Modern Manual Therapy Blog

In the Eval, Reset, and Stabilize System, "stability" doesn't mean strength. I use stability to mean the area can accept load in a threat free and efficient manner. After Sidegliding in standing is equal or FN bilaterally, but if the LCAP test is positive, homework should include exercises designed to help single limb stance and the lumbar spine's ability to accept load on the involved side. Below is a sample of a progression I may prescribe in this case. The example is for loading the right LQ with the exception of Eccentric-Isometric Goblet Squats, which is for mobility and proprioception for equal loading.

Think of adding stability exercises especially when SGIS exercises help reset LQ complaints, but despite patient compliance and high dosage, their single limb stance stability makes them unload more during ADLs than the loading resets can compensate for. 

5 Step Progression for Unilateral Lumbar Loading and Single Limb Stance



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Listen in to Dr E. sharing one of his early treatment stories (17 years ago!) of when a patient he treated did not respond to manual therapy...but got better with some unexpected fancy treatments.
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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 edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy.


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While growing up, every New Years Day my whole family, including my parents, three siblings, and myself, would go out for breakfast at the Golden Skillet. The Golden Skillet was your stereotypical diner, from the mediocre coffee to the old men (the “regulars”) always sitting at the counter reading the newspaper. Interestingly enough, one thing I always remember about this experience is our waitresses. It always seemed to be a middle-aged woman with some grittiness to her that showed she might have worked at the diner just a little too long.

“Alright, what would you like?” she would ask us, and then with no pen or order pad, and her arms behind her back, she would proceed to take each of our orders. She would then take our menus and walk away to input the orders.The next ten minutes of the table conversation would consist of “how the heck does she memorize all our orders?” Yet, sure enough, we seemed to always get the food we wanted just as we ordered it.

We always seem to have a fascination with memory. “I can always memorize people’s birthdays” or “I can memorize this many digits of the number pi.” I’m sure the examples are endless, but I don’t want to talk about memorizing things. I want to talk about the easiest way to not have to memorize things: the use of a checklist.

Again, I have received inspiration for this blog post from a nonfiction book, The Checklist Manifesto by Atul Gawande. Besides being an author, Gawande is an American surgeon and public health researcher. His book describes the trials and successes of the adoption of checklists in operating rooms across the world. He also describes the successful use of checklists in numerous industries, most notably aviation and commercial building and construction. At one point, Gawande notes that he cannot imagine a single industry in which checklists cannot provide a benefit. So, let’s look a little further at the benefits of using checklists, what makes a good checklist, and how physical therapists can use checklists for our benefit.

Simply put, the reason for checklists is that humans are fallible and have inadequacies. We miss things and make mistakes. There are limits to our attention span (some more than others) and our memory. Of course, this is okay. The world is complex and the field of physical therapy is no different. Just think about the complexity of the human body, or think of the multiple diagnoses, co-morbidities, tests and measures, and treatment techniques that you’re exposed to or perform throughout the course of day. A checklist offers a simple way to avoid errors and oversight. It helps you avoid problems and make sure the stupid stuff isn’t missed.

What makes a good checklist? Gawande describes the key characteristics of a good checklist include that it is precise, efficient, and practical. It should be to the point and only include the “killer items.” Additionally, a good checklist should only be used as an aid. It should aid the decision-making and skills of the professional. However, most importantly, a checklist needs to be practical, which means that you should practice using it and continuously make refinements to improve its effectiveness and ease of use.

Physical therapists can utilize checklists in a variety of situations. We can have a checklist for initial evaluations. For example, a checklist might include history, posture, strength, ROM, functional mobility, etc. From here, we could have sub-checklists for different sections of the evaluation. What part of the patient history should I absolutely ask and not forget? We can use checklists that are specific to certain diagnoses or patient populations. We can use a checklist for red flags. What are the red flags that I absolutely must ask about for each patient? The same thing can be done for yellow flags and psychosocial factors. There also are the huge lists of contraindications and precautions for different treatments and modalities. Don’t tell me you’ve memorized all the contraindications to electrical stimulation, and for every patient you ask about each one.

