needs to be replaced, or “fixed”. Unfortunately, for the same reason we mention tissue damage doesn’t equate pain, fixing the structure doesn’t promise pain relief, and we can look to lumbar fusion outcomes to see it isn’t a cure-all to decompress and immobilize areas reported painful. Some areas respond better to "fixing" than others. We can often mistake symptoms for a disease, and be confused on the relevancy of a patient with one, or both of those variables. Either way, if we are going for conservative treatment, we need to go about it right, with the right outlook and information. This conceptualization should act as a critical foundational understanding to which the rest of the rehab experience can fall under. Following a narrative of adaptation, strength, desensitization and graded exposure, patients will have a better understanding of what physical therapy means, and their individual role in rehab from the specific irritable tissue to the global influencing factors in their lives.

-Tal Blair, DPT - via Motion Guidance blog - check out the MG Clinicians' Kit below!
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Keeping it Eclectic...

The patient in the video had several level spinal fusion from T7-S1. He had several years of being able to golf and return to function and running. However, he noticed continued lumbar lateral shift to the right. His lumbar spine and left LE is still Sx free, however it has atrophied significantly and in the past year, he has found it difficult to load. His balance is affected and he now needs a cane to walk. He is a PT and is also going to several PTs for gait and general strengthening/conditioning.

edit: this post was first found on Shift Movement Science, an awesome blog by my good friend Dr. Dave Tilley, DPT. If you listen to Untold Physio Stories podcast, you'll know I'm a HUGE fan of failure stories and what we can learn from them. Dave's story here is powerful and well worth a read! - Dr. E

In the 12 years that I have been coaching gymnastics, I have been lucky to experience some incredible moments. Like when one of our gymnasts hits a huge routine at Regionals and qualifies herself to nationals, causing everyone to erupt in celebration. Or the tear-jerking moment when a graduating senior tells a room packed full of parents and young gymnasts – “I am proud of the person I have become thanks to our gym, the coaches, and gymnastics as a whole.”

In contrast to this, I have also had experienced some truly awful moments of regret. Today I would like to share the lowest moment of my coaching career, in an effort to help you not make the same mistakes I did.

It came when I received a phone call from another one of our soon to be graduating seniors. Through her tears,  she told me that an MRI had just revealed two severe stress fractures in her back, that she was quitting gymnastics, She would no longer be pursuing her dream of competing in college, which she had been working her entire life for.

Her parents had made her go to the doctor because along with the chronic back pain she was ” just trying to push through”, she started having shooting leg pains that made her unable to drive, sit in school, or put her socks on. After deciding with her family that gymnastics was too dangerous for her long-term health, she would now be changing schools so her family could save money.

I remember literally not being able to formulate words. Adrenaline surged through my body, and I instantly felt like I wanted to throw up. After finishing the conversation in a pretty much numb state, I hung the phone up and stared blankly at my computer for 25 minutes. Every negative feeling and negative thought you could imagine ran through my head. “How did this happen? Do her parents hate me? Am I an awful coach?”

The worst part? I was also her Physical Therapist. This happened the year after finishing my doctoral work in PT, when I was in my first year of both coaching and treating full time. Not only was I responsible for training decisions that contributed to her fractures, I was the one who was supposed to be fixing her fractures.

Now there were many factors over the years that likely accumulated to her career-ending back injury. But one thing is for sure – the toxic combination of lacking self-awareness and a massive ego blinded me to see the clear red flags that her back pain was not just “part of gymnastics”.

Thankfully, upon years of reflection and reverse engineering that terrible situation, the injury rate at our gym is fractional compared to the rate that it was when this occurred. Accidents still happen, and we do have gymnasts who battle lower back issues, but they are much less severe and come with less collateral damage. Here are 5 valuable coaching lessons that had I known then, her and I may have had a much happier 6-month end to her gymnastics career.

