Knee Pain & Modalities – Movement Debrief Episode 24

Movement Debrief Episode 24 is in the books. Here is a copy of the video and audio for your listening pleasure.

Here were all the topics:

  • What ACL graft should you get?
  • What does the systemic process look like for knee pain?
  • What local factors are important for knee pain?
  • the importance of plyometrics for knee pain
  • Is there a place for modalities?
  • What modalities I incorporate into my practice

If you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 7:30pm CST.



Zac Cupples iTunes                

Here were the links I mentioned tonight

Enhancing Life

Darkside Strength

Adam Bryant

PRI Impingement and Instability Course Notes

Here is the Active Midstance Test

Here’s the Copenhagen Adduction Test

Bill Hartman

A Randomised Controlled Trial of ‘Clockwise’ Ultrasound for Low Back Pain

E-Stim and BFR

Here’s a signup for my newsletter to get a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies:


Check out the mentor program

Stress Response, Proximal First, Sensation Loss, and Your Health – Movement Debrief Episode 12

Let me guess, you are devastated you missed last night’s Movement Debrief.

You should be. It was by far the most interactive debrief we had yet. Loved how active everyone was, and definitely some people help me get better.

Kudos to Steve, Jo, Yonnie-Pooh, and the many others who commented on today’s Debrief.

Here’s what we talked about:

  • How the stress response impacts many areas
  • Treatment hierarchies
  • How to restore sensation loss post-surgery
  • Functional Medicine
  • Why taking care of your health helps others

If you want to watch these live, add me on Facebook, Instagram, or Twitter. (occasionally) They air every Wednesday at 8:30pm CST.


Manual Therapy Musings

When I think About You…

Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process.

To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments):

  • Nonmanual (including exercise and education) = 80%
  • Manual = 20%
  • Modalities = 0%!!!!!!!!!!!!
Especially happy with the last number...and that I forgot how to work these useless things.
Especially happy with the last number…and that I forgot how to work these useless things.

Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set:

  • PRI manual = 14%
  • Other manual = 6%

As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success.

Greatest skits on the internet per Cochrane review.


There’s a reason for the shift

I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program.

Rarely is learning involved in manual therapy. Continue reading “Manual Therapy Musings”

Course Notes: Spinal Manipulation Institute’s Dry Needling 1

You Mean Zac Didn’t go to a PRI Course?

Yes. From time to time I occasionally take a gander at what else is out there in PT land. It was probably about time I check out this whole dry needling thing and see what the fuss is about.

I took the Spinal Manipulation Institute’s version based on some recommendations from a few colleagues I trust. Ray Butts was MC’ing for the weekend.

He was a straight-up needling gangsta
He was a straight-up needling gangsta

I know needling is quite the controversial topic, but I was amazed at the sheer quantity of evidence supporting this modality. Like, an insane amount. I am not sure what the “haterz” found their criticisms on, so please comment if you have some ammo (I am a noob to this after all).

And Ray’s lecture on dry needling mechanisms? Oooohhh lawwwwd. Easily one of the best foundational science lectures I have ever heard. Period. The passion this group has not only for science but the physical therapy profession is inspiring. They made me excited to be a PT. Perhaps even inspired me to contemplate the PhD route.

Then I looked at my student loan bill again.
Then I looked at my student loan bill again…

All that said, I am unsure as to where needling will fit into my practice. The assessment that would point you toward needling someone was sorely lacking. I’ve noticed this problem to be quite common in manual therapy courses. It’s pretty much you hurt here/have this diagnosis, then use this protocol. Continue reading “Course Notes: Spinal Manipulation Institute’s Dry Needling 1”

The Sensitive Nervous System Chapter IV: Central Sensitivity, Response, and Homeostatic Systems

This is a summary of Chapter IV of David Butler’s “The Sensitive Nervous System.”


Central sensitization is a phenomenon that occurs in the dorsal horn, which can be best described via 4 different states:

1)      Normal: Inputs = outputs; innocuous sensations are perceived as such.

