December Links and Review

Every week, my newsletter subscribers get links to some of the goodies that I’ve come across on the internets.

Here were the goodies that my peeps got their learn on in December

If you want to get a copy of my weekend learning goodies every Friday, fill out the form below.  That way you can brag to all your friends about the cool things you’ve learned over the weekend.

Biggest Lesson of the Month

I’ve been thinking a lot about generalism and specialism. Becoming a generalist involves implementing things with an individual that intend to have systemic effects, whereas the specialist implements things that intend to have a specific effect.

Think about encouraging your clients to sleep effectively, eat more vegetables, and move effectively. Implementing these three strategies will lead to system-wide effects first and foremost, and may impact a specific goal that you have. These are the tools of a generalist

On the flipside, consider a surgical procedure, medication, etc. These modalities have a higher likelihood of meeting a specific goal first and foremost, but the system-wide effect is less certain.

Though upon careful reflection on this thought, really anything we implement as a generalist or specialist is riddled with uncertainty.

Both types of practitioners are necessary to maximize health, longevity, and/or performance.

Quote of the Month

“Ego is about who’s right. Truth is about what’s right.” ~Mike Maples Jr

Ego is something I’ve been working on getting control of over the last year, and it has been most impactful in my overall happiness and well being. I just wish I took this quote to heart much earlier in life.

Hike of the Month

Hiking frequency has gone down a bit because it’s so…dang…cold, but I had a dope hike at Joshua Tree.

#throwback to older times, fam

It wasn’t the most challenging hike, but had a wide variety of things to see. Whether it was an old mine, or climbing a mountain, you could definitely get your nature gains on point.

And the Joshua Trees themselves, Hyoooge. Way bigger than any of the others I’ve ever seen.

Rehabilitation

Is keeping up with evidence realistic? Welcome to a Blog I’d Like to Read

Peter Attia is one of the most interesting MDs I’ve come across. While most of this blog talks about his plans for the future, his thoughts on keeping up with the evidence are worth the read alone.

Destruction of a medical divide with “Complimentary and Alternative Medicine” Belongs on a Tombstone

Douglas Kechijian just keeps killing it with content. In this post, Doug provides coherent critiques on the supposed separation between CAM and EBM. The two aren’t as far off as you think.

Here are Three Reasons to Consider Travel PT

Here are the reasons why I considered this wonderful job style.

The struggles of keeping up with the EBP Joneses.

With the shear amount of journal articles released on a given day, it can be near impossible to stay fully evidenced-based.

Here is a quick little tip on how I keep up with the research if you aren’t already doing this.

Research shows breathing critical for survival

So you should probably master the basics on how to do so. Daddy-O-Pops Bill Hartman put out a great article this week titled Breathing Exercises to Move Better and Reduce pain.

In this joint, pops goes over why breathing retraining is important, how it can impact movement, and how to master the basics.

Definitely check this one out.

How to reach like a legend

I found quite an effective cue that I’ve been using as of late to enhance reaching-based activities.

Many times, peeps will round their back as opposed to retracting the thorax, but if you use this cue, the problem is often solved.

Give it a shot!

Performance

Do you even recover, bruh? 

All Pain, No Gain: Why High Intensity Training Obsession Has Failed Us All thinks otherwise.

I was first made aware of the constrained theory of energy expenditure by Mike Roussell, and Joel Jamison takes the concept to another level. This article made me really think about how I am approaching building my own fitness, and just how important recovery is.

Excited to make it through the series as it comes out.

What these coaches want from a strength coach.

Monitoring players for fitness and fatigue: what do coaches want helps bridge that gap.

One of the most challenging aspects I had with sports science is getting buy-in from the coaching staff.

Here, Yan Le Meur boils it down to the most important aspects that a coach wants to know, as well as which variables are most actionable from an intervention standpoint. It’s an infographic I wish I had while in the league.

Insights on assessment

Thoroughly enjoyed Dean Somerset’s take on What Assessments Work Best.

