After being in PT for almost 20 years, I've spent the last 5 years looking at methods outside of traditional physical therapy and patient education. Everyone is searching for the elusive magic bullet that will help the non responders. That is why I started studying mindfulness, nutrition, and sleep. I've touched upon sleep here before.

I've known that sleep is vital to recovery, for athletes with recurrent injuries, and is associated with individuals in chronic pain. So I wanted to dive into the why. I often educate my patients on the importance of sleep, but did not have the background on the mechanisms of why sleep is so vital.

After reading Why We Sleep: Unlocking the Power of Sleep and Dreams, I've become convinced that of all the basic pillars (Sleep, Nutrition, Exercise), Sleep may be the most vital and often ignored. 

How this Book Can Help Your Patients

Decreased sleep less than 8 hours on average can lead to

• persistent flight or fight mechanisms - increased levels of cortisol
• this was the most AHA moment I've had while listening to the audiobook on Audible, as poor sleep quality/quantity has been associated with persistent pain states and central sensitization
• decreased athletic performance, increased likelihood of injury and delayed recovery times

Learning these vital points and learning about their specific mechanisms will only strengthen your patient education.

How this Book Can Help You

I purchased the audiobook and ebook in order to learn how to better educate my patients.  I also got A LOT out of it for my own health and recovery. Turns out my "I can get along with 6 hours of sleep a night" would put me in a less than 5% of the population with a rare genetic profile. I've been getting 8 hours a night for about 5 weeks. Similar to when I went mostly plant based, I've had

• increased energy levels
• better recall - which honestly I just blamed on getting older and having an army of children
• better ability to concentrate and increased productivity

Reading this text has been game changing for me in the same way changing my entire nutritional profile has. The audiobook in particular is narrated excellently by Steve West, who has an accent on part with the Headspace app guy. 

The author, Dr. Matthew Walker, breaks down sleep in a way accessible to everyone, and not just clinicians. It's highly recommended and at the Top 5 of my Non PT related books that everyone needs to read.

For this review, I purchased the Audiobook on Audible with my own funds, but the links to the book are amazon affiliate links. If you purchase either with the link, you are supporting our blog. Thanks ahead of time if you do! Next step, get the author on Therapy Insiders Podcast!

Check it out on amazon!

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 just recently finished working through Fordyce’s Behavioral Methods for Chronic Pain and Illness that was republished by IASP with invited commentaries. Francie J. Keefe was one of the editors and commentary contributors in the book along with Steven J. Linton providing another one of the commentaries, both of who will be speaking at the upcoming ISPI Clinical Conference. This seminal work was originally published back in 1976 and is still relevant in many ways today. At the time of its publishing most chronic pain patients sent to a psychologist for examination were accompanied by the question, “Is this patient’s pain real or psychogenic?” Unfortunately, some people still are asking this question today as they evaluate their chronic pain patients, is it real or just all in the patient’s head. Dr. Fordyce over forty years ago started the process of trying to reframe this type of question into ones looking instead into social and environmental influences on a person’s pain behaviors. Dr. Fordyce found that it was not the health care provider’s job to serve as the lie detector to determine: is this pain real or not. Instead our role is to establish a warm, empathetic therapeutic alliance with patients to assist them through their pain behaviors toward more “well behaviors.”

   

This book is full of significant nuggets on treating people in pain even though Dr. Fordyce wrote it over forty years ago. I thought I would share one that was on the second page of chapter one.

“Pain is not simply a neurophysiological event. To hold that it is, is to fail to come to grips with what happens to patients. It is equally true that pain is not simply what a patient says it is. There are at least two reasons why this statement is true. One is that the patient’s knowledge and perceptions will limit his ability to discriminate well enough what is going on. Patient reports about pain will be subject to influence and distortion by a host of factors deriving from ongoing cortical activities, from the immediate stimulus situation, and from prior experience. There is a most important second reason why the patient’s pain is not necessarily what he or she says it is, which relates to the first reason but which should be viewed from a different perspective. For the problem to be identified, the person must in some fashion communicate to the surrounding environment that he or she is experience pain. The report of pain particularly chronic pain, may be verbal or by some other form of audible or visible action; some behavior. What the patient says the pain is (the verbal report) is not to be considered the final, definitive answer of what it is, even for him or her. That is of course true because of inherent patient limitations to observe the total system or to have the knowledge properly to interpret the data gained from experiencing current bodily states. But it is also true because there is no inherent reason why what patients say and what they do will correlate highly or be the same. This is a discussion of chronic pain, but the same point could be made about virtually any other human activity. The point is that verbal statements about pain are one kind of behavior, and the other visible and audible methods by which the problem is communicated to the environment are another. For the moment they will be distinguished as verbal and nonverbal pain behaviors. The latter group includes non-language sounds (such as moans and gasps), body posturing and gesturing (limping, rubbing a painful area, grimacing), and displaying functional limitations or impairments (reclining excessive to rest or staying home from work because it hurts too much.) Each of these sets of behaviors meets different contingencies or consequences in the environment. As a result, verbal and nonverbal behaviors are not only somewhat free to vary from each other; they in fact do vary from each other far more than we often are ready to accept. The discrepancy between what people say and what they do is not simply a question of honesty or candor. Verbal and nonverbal behaviors each meet consequences. These consequences are often not the same. Since consequences influence behavior, it follows that verbal and nonverbal behaviors – even when focused around a single conceptual theme or topic – can be expected to vary from each other. The variation is an inevitable result of learning or conditioning.”