It seems clear that physical therapists can benefit from using checklists. There are probably different examples that I didn’t even think of. So, what are the reasons we don’t use them? First we have to consider the mindset of the skilled expert clinician. “I am a knowledgeable and skilled therapist and I don’t need the aid of a checklist, and plus, my patient will consider me less skilled and knowledgeable if he or she sees me using a checklist”…This thinking is flawed. A checklist is not supposed to completely eliminate any decision-making, problem solving, or skilled care. The purpose of the checklist is to take care of the simple stuff, so that you can focus on the complex stuff. If used correctly, a checklist should not turn you into an automated robot or diminish the personal connection with the patient. In fact, a checklist can improve communication with the patient, improve thoroughness, and make sure important things aren’t missed.
“I’ve never used a checklist, and I’ve never had a problem.” 
Another argument against using checklists might be, “I’ve never used a checklist, and I’ve never had a problem.” It’s true that most parts on a checklist can seem unimportant or unnecessary (“Do you have Raynaud’s syndrome?” “Do I have what?”). However, as Gawande notes 49/50 times there is no problem…until there is. The things that are uncommon, but can occur, are the things we are most likely to miss. Following the checklist is the easy way to not miss those things.

We shouldn’t fear the rigidity of implementing checklists. As Gawande notes, checklists “get the dumb stuff out of the way, so you can focus on the hard stuff.” Consider that Steve Jobs wore the same clothing (black turtleneck and blue jeans) every single day. He did this because he didn’t want to expend mental energy making silly decisions such as what to wear for the day. He wanted to use his mental energy creating amazing products for Apple. We should use checklists the same exact way. Let’s expend our mental energy on the tough stuff and keep the simple stuff simple.

Note: This post should really be considered as a synthesis of Atul Gawande’s book, The Checklist Manifesto, with my personal thoughts in relation to the field of physical therapy.

via Luke Pedersen, DPT



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Image result for neck surgery
https://upload.wikimedia.org/wikipedia/commons/thumb/4/4e/ACDF_surgery_english.png/350px-ACDF_surgery_english.png

It is well established that conservative treatment should be the primary choice of intervention for non-specific neck pain as the benefit of surgery over conservative care is not clearly demonstrated.  For rehabilitation professionals, the use of exercise therapy and/or manual therapy is obviously the most appropriate decision and should always be utilized prior to most invasive, risky procedures.
This is echoed in the Cervicogenic Dizziness / Cervical Vertigo literature as well.  We have three systematic reviews demonstrating the benefit of non-surgical and non-pharmacological interventions, specifically manual therapy, for these patients.  The high level of evidence all originated in 2005, then again in 2011 and even though just showing effectiveness of acupuncture, endorsed recently in 2017.  Although only three SRs, I think this is very positive considering a condition not well studied and continues to carry the burden of controversy.
Even with substantial evidence showing the effectiveness of conservative care, specifically manual therapies, for Cervicogenic Dizziness / Cervical Vertigo, there are still several citations illustrating success following surgery.
Here is a glimpse of the literature with accompanying conclusion:
Yang Y et al 2007
“Percutaneous laser disc decompression can decrease intradiscal pressure, increase local temperature and remove the spasm of the vertebral artery while providing a remarkable therapeutic effect for the treatment of cervical vertigo.”
 Ren L et al 2014
“Excellent outcome in 18 out of 35 patients who underwent percutaneous laser disk        decompression”
Li J et al 2014
“Good results following more extensive cervical surgery”
Park J et al 2014
“Patient vertigo disappeared after surgical decompression of transverse foramen of C1”
Liu XM et al 2017
“ACDF provided a good resolution of cervical vertigo in a retrospective study of 116 patients”
Yin HD et al 2017
“Radiofrequency ablation nucleoplasty improves the blood flow in the narrow-side vertebral artery in 27 patients diagnosed with cervical vertigo and illustrates the therapeutic effect on cervical vertigo. Radiofrequency intradiscal nucleoplasty can be used as a minimally invasive procedure for treating cervical vertigo”
You can see a trend in the just the last few years indicating success of vertigo/dizziness after surgical procedures.  As an evidence-informed practitioner or even a vestibular specialist who isn’t trained in treating the neck, and recognizes lack of consistent relief in your patient, you may seek out this research and consider referring on to a surgeon.  Before you do so, let’s dive into the most recent article with surgical success to jack into a clinical reasoning discussion.

Patients/Methods: Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain
Results: There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group.
Conclusion: This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis.