I love how Dean preached individualization in regards to the assessment process. Many times we seek models that place clients into buckets or patterns, but Dean reminds us to keep the client’s goals in mind. This cannot be emphasized enough.

Sports science overrated???!?!

Hearing Doug Kechijian’s podcast with Fergus Connolly definitely has me thinking so.

In this podcast, Fergus talks about why it is hard to make decisions on sports science data, why you should sleep on technology for awhile, why the art of coaching is still relevant, and so much more.

You and your science. pshh.

Personal Development

The One Key to Happiness

Moving from Impressing Others to Impressing Yourself was a very salient read for me.

Many times we all fall into the trap of saving face, of looking good in front of other people. Trent Hamm provides a coherent argument against this type of thinking in order to curb spending.

But the lessons extend well beyond money.

Kill those unproductive days with Death Clock

Ever find yourself having a hankering to watch just one Youtube video only to find yourself watching 6 hours worth of cat videos? This app, which Tim Ferris exposed me to, nips that time waster in the bud by showing roughly how many days are left in your life. Like sand through the hourglass or something, fam (see what I did there?)

Turning 30 is all types of hell…

But my boi Seth Oberst makes the most of it.

Seth recently reflected on the 30 lessons he learned by age 30, and I found the post incredibly inciteful. I’d call it part rehab, part philosophical, part psychological, and full awesome.

Learning from a cat like Seth has made me a much more well-rounded clinician.

Confidence low? Become a philospher

More specificially, a Stoic philosopher.

In Eric Barker’s Stoicism Reveals 4 Rituals That Will Make You Confident, Eric discusses strategies that the Stoics used, which are also used in cognitive behavioral therapy, to improve confidence levels when things go awry.

My favorite has to be challenging distored thoughts. Way more productive than challenging your mortal facebook enemy on Dry Needling for the 17th time this month.

Appreciate stoicism and you too, may have a bust built in your honor someday!

The choice is yours…or is it?

Making decisions can be an overwhelming process.

So do fewer of them.

In Choosing without Deciding, Seth Godin briefly provides an effective strategy for deliberating on decisions that require deliberation, and leaving less important choices to easier means.

Health & Wellness

Helping save healthcare with Chris Kresser – Unconventional Medicine

More great Robb Wolf podcasts. This time, it was my boi Chris Kresser. I absolutely love some of the solutions he presents to saving healthcare, as well as how salient he creates awareness of the problem of healthcare.

Am I stressing you out? Doubtful according to Andrew Bernstein – The Myth of Stress

Stressors are a myth. It’s all in how you react to stress. Hearing that concept alone is worth the listen from yet again, another great Robb Wolf podcast.

Are you selling your sleep short?

If you only give yourself 7 totals hours in bed (with 1 hour of scouring the cats of Instagram), chances are your sellling your sleep game short.

In this great read called How to Get a Tiny Bit More Sleep, Melissa Dahl discusses the concept of sleep opportunity. Something we rarely consider when we are trying to catch those z’s.

You can have holiday cookies…

If you are getting after it the rest of the time.

In a wonderful post, Daddy-O Pops Bill Hartman talks about How to Eat Whatever You Want Over the Holidays and not Feel Guilty. Having the habits in place throughout the rest of the year is the key to enjoying the holidays guilt-free.

The benefits of a digital detox

If there is one thing I struggle with, being an internet cat and all, it’s getting too engrossed into technology.

In Digital Detox: How and Why to Recharge Your Mind with an Unplugged Weekend, Drew Housman discusses what his experience was like eliminating technology, and the incredible benefits he obtained from it.

The two things I am attempting to do: go hike more (no service no problems) and airplane mode the first 30 minutes of when I get up.

Your time restricted eating questions have been answered

Round 2 of Rhonda Patrick’s podcast with Satchin Panda talks about how coffee impacts circadian rhythm, practical implementations, the difference between 16:8 fasting and TRE, and so much more. A very fun listen.

Music

So uh, Blackbear released an incredible mixtape…

NOTE: NSFW, lots o’ foul language with this one.

So a cat who I’ve been really digging, Blackbear, released a new mixtape called Cybersex, and it’s unbelievable.