Reading this I can see the influence Fordyce had on Johan Vlaeyen (another editor of the republished work), when Vlaeyen stated last year at a conference I was at: “Pain is about behavior.” Bill Fordyce was one of the early pioneers to see pain beyond a biomedical approach. He points out in this text that pain even extends beyond the neurophysiology of the brain also. It is seeing pain in the broadest context of a biopsychosocial approach and behavior. He points out the importance of biology and neurophysiological aspects, but potentially even more important the social components. While this was his point over forty years ago, I would argue we still struggle in the medical community to see the importance of these social behaviors within the pain experience of individuals as they come to us each day in pain. In addition, the research into these social behaviors is woefully lacking. Pick up any medical journal and look for articles that are looking into pain and you will see the discrepancy of what we are looking at in trying to understand pain. How many articles are directed toward the biological end of pain, how many at the psychological end compared to how many toward the social aspects of pain behaviors. We see the variations in our patients daily and Fordyce points out these variations can be attributed to the inevitable result of learning and conditioning.

Okay your turn: Are we looking into the learned and conditioned behaviors of our patients? How do you do that? Do you need to or is that someone else’s job? – What say you?

Via Kory Zimney

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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I just finished the latest book on my reading list, “The Chimp Paradox” by Dr. Steve Peters. It was a quick and interesting read and I encourage you to pick it up. For those who don’t know, Dr. Steve Peters is a sports psychologist who works with elite athletes. I wanted to read this book because as a physical therapist, I spend so much time educating patients, generally about rehabilitation concepts. However, many of my athletes have expressed challenges with anxiety, stress, and sleeping especially around periods of increased intensity of training and competition. So I was looking around for some good resources to share when I came across this book.

“The Chimp Paradox” describes a mind management model that segments the brain into a chimp, a human, and a computer, reflecting an overly simplistic representation of the different lobes. This Chimp Model describes why decision making can be so difficult - as two independently thinking systems vie for personal goals, often with conflicting agendas. Basically, the chimp is obsessed with survival and makes decisions based on jungle principles. The human, on the other hand, longs for harmony and social order and makes decisions based on logic and consequences. Split second, emotional decisions are owned by the chimp. And only with safe decisions can the chimp sleep and let the human make a logical decision. Now you can see how it’s possible to make a rash decision and later not understand why. It’s your chimp! All would be in chaos if not for the computer - a programmable system that makes decisions based on pattern recognition from historical data from both the chimp and the human.

Dr. Peters introduces this simple model to help people understand the complexities in their head that affect decision-making and response mechanisms, and in turn learn to control them. This is a useful tool for both athletes, as well as the general public. The reason that it’s a paradox, is that we cannot get rid of the chimp, it’s part of who we are - we love it and we hate it. Although the chimp can seem like a scapegoat of sorts, Dr. Peters does mention repeatedly that like a pet dog, in the end we are 100% responsible for the actions of our chimp. In the book he offers tools, exercises, and reframing strategies to learn how to control, or “box in” your chimp.

Do you ever wonder how one person can shine under the bright lights of competition and another at the same skill level can buckle? How one person's success can create complacency and another's, crippling fear? Perhaps the answers are in learning the why of the chimp vs. human tug of war and the how of boxing it in. I would be doing you a disservice if I tried to explain the mechanisms of boxing in your chimp - so for sure I recommend reading the book. But here are a few of my favorite points:

• Are you being hijacked by your chimp? Simply ask, “Do I want to feel this way?” or “Do I want to be doing this?” If yes - human. If no - chimp! (The chimp also loves to start sentences with “But what if…” so beware)
• Your chimp is in survival mode and in the jungle, survival means being part of a pack. To stay a part of the pack, your chimp desperately wants to ensure that you please everyone and prove yourself constantly. Sound familiar?
• The computer is a reflection of both chimp and human. It is made up of programmed responses that may or may not be constructive. The human and chimp always look to the computer first! By rehearsing your beliefs you can stack the computer with constructive responses to control your chimp, and thus your stress response.
• Reframing sentences can help prevent your chimp from being emotionally triggered, for example, “could” vs. “should.” Think of the difference between the phrases “I should have gone to the gym” vs. “I could have gone to the gym.” Dr. Peters talks about the attachment of judgment to the world “should,” and the introduction of hope with the word “could.” I have already started to do this and I feel like it completely changes my emotional response.
• Look back at where you came from and see progress versus looking forward to where you want to be and see how far you are. This makes life encouraging and rewarding instead of demoralizing
• Chronic stress arises from your perceptions and expectations. If you hold a core belief that “life should always be fair,” then your chimp might lash out when someone cuts you in line or gets more than equal share. Life isn't always fair. Make sure your chimp understands that.
• Dreams versus goals; dreams are a possibility but accept that they may not happen. For example, basing your confidence on doing your best (a goal) rather than winning (a dream), will help keep your chimp from freaking out for fear of failure.

Finally, I’ll close with a passage from the book about stress: 

"Stress can be physical or it can be psychological. One example of a physical stress is when we become dehydrated. The body reacts by making you uncomfortable and thirsty. You drink and this corrects the situation and removes the stress. Psychological stress should be dealt with in a similar way, so that when you experience stress you should search out a constructive way to deal with it. You do have a choice: you can react to the stress or you can deal with the stress."

In the end, how you feel about and deal with a situation is your choice. Choosing well is a learned behavior; and each time you choose well that path is strengthened in your computer. And ultimately, these choices will lead to your happiness and success. So box in that chimp and choose success!


Resources / Image Credits:
Find the book on Amazon
Learn more at chimpmanagement.com

Read more from Laurey at LaureyPT.weebly.com

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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#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...

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Sitting is the new smoking if you haven't heard. Multiple studies have confirmed the effects of prolonged sitting on our overall health.

I was contacted by Dr. Ryan Klepps of StriveHub, a web based portal to help your practice manage customer retention, manage outcomes, patient satisfaction and more!