Out of China, Dr. B Peng and his colleagues recently had this article published in the Bone & Joint Journal (not the best journal but higher impact factor than JOSPT). This is a level 2 multi center prospective cohort study—not bad when considering level of evidence as we have very few studies higher up on the chain and most involve the same name of Susan Reid & her colleagues from the land of Australia.
From initial glimpse of methodology, results and conclusion (you know we all typically look at the abstract…), my thoughts are that if my patient has arthritis and dizziness, then if they have surgery, they will have less intensity and frequency of dizziness compared to conservative route.
The first thing I did was to look at what type of conservative treatment was performed.  Here is the description:
Conservative treatment included physiotherapy, intermittent cervical immobilization with a collar, nonsteroidal anti-inflammatory drugs and rest.
This doesn’t tell us much what kind of physiotherapy was performed (stabilization exercises, heat/ice, e-stim, massage, squeezes for the shoulder blade squeezes with theraband, neck ROM—hell we don’t know!).  We don’t know what was meant by rest, or what was meant by intermittent immobilization of the spine (does anyone do this nowadays anyway?).  For all purposes, it could be the Physio Blend buffet style…but doubtful.
The second thing I did was look at the type of patients that were recruited.
Between March 2014 and March 2015, 157 patients with cervical spondylotic radiculopathy and/or myelopathy from three spinal centres (General Hospital of Armed Police Force, Beijing; 304th Hospital, Beijing; Changzheng Hospital, Shanghai) were enrolled in the study.
Additionally, the patients had failed conservative treatment (3 months of treatment!) prior to potentially having surgery—-34 of the 157 patients declined surgery—but continued with conservative treatment—and this was the group that surgery was compared to!  I’m sure the patients who continued with PT after 3 months were stoked to continue more of the same cervical immobilization, rest, NSAIDs and general physiotherapy….
The third thing I did—write this blog.

Big key points:

This is not a bash against the article—I thought it was well written and authors were open to the limitations in the conclusions.  They even stated the patients selected for study were for myelopathy/radiculopathy and not dizziness!  But, knowing the time and effort that goes into reading research in the profession—the title and abstract could be misleading to the consumer and I felt this blog would be beneficial to my rehabilitation colleagues.
Just like any condition we treat, this paper exemplifies a double entity.  Yes, the patients had improvement in dizziness following the procedure, but I would really say these patients had success of cervical pain due to cervical spondylotic radiculopathy and/or myelopathy, NOT cervicogenic dizziness.
This paper also exemplifies the notion that dizziness can arise from the neck, and can improve with intervention!  So yes, still can be controversial in the medical eyes, but this group sought out improvement in dizziness following the procedure indicating a cause/effect relationship.
Further, if you’re a vestibular therapist seeing patients you think that symptoms could be arising from the cervical spine, don’t just pass on to your orthopedic mate in the clinic.  Get some training, some real training.  We can help you with that.
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 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...

Another great and often asked question from a blog reader, "Roo Ree" which I completely butchered. It's Irish (and spelled very much so). Fortunately, patient compliance with homework is something I'm a bit better at.

The question is, "My patients often do not understand their homework, showing me something different, or showing me the assessment instead of the homework. What am I doing wrong?"

Like much in the Eclectic Approach, the answer is, "If I can do it, so can you." #antiguru

Help! My Patient's Don't Understand Their Homework




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...


For the last several years, I’ve been writing up predictions on what is to be expected for the year to come. Typically, I release these early in January of the relevant year or December of the year prior. This year, things got away… and, I mean… AWAY away….. that plague of a flu that hit this season? Yup. That happened, x2.
But, with all things — you make the best of it and it gave me plenty of time to reflect over the happenings. There were several large trends, none so surprising, to be appreciated… and, some interesting marketing trends that seemed to loom over the horizon.
Suffice to say, 2017 taught us a few things on the digital market front:
  1. It was the year of websites.
  2. It was the year that social media “failed” — because, it’s not social media… it’s just plain media, now.
  3. It was the year that all the other major predictions, seemed to hiccup and never come to fruition.
All that said… it was good that I was able to reflect and truly ponder what is to be expected for this year. And, so… without any further ado…. here are!

