Modern Manual Therapy Blog - Manual Therapy, Videos, Neurodynamics, Podcasts, Research Reviews: Jesse Awenus

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This post was originally found on Jesse Awenus' blog. I often wonder now, being skeptical (but not as skeptical as Jesse), if I would go though an entire fellowship all over again. The answer changes often. Do I think it's worth it, yes! Knowing what I do now about the over abundance of passive assessments and treatments and lack of educational strategies, including Therapeutic Neuroscience Education, would I do it all over again? Most of the times, I answer yes, as long as the program had the right content. Thanks for the post Jesse! - Dr E

Lets face it, going through the community based level system run through the Orthopaedic Division or through either Western’s or the newly formed McMaster masters program in Manual and Manipulative Therapy is tough. These are structured programs that require many months of study, practice, exams, and mentorship. Let’s also not forget all the associated course/tuition fees and lost income from time away from work to finish these programs. I finished my advanced diploma in 2015 and it took me about 5 years to get through it all. I recall having to say no to many weekend getaways during the summer of my advanced exam as I would be at home hunched over my desk studying anatomy, biomechanics, pathology, and everything else the people reading this know all too well about. It was quite the onerous process to say the least.

So why do we do this to ourselves? What posses a physiotherapist to take on this extra burden after already completing 6+ years of university study to become a registered physiotherapist. While I’m sure this answer differs for many, I think it comes down to a few key concepts. First off, physiotherapists by nature have a thirst for knowledge and betterment. I know this because year after year the Allied Health Professional Fund (AHPF) in Ontario consistently states that we as physiotherapists use up our funding much quicker than every other listed profession combined! (We sure do like our continuing education). We strive to do better for our patients and figure out exactly why we fail to help a portion of the patients who seek us out. Second, physiotherapists love a good challenge. Despite all our bitching and moaning about the process of becoming an FCAMPT, we enjoy the ride and the community it builds for us both professionally and socially. I can’t tell you how many amazing physiotherapists I wouldn’t have otherwise known had I not done all my levels. The professional networking at these courses cannot be understated.

Other reasons for gaining fellowship may include increased status within the profession, monetary gain from clinics/bosses who provide additional payment for course completion, and for self satisfaction. I’m sure people reading this have their own reasons for taking a level course or doing another masters program.

I would be remiss if I said everything I learned and studied was based on solid evidence and I would be doing a disservice to my skeptical nature if I didn’t have grievances on how the program is taught. While this article isn’t a commentary on the current state of manual therapy education in Canada, I do think it’s prudent to point out that many of the pathobiomechanical models that are routinely taught within the CAMPT program don’t follow suit with emerging evidence. I distinctly recall being made to feel inept when I couldn’t feel thoracic spine passive intervertebral motion (PIVM) as well as the person instructing me. If I’m to be honest, I recall leaving class some days feeling more stupid and incapable then when I entered. It was later on in my career that I realized that was simply not the case and that there have been repeated studies concluding that identifying lesions by motion palpation are not reliable (Huijbregts et al 2002, Nyberg et al 2013, Seffinger at al 2004). I began to worry that the physiotherapist down the street from me would be better able to help a patient in pain because they were able to be more specific in their treatment selection and delivery then me. Fortunately, I realized this was also not the case. There are now a number of studies showing similar benefits among patients receiving “therapist selected” and “randomly selected” mobilizations or manipulations. Both groups seem to show equal short-term improvements as long as they receive any form of manual intervention (Donaldson et al 2016, de Oliveira et al 2013, Chiradejnant et al 2003, Aquino et al 2009). I learned through many hours of reading research that manual therapies can be very effective for nociception reduction, but the exact mechanism for this is till up for debate. If you can keep these ideas in mind as you go through the CAMPT program, I think you will enjoy it much more.