For those who don’t know who Blackbear is, imagine if Jason Mraz became punk, hip hop, R&B, all in one, then up the attitude by 1000x. Then you have Blackbear.

This album shows his range of talents, and he hangs with many of the awesome features, including Cam’ron (#diplomats), Rick Ross, 2 Chainz, Ne-Yo, and many more.

My top 3 tracks: Playboy Shit, Bright Pink Tims, and Gucci Linen.

So why aren’t you listening to CyHi the Prynce?

After I was sadly disappointed with Eminem’s newest album (which really hurts because he is my top emcee), I was lost. Was there going to be anymore good hip hop released?

Then I listen to No Dope on Sundays by CyHi the Prynce, and my faith was restored.

I tried to think of my top tracks, but really the album from start to finish is absolutely awesome. Even the trap-y tracks are rock solid. Amazing features, and street poetry at its finest.

No more sleepin’ on CyHi, fam.

Which goodies did you find useful? Comment below and let me know what you think.

Photo Credits

Sports Authority of India

J.D. Falk

Wikipedia

November Links and Review

Every week, my newsletter subscribers get links to some of the goodies that I’ve come across on the internets.

Here were the goodies that my peeps got their learn on from this past August.

If you want to get a copy of my weekend learning goodies every Friday, fill out the form below.  That way you can brag to all your friends about the cool things you’ve learned over the weekend.

Biggest Lesson of the Month

Don’t beat yourself up if you aren’t hitting perfection day in and day out. Consistent progress over time is the key.

There have been many days where I wasn’t motivated to stay on task, and faltered. The key to getting back on the proverbial horse the next day was to not beat myself up. Instead, acknowledge that these things happen, understand I’m human, and get after it the next day.

You’d be amazed at what this shift in perspective can do.

Quote of the Month

“Greatness is a lot of small things done daily” ~ MJ Demarco

MJ Demarco again takes the cake this month. This quote made me reflect a lot on just how many small, quality habits, can make an impact on life. What small things can you do to become great?

Hike of the Month

A late steal this month, but got a chance to check out Death Valley National Park.

Salt > snow. Equally as pretty, less slippery, and DEFINITELY warmer

I wasn’t really sure what to expect with this place since, ya know, it’s hot and things are kinda dead n’ stuff, but the variety in landscape was quite unbelievable. Landscape that I have never experienced before, whether salt lands or sand dunes. I’d definitely consider checking this awesome place out.

Rehabilitation

 

Here’s a little sneak preview of the free talk I’ll be putting up for you guys once I re-record it!

Blog: What Evidence Based Practice is Not

Doug Kechijian always telling it like it is. This time, my younger older brother discusses how to think about evidence based practice. How it is much more than a bomb of Pubmed citations. I also love how he touches on effective discussion on the internet.

Here is a little variation on differential tendon gliding you can try next time you see someone with a flexor tendon repair.

Blog: Should We Delay Range of Motion After a Rotator Cuff Repair Surgery?

Mike Reinold again coming on strong with this post. This time, Mike looks at a systematic review comparing early vs. delayed motion after a cuff repair, and I love his interpretation.

Training

Video: Kettlebell Swing Tutorial w/ Justice Williams (via Tony Gentilcore)

My kettlebell game is something I’m hoping to improve upon over the next year, and this was a great intro point to it. Here, Tony Gentilcore and Justice Williams provide an excellent coaching tutorial on the wonderful/brutal exercise known as the kettlebell swing.

 

Productivity

 

Article: Trick Yourself Into Writing Well by Telling Yourself to Write Badly

Lifehacker is an awesome website for many reasons, and this article is an example of that.

Many times, getting started writing is the hardest part, here, the peeps at Lifehacker give you a trick to getting started. Works wonders for those days I don’t want to write.

Making this one little tweak to how I plan email checking throughout my day has made a big difference.