1. Ego Is The Enemy

Credit to Ryan Holiday, who wrote the incredible book Ego Is the Enemy.  I have come to realize that my large ego as a younger coach likely caused hundreds of gymnasts I worked with to not reach their full potential, or to get hurt. During my current travels, many people tell me that they are impressed with my work ethic and humility. Well, now you know where it comes from. It took this gut-wrenching experience for me to realized I was, unfortunately, making some training decisions based on how I would look, not how our gymnasts would feel. I now try to weave humility into my moral fabric every day . I strongly recommend that coaches who are just starting out do the same. 

2. Embrace Reality, and Deal With It

All credit to Ray Dalio on this. The gymnast I mentioned had months of warning signs that I chose to not act upon. Again, my ego was allowing me to believe that I should not acknowledge the situation because it would make me look bad. Being a coach with gymnasts who have back injuries isn’t a great look for a PT who is supposed to be an expert in preventing back injuries. The take away is this: Fires don’t turn to ashes just because you chose to look away. They turn into raging wildfires. The sooner you look at your problems in the eyes, the better.

3. Do The Harder Thing, Especially When It’s The Harder Thing To Do. 

I know more than anyone else, as a coach it is incredibly uncomfortable and anxiety provoking to really look at the things that terrify you. I was scared to tell this gymnast “I don’t know”, I was scared of what people would say or think about me, and I was scared to own up to the reality of her injury progressing. If I had followed Steps 1 and 2 early and admitted there was a problem, her and I would have had a much happier 6 month ending to her gymnastics career.

4. The “Ivory Tower” Is a Lonely and Dangerous Place

The Ivory Tower is an expression for people who think they are better than others and possess a sense of entitlement. During this time period of coaching, I thought that I was special because I had a doctorate and knew a lot about the medical field. All this did was create resentment in the coaches and gymnasts I worked with, rightfully so. When I was spewing out big medical words to sound impressive, they would roll their eyes at me and gossip behind my back. The only thing I gained from living in my big Ivory Tower was a more painful fall from grace when I finally opened my eyes. Now, I try my best to practice empathy and hear our people’s point of view whenever possible. I openly tell our gymnasts, coaching staff, and the parent’s they have full permission to call me out if I’m acting like a jerk (so long as it’s delivered professionally)

5. Learn, or Lose

I saved this for last because it really encompasses all the points above. From the more technical learning (new drills, new business tactics, how to spot a skill) to the more “meta” learning (self-awareness, reflection, perspective taking) there should never be a day you don’t sponge up new knowledge. Even if it’s about something you have done for 10 years and could do in your sleep. There may be a better way, a new way, or a more efficient way. In our current age, technology changes at a blistering pace and new ideas are surfacing every day. Gymnastics is no different. If you don’t physically build in time for learning in your calendar, your doing yourself and the gymnasts you work with a huge disservice. I didn’t have the tools I needed to help this gymnast, and I paid the price. Now, I block one hour of continuing education first thing every morning.

The Problem with Gymnastics Education

Building off number 5, I feel people’s frustration with not having the time, access, or money for new gymnastics education based on the actual problems they face working in gymnastics.  Everyone in gymnastics tells me that trying to find new information online is exhausting at best, and when they do find something it is either impossible to implement during practice or they are unsure about the science behind it.

To solve this problem, I built a brand new online gymnastics platform called The Hero Lab that gives people monthly gymnastics webinars based on requested topics, a discussion forum to get help with their everyday struggles, and an international network of gymnastics professionals. I want people to have all the tools they need to be happier during training, help their gymnasts, and build incredible gymnastics cultures, right at their finger tips.

The Hero Lab absolutely exploded when I launched it yesterday. We had a huge range of gymnastics professionals from across the world join including Olympic and elite level coaches, Registered Nutritionists, expert medical providers, PhD level Mental Health Professionals, and more.

I wanted to make sure you could see what all the hype is about, so you can learn more by clicking below. I PROMISE you do not want to miss out on this.

The Wait is Over – The Hero Lab is Officially Here!

Have a great week,


Dr. Dave Tilley DPT, SCS, CSCS

CEO of SHIFT Movement Science

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

Learn more online!

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...

In this quick video, I emphasize the importance of learning how to sell physical therapy and what it means to the patient's overall happiness.