5 Marketing Predictions for 2018

#1. MATRIX RELOADED.As mentioned, 2017 was the year of websites and New Year 2018 was when social media “self destructed” with all of Facebook’s business and fan page algorithm changes. Honestly though, it is no different than when in 2017, Google killed pop ups, when in 2016 Snapchat killed Twitter, or when again in 2017 Instagram killed Snapchat… and, through end of 2017… Twitter had a rebirth.
All these things come to pass in cycles; 2018 is the year that people (and, brands) will consolidate and reboot their footprints with a fierce user focus on all fronts — inbound, outbound, paid, organic…. ALL. OF. IT! Look to how international users like to manage their accounts. Typically, it’s through highly centralized and consolidated streams. One app to keep an eye on in terms of functionality: WeChat, the “Chinese Facebook.” Through this app, you do all your calls (voice and video), purchasing, ride sharing functions, social channels… everything.
#2. MARKETING GONE RETRO.You can expect 2018 to be the year everyone goes back to basics. Keep your eyes out for brands that are going to dust off the history books for tech-powered retro approaches in marketing, consumer engagement, branding, PR, etc. etc. etc.
The number one reason we can expect companies to go retro is because “back in the old days” people actually connected. That, is what has been lacking most of the end of 2017 and this fluttery start of 2018… there’s automation everywhere, there’s technology everywhere, there’s media and screens and swipes and taps… EVERYWHERE. What’s missing is connection. And, those who learn and master the “subtle science and exact art” (Harry Potter fans, know what I’m talking about) that the balance of authenticity and automation — such storytellers, will win and win BIG.
#3 REVIEWS.Reviews will matter more than every before. When it comes to content clutter (as we discussed in multiple blog posts in 2017), consumers go back to basics (ie. retro) and lean on two primary things: (1) search engine results, and, (2) reviews. Reviews, social media, forums, etc… all these are seen as Word of Mouth 2.0. There’s no other way around that truth. And, because of it, consumers will rely on multi-channel proofing via reviews as a precondition to purchasing behaviors. So, if you don’t have a system for feed-forward loops on gathering 5 star reviews from your company’s brand ambassadors… [A] we need to talk; [B] you need to get on identifying a platform; and, [C] you need to sit down and name 10 potential brand ambassadors, right this very second!
#4 STORIES WIN.As alluded to in #2 above, storytellers will win and win big. Stories are the original media of the human condition — it is the way we communicate, pass on knowledge, lore, and conventional wisdom. These are all active considerations of the prospective consumer -AND- the prospective consumer seeks validating stories about WHY they should buy your brand.
WHY?!
It can’t be objective. No, no… no! We know all too well from psychology and cognitive science that when people buy, they buy for emotional reasons from those very centers of our brains. We then justifythose decisions based on the rational elements within our mind in support of that emotional decision; however logical we may claim to be as individual thinkers.
We can’t ignore this science if we are to be precise and effective marketers. Therefore, share stories. Stories about HOW your brand brings value, changes lives, empowers others, and brings good to the community — these are the stories to share about… certainly not how someone’s functional measures improved… *barf*
Share! Share, how your company helped someone regain their livelihood when all hope was lost. Tell it, with gripping emotion and striking relate-ability. Tell it as if it was your close friend or family. Tell it so that everywhere who hears of these stories, feels its deep and leaves them with warmth, hope, and the desire to engage.
Oh, Hint! The best way to tell contemporary stories: VIDEO. High level production value video.
#5. ECOSYSTEMS.Only ecosystems will survive. Now, that might sound bleak, but that is the harsh reality of 2018’s marketing landscape. One dimensional, tactical approaches to marketing will quickly burn out. Foundationally driven, strategically oriented approaches will survive and even grow!
It’s all about the long game and it needs to be just as data driven as it is user focused.
Just as in the clinical world, we would customarily never ONLY use one singular clinical intervention (ie. only use TherEx, or only use Neuro ReEd, or only use Therapeutic Activities — shoutout to our Physical Therapy roots and our PT colleagues reading this post)… such is the truth in effective marketing. In fact, it has always been this way. It’s just that the acid test for 2018 will be that much more grueling to stand up to; if you’ve been relying on what is essentially a singular approach, it’d be an incredible important thing that you expand your lead sources beyond the status quo.
Proof your lead sources in this fashion: If the way your business continues to have steady business comes from one type of customer conversion journey… if how they come to find you always sounds the same… you NEED to start diversifying NOW!