It may seem like I’m saying that becoming an FCAMPT was a waste of time, but that couldn’t be further from the truth. The program I was taught gave me a much more solid foundation in differential diagnosis, screening for red flags and understanding anatomy at a much deeper level. I feel better off for having been through the system and I am glad I stuck through it. There are rumblings that when the new manuals come out next year there will be less emphasis on motion palpation and biomechanics and more emphasis on neuroscience education and a more current model explaining the possible reasons why our hands can help make people feel so much better. I welcome these changes and hope to see more made in the future to keep our program relevant in light of all the emerging evidence surrounding manual therapy. I am a proud FCAMPT and I encourage anyone with any questions about it to contact me. I would be happy to help in any way that I can.

Jesse Awenus B.A Hons (Kin), MSc.PT, Dip.Manip.PT, FCAMPT
Registered Physiotherapist
www.JessePhysio.com

References:
Aquino RL, Caires PM, Furtado FC,. Applying Joint Mobilization at Different Cervical Vertebral Levels does not Influence Immediate Pain Reduction in Patients with Chronic Neck Pain: A Randomized Clinical Trial. J Man Manip Ther. 2009 Apr 1;17(2):95–100.

Chiradejnant A, Maher CG, Latimer J, Stepkovitch N. Efficacy of "therapistselected" versus "randomly selected" mobilisation techniques for the treatment of low back pain: a randomised controlled trial. Aust J Physiother. 2003;49(4):233- 41.

De Oliveira RF, Liebano RE, Costa LC, Rissato LL, Costa LO. Immediate effects of region-specific and non-region-specific spinal manipulative therapy in patients with chronic low back pain: a randomized controlled trial. Phys Ther. 2013; 93: 748– 756

Donaldson M, Petersen S, , et al A Prescriptively Selected Non-Thrust Manipulation Versus a Therapist Selected Non-Thrust Manipulation for Treatment of Individuals With Low Back Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2016 Mar 8:1-29.

Huijbregts PA. Spinal Motion Palpation: A Review of Reliability Studies. J Man Manip Ther. 2002 Jan1;10(1):24–39.

Nyberg RE, Russell Smith A. The science of spinal motion palpation: a review and update with implications for assessment and intervention. J Man Manip Ther. 2013 Aug;21(3):160–7.

Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson VM, Murphy LS, et al. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine. 2004 Oct 1;29(19):E413–425.

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...

I had the opportunity to do Jesse Awenus' podcast recently and he dove into several great topics that I haven't talked about in a while.

From Jesse's description....

This interview is for anyone who is interested in becoming a physiotherapist or who is already one and wants to learn what steps to take to become a success. During this candid conversation we discuss:

Why Erson become a PT and what surprises he may have encountered along the way

The evolution within orthopaedic physiotherapy from anatomy focused to biopsychsocial focused care and how this changed ways of practicing

Why Erson decided to start a website and how to use social media to grow a business

How to manage the time constraints of staying current within the field while trying to raise a family and grow a business

And so much more....Enjoy!

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

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Do you have any patients who are “lifers.” Should we discharge them? Do they need continual reinforcement? As practitioners we all have them and in this episode Jesse Awenus talks about this important topic. To keep up and read his excellent blogs, visit jessephysio.com

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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.

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

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Is all pain due to an anterior related pelvis? What if a guru taught you this was the case? Jesse Awenus shares a story from when he was a new grad and was exposed to, bought in, and then rejected this appealing concept. To keep up and read his excellent blogs, visit jessephysio.com.

Please subscribe and rate us on iTunes!

Subscribe on Google Play Music

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...

#IFOMPT2016 SoMe Team: Jack Chew, Rachael Lowe, Laura Ritchie, Jesse Awenus, Steve Nawoor and Alex Chan

It’s been a week since I got back from #IFOMPT2016 and I purposely waited this long to write my review of the conference because I needed some to time to take in the plethora of information that I was exposed to. I won’t dive too much into any one specific talk because the fabulous SoMe team did an excellent job doing detailed reviews of all the keynote lectures for you to read at your leisure. This will be my personal thoughts about the weeks events.

First off, I am so proud to call myself a physiotherapist. The amount of brilliance that lies within this profession both locally (Go Canada!) and abroad is astounding. The shear number of PhD physiotherapists breaking down walls and answering the question of “why does what we do help? (or not help)” is astounding. IFOMPT had researchers talking about such things as best practices for those with knee OA, to ischemic pain from static postures, to the psychosocial elements of pain. There is a shift in our profession and I think if you keep reading below you will begin to understand what I mean.