I am often asked why coaching? And why coaching to overcome pain? So in this blog, I’ll tell you why coaching has become the main way in which I help people to ease their suffering and overcome their pain, blending the latest understanding of pain with strengths-based coaching. I haven’t looked back since.
I knew that I wanted to get the best out of each individual, encouraging them to reach their potential, to make a real difference. Just helping people understand pain and providing exercises was not yielding results that deep down I knew could be achieved. There was something missing; something vital.
Why coaching? ~ getting the best from individuals
For many years I coached youngsters to play cricket. It occurred to me that what I most enjoyed was seeing how the individual’s approach to the game impacted upon his or her performance. This is the same when we want to overcome a challenge in life. Understanding our existing approach enables us to see what is working and what is limiting us. When it comes to pain, this same understanding is the key.
Usually someone comes to see me for help because they are desperate or inspired. Often it begins as the former and we seek to shift to the latter as they learn how their pain story has emerged and persisted before realising that there is much they can decide to do. Notice the word ‘decide’, which is so potent and arguably one of our greatest powers.
As much as we need to gain a good grasp on this, we also need to know why the person has not got better when we are designed to do so in the name of survival. We are survival machines are arguably spending too much time in such a state, or a state of protect.
Why has this person NOT got better?
In a sense we all need a great coach in our lives. Coaches and coaching come in many different forms. As parents we are coaches, as co-workers we are coaches, as friends we are coaches, and of course as a sports coach you are a coach. It matters not the arena, just the fact that you want to encourage another person to perform in their best way whilst shedding limiting factors, and moving onward as they grow and develop. These are one of a handful of basic human needs without which we suffer.
Coaching is results driven but is not only about focusing on the prize. To focus on the prize or just the result is to try to control the uncontrollable. The result does not yet exist except in mind. Too much attention here means the necessary step right now can be missed. Accepting where you are right now is a must. To want to be somewhere else is another major cause of human suffering.
The purpose of a coaching programme is for the client or patient or coachee to achieve their picture of success. However, along the way there are the little wins together with the bumps in the road. Wins and bumps are both are learning opportunities that allow growth and a reorientation towards the picture that offers a direction and a motivating force.

A pause for thought: can you think of someone who has coached you and made a difference to your approach to life? This will be a concrete example of why coaching has worked for you.

One way to think about coaching is that it gives the person the know-how. They have a toolbox of exercises, strategies and practices, but they must know how to use them with effect in their own world, not just in the clinic. I say to my patients, My wife could buy me the best drill in the world and ask me to hang some pictures, but I still make massive holes in the wall because I lack drill know-how. Self-coaching, as we coach others to become their own coaches because they are with themselves all, well most, of the time. I say this only in partial jest because how often are we not there as our minds drift off? To be present is one of the key skills that we practice in the Pain Coach Programme.

A Pain Coach ~ a few key characteristics: highly motivated to take action to ease the suffering of others, self-compassion, compassion, a huge desire for learning, a deep listener, appreciate kaizen and the beginner’s mind, and enjoy rock music (optional). 

Self-coaching each moment is about being in touch with reality, being present, being compassionate (especially to self) and encouraging myself to take (positive) actions towards my picture of success. I ask: what are my needs right now and how can I best meet them in a kind and healthy manner? This is quite a skill when many are self-critical and we live in an age that promotes self above others and the planet.  On this, I see increasing numbers of people who suffer pain problems that began as a mismatch of values (more of that at a later date).
The Pain Coach: coaching others to self-coach to overcome pain
To coach others is a privilege as well as a way of being. For the many, many people suffering pain they need to know both that they can make changes when they decide to do so, and that there are people (us, the clinicians!) who exist to encourage them and support such changes. They are not changing who they are, just their approach to pain by understanding what we really know about pain and using practices and exercises to gain momentum in a chosen direction using their know-how and self-coaching.
This is why coaching for me is best job in the world! We coach ourselves and we coach others to coach themselves. We witness growth, the building of wellness, the realisation of sustained happiness and joy and get to share in it all!
Interested in Pain Coaching to make a difference and get the best of you and your patients? Workshops by request, please call us on 07518 445493 or see here for current dates: ChicagoLondonPreston

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

Learn more online!

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...