Now, I do have a few more predictions of the non-marketing type.
  • Student debt will become an uningnorable and fiercely deciding factor in the job market, talent acquisition, and staff retention.
  • Wearable, communication portals, and apps will become even more a thing, especially as it pertains to data science and it’s impact on population health.
  • To the above: If Physical Therapists DO NOT define their roles within data science and population health management, it will once again be defined for us and will cripple our presence for the next foreseeable evolution within the healthcare schema.
  • This year, non-payer healthcare consumerism (ie. CashPT) proves itself as “not a fluke”… particularly for established practices with a healthy community footprints that happen to have long waiting lists.
  • “Young” practices will begin to find ways to share resources in working together; established practices must shed their differences in a unified economic pursuit… or, die trying.

Well! That’s all I have for now. As per the past, I’ve been pretty darn on the spot with my predictions and the next 11 months or so will tell for what I’ve now stated in black and white.
So, until next time, may your 2018 continue to sprint with success in strength. And, should there be anything you need or any questions you have… you need only reach out.
Ben Fung, DPT, MBA
Co-Founder, COO, UpDoc MediaCo-Founder, CFO, Recharge|HoCo-CrossFit
ben@updocmedia.com
C: 470-BEN-FUNG
Twitter: @DrBenFung
Snapchat: DrBenFungInstagram: @DrBenFung



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...


Motion in E-Motion


There’s no mistaking the word motion in e-motion. The two are inextricably bound. The way that you feel, your emotional state, is governed by what you are focusing on in this moment. And what you are focusing on is an affordance, or opportunity within the context–the opportunity to act or think in a particular way.
What you are focusing on appears to pop in to one’s awareness. Sometimes it drifts off, and sometimes we toy with it, so it seems to stick around. If it is a thought about something pleasurable, you embody a sense of joy, excitement and a desire to repeat the behaviour. If it is a thought about something unpleasant or scary, you embody other emotions such as fear or anger. All are based upon what you are focusing on and the interpretation of that focus, or the meaning to you.

Your state is governed by what you focus upon

Nothing is anything until you give it a meaning, and that really comes from our conditioning over many years–beliefs that you have gathered through life and what you have been told. Were they right though?
Our state is characterised in one sense by how it is embodied. How do I experience that state in my physical body? Noting a particular feeling or sensation in the body brings us to the conclusion that we are feeling a particular way. Contemporary neuroscience research is revealing fascinating relationships between our internal body sense (interoception) and our perception, cognition and decision making ability. Fundamentally, we all know that the ‘mood’ we are in affects the way we operate in the world: what do I notice? How do I move? What choices do I make? etc.
We can easily notice how someone is moving and posturing to gain an insight into how they feel. Add facial expression and language, and we have a fuller picture, yet the quality of motion is usually enough if you are observant. Likewise, we have a sense of our body as part of an overall assessment of ‘how I am’. Once we have established our state, we can decide whether this is one that affords us healthy opportunities or not. Do I need to change state?

motion in e-motion

It does not take long to change state of course. We do it all the time. One of the simplest ways to change state is to use motion–move around! Shifting our posture and facial expression result in feeling better together with actions that benefit others as we focus outwards instead on inwards. The challenge in the modern world is that we are encouraged to suit ourselves at the expense of others.
Motion is in e-motion, yet this is a two way street. We may use movement to feel better or build wellness, but we also move better when we feel well and in a positive state.
Here’s a fun game to play, especially if like me you are a commuter: look at your fellow travellers and see if you can work out what kind of state they are in right now. It maybe best to avoid asking them! As a bonus, you may also like to try the smiling game. See how many people smile back when you smile at them. Whilst you are smiling, use this as an embodied wishing them well, even saying to yourself ‘I wish you well with this smile’, just to generate the authentic smile that you can when it fronts the feeling. There you go, another example of motion (smiling) in e-motion.
These are some of the simple skills I teach and coach people in pain to learn to change state. I also teach clinicians who come on the Pain Coach Workshops how to build their own wellness and self-compassion with practical tools that get results in them and their patients. It is a matter of replacing old conditioned ways of being with new and better ones!




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...



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 edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane Physiotherapy 




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...