Dichotomy within the profession: Hands on vs. Hands off

IFOMPT is a conference with the term ‘manual therapists’ in the title. By this fact alone one would assume there would be a huge contingency of manual therapy presentations at this conference. This couldn’t be further from the truth. In fact, to my knowledge there was not one talk out of the 5 days that focused specifically on and only on manual therapy. I did not hear the words PIVM, PAIVM, or PAM once while there. There was no talk on rotated innominates, shifted ribs, or fixated joints. Well, there was but only to say that these are not diagnosis’s we should be giving to our patients.

Here is a perfect explanation of the dichotomy of opinions at this conference: Brian Mulligan vs. Lorimer Moseley

On the final day of the conference I attended a 90 minute workshop hosted by Brian Mulligan. This is a man that created mobilizations with movement and at the tender age of 83, was still as passionate and exuberant about his techniques as I’m sure he was when he first started. His talk was standing room only, meaning delegates has to be turned away at the door because of the amount of people who wanted to hear him speak. His presentation was very pathoanatomical in nature. He had one guy come up with a 20+ year history of back pain who had pain with extension. After a few quick spring tests to determine the joint levels at “fault” he did literally 3 minutes of mobilization with movement to open up the facets (which he diagnosed as the pain generating structure) and then re-tested extension, which was in fact much better then before. The crowed clapped and he was labelled as a miracle man by the man who was now out of a 20 year history of back pain. There was no talk of any psycosocial factors, no discussion around this man’s beliefs around his pain and no real differential. Suffice to say, those in attendance were quite impressed…well, some were. It was essentially a smoke and mirrors show to wow the audience.

I noticed the vast majority of younger PT’s (like myself) spent that morning at Mulligan’s course, while the older facet of the profession was at a more academic talk on the mechanisms behind the manual therapy we provide. It became apparent that there were many new grads in attendance who simply want to “fix” people. They want to provide an immediate result to the patients chief complaint, which is usually pain. Brian Mulligan did a very grand before and after show, bringing up live patients (including myself) to the front to demo techniques that he assures will fix pain problems within minutes. To quote Brian “I don’t need any rubbish study to tell me what I’m doing works, all I need are the testimonials of my patients”. This sentiment resonated with many in the very full room he was teaching in.

What is our therapy truly doing?

On the other hand, there were several talks by prominent PhD Physiotherapist Lorimer Moseley who discussed the biopsychosocial nature of pain, how complex it is, and how many different treatments have very similar effect sizes when done under randomized control trial. He spoke about the brains capacity to determine what is threatening to the body and what isn’t. He mentioned how discs cannot slip, pelvis’s cannot up slip or down slip and that thoracic rings cannot shift. And if they could, we would be pretty bad at detecting it with any reliability. Basically, he used actual data to explain why perceived anatomical abnormalities are not always pain generating issues. This was a stark contrast to the Mulligan talk about jammed facet joints and rotated innominates causing sacroiliac pain. Is it any wonder the novice clinician is confused?!

We went into this profession to help others. I will speak for myself when I say that I firmly believed going in that if I learned the right techniques of assessment and treatment I could use my hands to fix peoples pain. I would be a star! I even did a fellowship in manual and manipulative therapy in order to boost my ‘manual game’. I fortunately learned, quite begrudgingly I might add, that my hands were not “magical” as I so desperately wanted them to be. IFOMPT’s central theme was that listening to our patients, understanding their goals and concerns, and applying our hands to facilitate independent movement and not to align anything is what has been shown effective to date.