Personal Development

Book: What to do When It’s Your Turn

A dear friend of mine got me this book, which has become my pre-bed reading and I love it. Seth Godin, marketer extraordinaire, writes in this book about handling fear of failure, getting the courage to start something up, and how timing is never right. These are a few of many great topics that I’ve come across, and I always fall asleep in a good mood after I read a few pages 🙂

Blog: These are the 8 Friends You Need to be Happy in Life

Social engagement is something we don’t discuss much when we are trying to reach our health and performance goals. Here, Eric Barker talks about the eight people you should have in your life. How many do you have?

Article: How Frequently Should You Take A Vacation?

This is probably the most comprehensive guide to vacationing that I have come across. It turns out, vacations are incredibly important to your health.

Don’t like vacations? Consider your increase for cardiovascular disease elevated. Read the guide to maximizing them.

Just need to make life a vacation #movesomewherewarm

Blog: How One Young Couple Repaid $87,000 of Student Loan Debt in 27 Months

If you have student loans. Read this. It’s hard work, gruesome, but paying off debt has been a rewarding experience for me. If you are lacking motivation, or can’t see the light at the end of the tunnel, here is some hope.

Blog: Struggling Against Good Decisions with Bad Results

This was just a phenomenal message that can be extrapolated not to just finances, but life. Here, Trent Hamm discusses the importance of sticking to sound principles, even if those principles don’t always result in a desirable outcome

Book: Discipline Equals Freedom Field Manual

If you need a swift kick in the ass to get back into gear, this is the book. Many of the pages are snippets from Jocko Willink’s podcast, but the message is not lost. Jocko will make you rethink everything your doing, and eliminate the excuses for you not doing. Change your life, and read this book.

Book: Unscripted

After you’ve been kicked down by Jocko, let MJ Demarco pull off the finisher. This guy is becoming one of my favorite authors because he is brutally honest and pulls no punches in explaining how we fall into business and work traps that not only hinder us, but minimize helping others. If you want to be an entrepreneur (and you all should, this book tells you why) then this is a must read.

My favorite part? “The goal isn’t to make money, but to provide value to others.”

Health and Wellness

 

Podcast: Dr. Ruscio – The Real Deal with Gut Microbiota

I’ve been binge listening to Robb Wolf’s podcast, and I’ve come across Dr. Ruscio a couple different times. I admire his brutal honesty and simple approach to dealing with the gut microbiome, and I hope you guys like it as well.

Want to know some of my big keys for starting my day off right? Check out this week’s quick hit.

Podcast: Dr. Richard Maurer – The Blood Code

Again, another simplified and stratified approach to functional medicine courtesy of the Robb Wolf podcast. Here, Dr. Maurer outlines his key blood markers and first-tier treatment to help individuals with their health and wellness goals.

Article: Do You Need to Refrain from Coffee to Get the Maximal Effect of Caffeine?

If you want to maximize performance, do you need to give up coffee for a bit to get the benefits? Researchers compared how caffeine affects performance in heavy, moderate, and low users.

The answer might surprise you!

The addiction is now #ebp #blessed

 

Which goodies did you find useful? Comment below and let me know what you think.

Photo Credits

Nick Kenrick

Julius Schorzman

Squats, the (F)Utility of Research, Total Knees, and Pain vs. Suffering – Movement Debrief Episode 18

Just in case you missed last night’s Movement Debrief Episode 18, here is a copy of the video and audio for your listening pleasure.

in this debrief, I was stumped!

Andrew from Facebook asked a phenomenal question on the biomechanics of the squat, which led to great discussion on what it means and takes to squat.  Great contributions from Dani and Jonathan to the discussion.

Here were all the topics:

  • How I use research
  • Influences on full knee extension and flexion post-operatively
  • Changing perception of rehab post-total knee arthroplasty
  • The problems with chasing pain
  • Pain vs. suffering
  • What is squatting, what it means, and the biomechanicsIf you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 8:30pm CST.

Enjoy.

                

Here were the links I mentioned tonight

Pain and Stress in a Systems Perspective: Reciprocal Neural, Endocrine and Immune Interactions

On the (f)utility of pain

Subscribe to the debrief on Itunes

Join my mentorship program, get a movement consultation, or let me design an online fitness program for you.