2)      Suppressed: Inputs that would hurt do not; think an athlete who injures himself but finishes the game.

3)      Increased sensitivity: Pain system has lower activation threshold, leading to pain spreading and pain with light touch and gentle movement. This change occurs because A beta fibers begin taking over C fiber locations in the dorsal horn.

4)      Maintained afferent barrage, CNS influences, and morphological changes: Long lasting changes in the dorsal horn from a persistent driver, such as…

  • A fiber phenotype changes.
  • Persistent DRG discharge.
  • Persistent inflammation.
  • Supraspinal influences
  • Gene transcription change in dorsal horn neurons.
  • Inflamed dorsal horn or DRG
  • Maladaptive beliefs, fears, and attitudes.
  • Dorsal horn sprouting; A Beta fibers take over C fiber space.
  • Persistent glutamate activity.

Descending Control

The CNS has an endogenous pain control system which activates during injury threat, noxious cutaneous input, or expectations and learning. Such an example of this is when you go to a healthcare practitioner’s office and no longer hurt. Another example of when this system is activated is during aggressive manual therapy. Think about how good your body may feel after sustained pressure or even a needle to a trigger point.

Replacing an opium den near you.

Central Sensitization Patterns


  • Symptoms not in neat anatomical/dermatomal boundaries.
  • Original pain spreads.
  • Multiple areas: Either linked or get one pain, then the other.
  • Contralateral side may be painful, though not like the other side (mirror pain).
  • Clinicians end up chasing pain.
  • Sudden, unexpected stabs.
  • Patients call the pain “It.” For example, “It has a mind of its own.”


  • Ongoing pain perception past normal healing times.
  • Summation via repetitive activities (sitting at a computer).
  • Distorted stimulus/response relationship. May get pain 10 seconds or days after stimulus is applied.
  • Unpredictable response to treatment/input, but ends up being predictable (x may only work 2 days).
  • Every movement hurts, but not big ROM loss (Symptom instability).
  • “It hurts when I think about it.”


  • Can be cyclical.
  • Change in other systems.
  • Links to traumatic life events.
  • Anxiety/depression.
  • Miracle cures can work.
  • Likely in most syndromes (fibromyalgia, complex regional pain syndrome).
Could be a central problem.

Clinical Thoughts

1)      Educate, educate, and educate. We must let our patients know that pain does not equal damage.

2)      Do not focus on finding an anatomical pain source which can make matters worse.

3)      False positive are frequent on testing when tissues may be healthy (Eg, positive straight leg raise may just be adding slightly noxious input that results in an increased afferent barrage).

4)      The physical exam is best considered a sensitivity test.

Autonomic Responses

Increased levels of norepinephrine (physical stress), epinephrine (mental stress), and cortisol (shut down nonessential systems to maintain homeostasis) are upregulated and contribute to, but do not cause, pain. High sympathetic states can lead to problems that include tissue degeneration, mood swings, slow tissue healing, and increased infection susceptibility in people with chronic pain. Tissue change is particularly evident because the sympathetic nervous system innervates and interacts with muscles, joints, skin, connective tissue, inflammatory chemicals, AIGS, and the DRG. The parasympathetic nervous system is also important to mention to our patients in terms of healing effects of sleep and relaxation.

Motor Response to Pain and Stress

Can include the following:

  • Weakness.
  • Muscle spasm.
  • Change in facial expression/tone of voice.
  • Muscle imbalances (a coping strategy)
  • Loss of or decreased quality of ROM.
  • Loss of movement selection variety.
a very unattractive coping response. On multiple levels.

Immune system

Cytokines are the major player here, as they predominantly function to combat infection. However, these components also contribute to inflammation and pain.

Immunity changes can occur over several mechanisms and is interrelated to all other body systems.

  • CNS can activate the immune system to respond to any stressor.
  • Sympathetic nervous system modulates the immune response.
Maybe why you are getting sick all the time…