However under the radar this opinion was, there was still a huge subset of delegates who want desperately to believe that they can use their hands to detect joint faults and correct them to aid in pain reduction. I honestly believe many were scared to voice their pathoanatomical beliefs because of how ridiculed that model was being made out to be at the conference. What I did find funny was that the biggest theme of IFOMPT was the BPS/neurocognitive approaches to treating pain, yet the 2 big award winners were primarily manual therapy based clinicians/studies (Josh Cleland for this study and Brian Mulligan). There seems to be the knowledge that our hands aren’t doing what we think they are, but we are desperate to believe manual therapy can fix people’s pain. I think we are in a bit of a identity crisis within the profession….if we can’t fix people using our hands, then why are we labelled manual therapists? No one will admit it, but many still hold MT as the central keystone in their treatment intervention and are unwilling to let that go. That was evident by all the 1-1 chats I had with delegates around the conference.

The last thing I wanted to touch on was the fact that no one discussed the economic realities of practice that underpin much of what was discussed at the conference. The time it takes to employ a BPS model, desire for repeat business (elephant in the room), need for cultural authority in the msk domain are realities that I still feel are too taboo to be discussed at such a prestigious conference. I believe a HUGE barrier to widespread implementation of a more BPS model has to do with the fact that clinicians do not want to make the patient feel 100% independent with their problem. Many physiotherapists are business owners and if all their staff are seeing patients only 3-4 times and mainly giving exercise and advice to self manage conditions, a lot of money stands to be lost. I am genuinely curious if the economic impact of the implementation of a BPS has been studied. It’s much more lucrative to tell someone they need weekly therapy to fix their imbalances then to reassure someone and tell them to do generalized exercise for their pain on their own.

IFOMPT 2016 was the biggest and most evidence backed conference I have ever been to. The caliber of the keynotes combined with the fantastic social program makes me giddy for what IFOMPT 2020 in Melbourne, Australia has in store. I for one will not be missing it. I suggest you try and do the same.

Signing off from my blogging duties for now. I hope to meet many readers in 4 years time.

Enjoy being a physiotherapist, it’s still one of the best gigs in town!

: #GoRaptors

Last weekend I had the opportunity to attend Dr. Craig Liebenson's seminar for the second time. I first saw Craig over 4 years ago in Toronto and that review can be found HERE. It was funny reading my old review because much of my thoughts on the course and its content have not changed except for a few key details.

When I first took his seminar I was less than 2 years in practice and was still very new to a lot of the concepts being taught. This time, with more years under my belt, I was better able to understand the concepts being presented and had a firmer grasp on how to apply what works for me and leave behind what doesn't. Unlike 4 years ago, this time I was actively thinking about patients in my practice that would benefit from the concepts taught without overwhelming myself with minutia. I felt better able to appraise what was being taught, both the good and the not so good.

First of all, this course is almost impossible to review based on its concepts because it doesn't really have any specific method or model to it. This course was a mishmash of content derived from many other schools of thought. The course notes, I must admit, aren't fantastic as they are mainly filled with quotes, pictures, and charts without much context as to why they are there and how to decipher their applicability to what we do in our practices. This makes going back to review the material challenging as there is minimal framework as to why certain slides are put into the manual. In short, the manual is hard to follow.

Here is a sample of what was touched on

The inactivity crisis (obesity, diabetes, low back pain prevalence etc)
Postural "dysfunction"and our culture of sitting
Exercise as the best medicine
Traditional vs functional approach
The "Mag 7" functional exam (Toe touch, wall angel, overhead squat, single leg balance, single leg squat, single leg bridge, respiration/belly breathing)
Stuart McGill's "Big 3" (Bird dog, curl up, side bridge)
Kettle bell exercises
Core activation drills (wall press dead bug, side plank hip thrusts, stir the pot, plank rolls)
Crawling patterns and the developmental sequence

While sitting in the audience listening to the course content I made a list of what I liked about the course and what I really thought could have been done without or at least modified. I will share a few pros and cons as I saw them.

Pro: Craig is fantastic at getting his audience to change their gestalt on patient care. He challenges course participant to incorporate more active care into the assessment and treatment of each patient. He is very good at giving tips and "tricks" to help patients see the value of active care over a passive care. I talked to a few people in attendance who really wanted to try more active care in their practices after this course and I think that's fantastic.