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

 

Return to Play after a 5th Metatarsal Fracture – Case Report

I was recently featured on my buddy Scott Gray’s podcast,  a great clinician in the Florida area who I have a lot of respect for.

Before we dive into the podcast, let me tell you a bit about why I like this guy so much.

It’s not just because he is a part of the IFAST family.

I’ve been going back to the basics as of late, reviewing concepts such as tissue pathology, anatomy, surgical procedures, and the like.

If there is anyone who has the fundamentals down savagely well, it is Scott Gray.

He put out an Ebook called “The Physical Examination Blueprint”, which you can download by subscribing to his newsletter. Here he details all the essentials on screening your patients.

To me, the most important aspect of patient care is knowing who you can and cannot treat. Stratifying your patients based on who needs to be referred out, and who you can help is essential to providing the best care.

Quite simply, there are few better resources out there that outline how to do this than Scott’s ebook.

In it, he delves into what relevant questions to ask, tests to perform, and establishing a relevant diagnosis. Often underlooked, yet exceptionally important components of the clinical examination.

Again, I cannot recommend Scott’s ebook and site enough. It’s a great resource for many things PT, including many of his eclectic and unique manual therapy techniques. Definitely check this guy out.

Rehabbing a 5th Metatarsal Fracture to High Level Basketball

In this podcast, I outline a case I worked on back when I was in the NBA D League. 

This kid suffered a distal 5th metatarsal fracture with only a couple minutes to spare in a game. It was a brutal injury after one of the worst games in my life that I experienced, namely because we had three guys go down in one game.

Talk about awful.

I outline my entire process and every detail of what I did to get this kid back to high level basketball. A process that started with a fracture and ended with him establishing a franchise rebounding record the last game of the season. Pretty spectacular to say the least.

I feel very fortunate to have worked with such a driven and hardworking guy, and ultimately that was what his success hinged upon. Though minor, it was an honor to be this guy’s guide back to high level performance.

In this podcast, we dive into the following topics:

  • Immediate post-injury rehabilitation
  • Post-surgical care
  • The non-weight bearing phase
  • The weight bearing phase
  • Return to play Criteria
  • Return to performance criteria
  • Acute:chronic workload monitoring

Again, thank you to Scott Gray for featuring me on the podcast. I had a blast doing it.

If you’d like to download this podcast and get my free acute:chronic workload calculator that I used with this patient, subscribe to my newsletter by clicking here or simply fill out the form below.

Join the email list

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The Ultimate Guide to Treating Ankle Sprains

A Humdinger No Doubt

 

Ankle sprains. Such a bugger to deal with.

Worse than childbirth, as David Butler might say.

 

Ankle sprains are one of the most common injuries seen in basketball. The cutting, jumping, contact, fatigue, and poor footwear certainly don’t help matters.

Damn near almost every game someone tweaks an ankle.

Treating ankle sprains in-game provides quite a different perspective. Rarely in the clinic do we work with someone immediately post-injury. Instead, we deal with the cumulative effects of delayed treatment: acquired impairments, altered movement strategies, and reduced fitness.

The pressure is lower and the pace is slower.

You shed that mindset with the game on the line. You must do all in your power to get that player back on the court tonight, expediting the return process to the nth degree.

I had a problem.

Figuring out the most efficient way to treat an ankle sprain was needed to help our team succeed. I searched the literature, therapeutic outskirts, and tinkered in order to devise an effective protocol.

The result? We had 12 ankle sprains this past season. After performing the protocol, eight were able to return and finish out the game. Out of the remaining four, three returned to full play in two days. The last guy? He was released two days after his last game.

It’s a tough business.

The best part was we had no re-sprains. An impressive feat considering the 80% recurrence rate¹.    Caveats aside, treating acute injuries with an aggressive mindset can be immensely effective.

Here’s how. Continue reading “The Ultimate Guide to Treating Ankle Sprains”

How to Design Your Learning Program

Thanks Buddy

The other day I was texting with a friend and writer I respect dearly, Seth Oberst, and he asked me an excellent question regarding the reading process:

How do you determine what you read next though? ~Seth Oberst

I answered him then, though it felt brief and inadequate. His question inspired me to reflect on how I design my learning process.

Though I’ve mentioned my learning philosophy, it may be fruitful to delve into the details. Seth, I hope I don’t let you down. Continue reading “How to Design Your Learning Program”

The Sensitive Nervous System Chapter XIII: Research and Neurodynamics: Is Neurodynamics Worthy of Scientific Merit?

This is a summary of Chapter XIII of “The Sensitive Nervous System” by David Butler.

Intro

Research has demonstrated that often evidenced-based medicine is low on the list for why clinicians choose a particular treatment. From an ethical standpoint, it is important to consider evidence. This chapter is very short so I will just provide the highlights that I got from it.

Appraising a New Theory or Approach

There are six criteria that a new theory should be evaluated by:

1)      Support from anatomical and physiological evidence.

2)      Designed for a specific population.

3)      Studies from peer-reviewed journals.

4)      Include a well-designed randomized controlled trial or single experiment.

5)      Present potential side effects.

6)      Proponents discuss and are open to limitations.

Agreement

Here are some definitions of different ways research measures agreement.

–          Cohen’s Kappa: Measures nominal data reliability.

  • >0.75 is excellent agreement.
  • 0.40-0.75 is fair to good.
  • <0.40 is poor.

–          Pearson product movement correlation: Measures interval/ratio data.

–          ICC: Measures continuous data.

  • The closer to 1, the better.

Validity

There are also many different validity types defined throughout this chapter. The first two are proven through logic and have the least evidence support.

–          Construct Validity: Valid relative to a theoretical foundation.

–          Content Validity: Can I use this measure to make an inference?

The next two are higher up on the evidence support hierarchy.

–          Convergent Validity: The test shows a correlation between two variables.

–          Discriminant Validity: The test shows a low correlation between two variables.

Lastly, these are criterion-based tests that infer similar results compared to an established test.

–          Concurrent Validity: the compared tests are performed at the same time.

–          Predictive Validity: The tests are compared at different dates.

If only EBP were as exciting as evidence-based law.

The Sensitive Nervous System Chapter VI: Clinicians and Their Decisions

This is a summary of Chapter VI of “The Sensitive Nervous System” by David Butler.

Intro

All approaches (Maitland, Mckenzie, Mulligan) have myths. The common bond between them all is pain. Today we will look at building a clinical framework with pain as the cornerstone.

Evidence-Based Medicine (EBM)

EBM is defined as a conscientious, explicit, and judicious use of current best evidence in making patient care decisions. This concept is not merely reading researches articles, but it combines scientific evidence and clinical expertise. You have to know when to apply what.

For manual therapists everywhere, this creates issues and unease.

1)      Decision making moves toward an external body.

2)      Evidence suggests manual therapy improvements are more psychosocial than physical.

3)      A disconnect between researcher and clinician.

  1. The researcher thinks: “What does this work contribute to the literature?”
  2. The clinician thinks: “What does this work do for my patient?”
Likely not aligning OA on AA.

The movement towards outcome-based therapy per EBM is also problematic for several reasons.

1)      Clinicians begin to think statistical analysis becomes greater than any other form of knowledge rather than complimentary.

2)      Research doesn’t take into account the inherent uncertainty and subjectivity in a clinical encounter.

3)      Good evidence can lead to bad practice if applied in uncaring and unappealing environments.

4)      Outcomes may be coming out too quickly, leading to research development stopping in certain areas.

Butler’s thoughts are summed up very nicely when he states it would be a sad day if meta-analyses have the final say instead of exposing clinical errors. However, the self-scrutiny and analysis is a good thing as long as it stops short of reducing clinician self-confidence. For confidence is what allows us to practice in uncertainty and maximize the placebo effect, our most powerful pain reliever. The uncertain conditions which we practice in are what Butler terms the Grey Zone. These typify most syndromes in which underlying pathoanatomy and physiology is unknown.

Screaming with confidence. Just think how much serotonin drips from his patient's mouths when he explains pain to them.
Screaming with confidence. Just think how much serotonin drips from his patient’s mouths when he explains pain to them.

Clinical Reasoning Science

Clinical reasoning involves the merging of three areas: science, current therapies, and the clinician-patient relationship.

3 prongs

Butler also suggests that we need to shy away from thinking damaged structures and move towards movement dysfunction. We must realize that movement sensitivity does not involve the tissues only, but is a process that involves changes at a chemical and cellular level. When a movement becomes sensitive, changes occur in the ion channel, neurotransmitters, and nervous system. These changes are driven biopsychosocially.

Following this process, central processes are very much active in all types of pain. For example, acute pain depends on peripherally activated central processes. We must also look at recurrent pain, which is actually a chronic, central process as opposed frequent acute injuries.

Does that mean we need to be psychologists?

No.

We must treat faulty movement patterns, but that does not mean we cannot take aspects from psychology, namely…

Butler on Experience

There are two types of clinicians.

1)      One who has 20 years of experience in 20 years.

2)      One who has 20 years of experience in 1 year of practice.

How do we become the latter?

  • Reason
  • Learn
  • Experiment with management techniques.
  • Remain open.
  • Be aware of the outcomes movement.
  • Read widely
Don’t know who said it, but live every day as if it were your last, but read as if you will live forever.

Pain in the Clinical Reasoning Model

Step 1: Consider what pain is.

Pain is an unpleasant, sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Step 2: Differentiate class vs. source.

For example, patient x’s pain fits a peripheral neuropathic pain class, with the source being an L4-5 nerve root.

Step 3: Know your pain mechanisms. (3 types)

  • Input: Nociceptive, peripheral neuropathic pain (Entrapment outside dorsal or ventral horn, nerve root, peripheral nerve).
  • Processing: CNS plasticity changes, cognitive influences.
  • Output: Sympathetic, immune, and endocrine systems, potentially consciousness as well.

Step 4: Classify in terms of dysfunction.

  • General physical function/dysfunction: The patient’s main problems.
  • Specific physical function/dysfunction: Problems found by clinician that are related to patient’s problems.
  • Mental/psychological function/dysfunction: What the patient thinks/feels about his/her injury, the clinician, the treatment, and society’s approach to his/her disability. Distress fits in here.
Could be a mobility problem, could be a stability problem, but most likely a distress problem.

Step 5: Make sense of dysfunction

One needs to determine if the dysfunction is maladaptive or adaptive. For example, limping after a sprained ankle would be an adaptive response to allow for tissue healing. Limping for the same sprained ankle 25 years later would be considered maladaptive. Often too we must realize that we accumulate dysfunction over time, and minor findings may not be relevant to a person’s complaints.

Step 6: Find your sources

In terms of dysfunction and mechanisms. You need to know where you would fire a magic bullet if you have it. This could be a particular manual therapy or even explaining pain to reduce the fear of movement.

Step 7: Know your contributing factors

This can include any factor related to the predisposition, development, and maintenance of a problem. These factors can include psychosocial, genetics, anthropometrics, and ergonomics.

Step 8: Determine Prognosis

Prefer function over pain.

Step 9: Know precautions

Do no harm is first and foremost. When thinking manual therapy, use the least amount of force for maximum gain.

Step 10: Management

Realize and be comfortable knowing that chronic pain is something we may never cure, but it is something we can manage.

The Reasoning Process: Key Points

Reasoning is an evolving process throughout the treatment course that starts broad and moves toward refinement. This path occurs via the information gained from the patient assessment coupled with the clinician’s knowledge, understanding, and previous experience.

Most important, we must keep the patient as part of the reasoning process. Their hypothesis of their problem affects all reasoning categories and will alter as assessment and management proceed.

The intervention provided will affect the evolving concept of the problem, and the placebo effect can occur anywhere in the process. With that in mind, be mindful of any errors made during.

Without the patient front and center our work means nothing.