Con: Many times on the course he would use a demo who had pain doing a task such as a squat and would do an exercise drill with them, often targeting the core or another area of the body far removed from site of symptoms and then re-assess their pain in front of a crowd of at least 75 people. Each time the participant would say they felt better and was better able to do the functional test they had issues with before the exercise intervention took place. No one ever said what Craig did with them didn't help (I personally never bat 100, do you?) This smoke and mirrors show wowed me 4 years ago, but now I kind of take it with a grain of salt as anyone when pressured by a course instructor in front of a huge crowd of peers would say they felt better due to confirmation bias. Dr. Andreo Spina has an excellent video explaining why he doesn't use demo's in his course. Basically, you can temporarily trick the CNS into "better" movement but the results are often very short lived. I think without knowing it, he may have made it seem like a simple corrective exercise is a cure-all, when we know it's not. One other point that needs mentioning is that when he was instructing participants on how to do the exercises, he made it look easy. The problem is that most clinicians aren't treating healthy and fit 20-30 year olds with awesome body awareness, which is what the crowd demographic was. We are treating chronic pain patients with huge gaps in motor control and exercise capacity. This fact alone makes applying the concepts much more challenging then was let on in the course.

Pro: I liked how Craig was able to introduce the audience to many other approaches such as SFMA, DNS, McKenzie etc without bashing any one approach, stating many times that they each have value and are all tools that can be used depending on the patient in front of them. Many times I have found course instructors need to bash another courses or instructor in order to legitimize their methods/ideas. This manufactured controversy might appeal to contrarians (like me) , but it also looks unprofessional. I like Craig for his non-guru approach to functional medicine and does a fantastic job of letting people know their are "many roads to Rome" as he liked to say.

Con: This next point is just a personal opinion, but I found the lecture components to be quite preachy at times. At one point I counted over 25 quotes, one after the other, in his power point slides. He literally read quote after quote, which I think only served to dissuade the audience from paying attention because it started to feel more like a church sermon then a rehab course. Only this time it became quite confusing as to how and why certain quotes fit into the topics we were discussing. I personally could have done without the excessive number of quotes used to drive home points.

Pro: Simply put, I got some pretty awesome corrective exercise ideas that help with "buy in." Since the course I have incorporated some of his exercises like the side plank hip thrust as a post test "re-set" and have had great results. For example, I had a new patient who had ++ knee pain with single leg squatting. I had him do it 3-4 reps, each time being sore. I then had him to the side plank hip thrusts with the painful leg on the downside and after about 10 reps we re-tested his single leg squat and he literally said "holy shit, how did you do that!?" because his pain was virtually gone. Now, I know that won't last and there is a lot he needs to keep doing, but nothing beats that kind of buy in for patients to trust what I am saying and the motivation to comply with the home program. I am also sure a number of other drills would have worked, but hey..I can't argue with those results. In all fairness, there have been a few other cases where the corrective drills didn't make a change and I needed to think of other things on the fly. The course just gave me more ideas that really help the patient see the need to do exercise to help with their pain complaint. For this reason alone the course was well worth the time.

In all honesty I took this course again to help motivate me to keep pushing active care in both my assessment and treatment. I found myself "succumbing" to patient preferences for passive care and as a manual therapist it was easy to do that. It's a huge challenge in a service industry (and yes, private physio is just that) to not cave to what the patient wants. I always give exercises based on what I see as being issues, but I found myself being more lax with patient compliance. I needed a kick in the butt to get creative to find ways to get better buy in because I am a firm believer that passive care is great and helps with symptoms, but it will not provide the fix patients need if exercises isn't the staple of the program. And I know I get so much more job satisfaction if patients get better quickly and their goals are met. That just doesn't happen nearly as well with passive care (manips, mobs, needles, soft tissue therapies etc). This course was great at giving that push I knew I needed.

Overall, I would recommend this seminar for it's inclusiveness for other ideas in the rehab world and as a way to get your feet wet in the "functional" approach if you are growing tired of a structuralist model of looking at the body. You can find out when Dr. Liebenson will be in a city near you by clicking HERE.

Please feel free to ask me any more specific questions you have about this course in the box below :)

Jesse Awenus

Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic...