Recommended Resources

I oftentimes get asked what resources I recommend. The resources listed below have been essential at putting me down the path that I am currently going, and have shaped how I practice today.

Trips = reading opportunities.

The cool thing about this list? None of these are set in stone. If I find a better resource, or one of the blogs I recommend starts to resonate with me less, it leaves the list (no pressure).

I want to give you guys the most up-to-date resources as humanly possible, so please check back here frequently.

If you’d like articles and such that are tripping my trigger as of late, you may want to sign up for my newsletter. You’ll also get some access to almost 3 hours and 40+ pages worth of exclusive content on pain and breathing.

Here are my resources:

Foundational Sciences

Video series

Makemegenius – A youtube page dedicated to explaining scientific concepts that a kid could understand.

Crashcourse – Another series of short videos explaining complex scientific topics and more in 15 minutes or less. I wish I had this in undergrad.

Books

Gilroy Atlas of Anatomy – Easily the best paper anatomy atlas you can find in the land. The angles drawn, the clarity of pictures, this atlas has it all. Wait until you see the subocciptals from the side. #mindblown

Guyton and Hall Textbook of Medical Physiology – Easily the best and most comprehensive physiology textbook in the land, the depth at which this book dives into with concepts is otherworldly. If I need clarification on a physiological process, this is my go-to.

Physiology of Training for High Performance – Easily the best exercise physiology textbook I’ve come across. Very few explain the energy systems with such depth, and I absolutely love the sections on the stretch shortening cycel

Kinesiology of the Musculoskeletal System – Neumann is the gold standard for explaining how each joint works in the human body. There is simply no more of a comprehensive resource on movement than this book.

The Physiology of Joints Volumes 1, 2, & 3 – If you want a more thorough understanding of joint structure and function, look no further. Just good luck finding copies that won’t cost you an arm and a leg.

Why Zebras Don’t Get Ulcers – The classic written by the master himself, Robert Sapolsky. This is the gold standard text on all things stress. His writing style makes a normally boring topic exciting to read.

Principles of Neural Science – Prepare to have your mind blown. The depth at which the neurology goes within this book is incredibly challenging, but if you need to reference something neuro-related, this is the book to have.

Apps & Technology

Visible Body Atlas – The gold standard 3D anatomy atlas. The visuals are stunning, and it is incredible to see how the anatomy looks from multiple angles.

Visible Body Muscle Premium – Yes, you need this too. Seeing how muscle contract to move the bones is worth the price of admission.

Rehabilitation

Blogs & Podcasts

Bill Hartman – Daddy-O Pops Bill Hartman is the cat who I look up to the most, not just in the PT realm, but in life. His blog consists of neat little tips to improve multiple aspects of your life, and he is the go-to-guy when thinking about developing your system or model. I appreciate his systematic approach.

Resilient Peformance Physical Therapy – My boys, Doug Kechijian, Trevor Rappa, and Greg Spatz, put out a lot of great content. These guys do such a great job of putting problems of the profession into perspective, and looking at things with as little bias as possible.

Doug also host a wonderful, eclectic podcast, where he interviews many people within and outside the profression, drawing comparisons to things we experience in performance and rehab.

Mike Reinold – Mike is who I look to for all things post-surgical, pathology, and PT research. I admire his breadth of knowledge base in these areas, and his Ask Mike Reinold show is full of great pearls.

Charlie Weingroff – Charlie is one of those cats who does a good job bridging the gap between rehabilitation and performance. Though I know we practice differently, I find myself nodding my head a lot when he discusses systems and principles. I appreciate his ability to integrate multiple thought processes into his own approach.

Modern Manual Therapy Blog – If I want to learn about manual therapy, TMJ, and more, Erson is my guy. I took his course many moons ago, and admire how well he assimilates multiple systems into his own approach.

Seth Oberst – I love how Seth integrates meditation, interaction, threat reduction, and many other aspects into his approach. When it comes to stress mitigation, Seth is the guy.

Scott Gray – Scott is a PT I admire when it comes to evaluation, testing, and diagnosing conditions, definitely not my strongest suit of things.

Healthy Wealthy & Smart – A podcast put on by a physical therapists named Karen Litzy, Karen goes around interviewing physical therapists from all walks of life. I’m always getting an inspiration to study something further or a pearl of clinical application every time I listen to her interviews. Her advocacy for the physical therapy profession is admirable.

The Ca$h Based Practice Podcast – Jarod Carter was the early pioneer regarding building a cash based practice. Business was never my strong suit, so getting access to the information in this podcast has been clutch.

PT Adventures – How do I learn about contract negotion? What do I look for in a recruiter? OMG where was that picture taken?!?! These guys know all the ins and outs when it comes to travel PT, and are by far the foremost experts on the topic. Their complementary E-book is an absolute must, even if you aren’t considering travel.

Apps & Technology

A Manual of Acupuncture – I was taught dry needling through somewhat of a medical acupuncture lens, and if you dive into the literature you’ll need to know the acupuncture points. I would be lost if it weren’t for this app.

Recognise Apps – Essential for graded motor imagery retraining. This app not only has graded left/right discrimination challenges, but also tracks accuracy and timing. The best on the market, and has all body parts available.

Books

Diagnosing & Assessment

Differential Diagnosis for Physical Therapists – Do no harm is priority number one. This book is your guide that ensures you keep people in your clinic who you can help, and refer those who you can’t.

Primary Care for the Physical Therapist – If we push the physical therapy profession to first line providers, this text will become more and more essential. This book teaches you the things you need to know to become a primary care provider.

Orthopedic Rehabilitation Clinical Advisor – When it comes to specific orthopedic diagnoses, this is by far the most user friendly. This book gives you ideas in terms of differential diagnosis, testing, prognosis, and so much more.

Netter’s Orthopedic Clinical Examination – Want to know which tests are most accurate and effective? This text is the one for you then. Love how they look at multiple different assessment pieces, and use evidence to either support or refute their utility.

The Malalignment Syndrome – Want to understand and appreciate asymmetry in the human body? Then this is the resource for you. This book shows many of the common restrictions seen in our movement assessment, and explains from an osteopathic standpoint what is going on.

Pain & Nervous System

Why Do I Hurt – The essential book for understanding basic pain neurobiology in the easiest way.  I absolutely love Adriaan Louw’s analogies and examples for explaining pain to patients. It’s a quick read well worth the time.

Therapeutic Neuroscience Education: Teaching Patients About Pain – In the explosion of pain science books, this one is by far the most practical. Here Adriaan Louw simply explains how pain works, and provides excellent strategies for educating patients with easy-to-understand language.

The Sensitive Nervous System – This is the heavy version of understanding how this whole nervous system and pain works. David Butler discusses the nervous system, central sensitization, neurodynamics, and so much more. Fantastic read.  [read the book notes here]

Clinical Neurodynamics – Michael Shacklock looks at the concepts of neural mobility through a more anatomical and physiological lens, and taught me how to appreciate the neural container (the tissues surrounding the nerve).  [read the book notes here]

Topical Issues in Pain Volume 1 – Louis Gifford is all about not getting too sciency and more about practically applying this pain science stuff. His early work is essential reading.

Treatment

Recognizing and Treating Breathing Disorders – If you want to know all the essentials in applying breathing to treatment, this is the gold standard. Anytime I go to review physiology of breathing, this is my go-to text. [read some of the book notes here]

Region-Specific

The Pelvic Girdle – Diane Lee provides the go-to resource for learning all things about the pelvis. The first half of the book is gold—anatomy, kinesiology, etc. The treatment half? Well, it’s not what I would do, but whatever 🙂

Orofacial Pain – This book is incredibly dense, and surprisingly one of the best pain science texts around. But if you want to learn the ins and outs of orofacial pain, it’s a must.

Hand and Wrist Rehabilitation: Theoretical Aspects and Practical Consequences – To go-to for all things hand and wrist. The graphic showing wrist kinematics are like nothing I’ve ever seen, and worth the price of admission.

Courses

Spinal Manipulation Institute – These guys are the go-to for learning dry needling. I’ve also taken their extremity manipulation class, which was nicely done as well. The consistent theme with all of their coursework is evidence. They do a great job outlining what the research says, and even what it doesn’t say. I appreciate them attempting to minimize their biases.

Active Release Technique – I only took these because I was able to go on someone else’s dime, and I was pleasantly surprised. The preparation and execution of the class greatly improved my understanding of anatomy and movement. The technique and concept itself is simple, yet quite effective. Especially considering the short amount of time it takes. It’s a great soft tissue technique, though pricier than necessary.

Johnny Owens Bloodflow Restriction Training – I thought this was a gimmick at first, then my boy Johnny Owens dropped research bombs on me left and right. I was amazed at how effective this was, and I’ve personally seen some nice changes both in myself and clients with utilizing BFR. Johnny hosts the gold standard class.

Postural Restoration Institute – A good way to get you started thinking about the movement system as a whole, and seeing how exercise selection can impact multiple areas. I typically recommend the following class order: Myokinematic RestorationPostural Respiration → Pelvis Restoration → Impingement and Instability. I would cap it at that. I’ve found if you have a good understanding of these courses, and enrich your understanding with similar sources, you’ll rarely if ever need to explore the more esoteric routes.

Dermoneuromodulation – ART is a bit more aggressive of a manual technique, DNM is much much lighter and quite effective. Diane also has the best explanation on manual therapy mechanisms I have ever come across, and that is worth the price admission alone.

Explain Pain – When I took this class by David Butler, I was absolutely blown away. Easily one of the best classes for understanding pain mechanisms, and some of most helpful metaphors you will find for education.

Therapeutic Neuroscience Education – Whereas Explain Pain is more science-heavy, Adriaan Louw’s iteration is all about practical application. He has some of the simplest and most effective ways to explain how pain works to clients. A must take.

A Study of Neurodynamics: The Body’s Living Alarm – While I haven’t taken this class formally, Adriaan’s version of Mobilisation of the Nervous System had way more practical applications that other iterations of the class I’ve taken. When it comes to neurodynamics, you need treatment ideas. Adriaan is the guy who I got that from the most.

Graded Motor Imagery – What do you do when all movements hurt? That’s where GMI comes into play. This class takes you through introducing someone into movement by teaching left/right discrimination, visualization, and mirror therapy. I use this quite a bit in early phases of rehab; especially if someone is not allowed to move the affected area.

Performance

Blogs & Podcasts

Mike Robertson – Mike was one of the first dudes that got me inspired to dive into this field. He has some of the most in-depth coaching posts like ever. Period. We also think very similarly from a coaching standpoint. Head to his site if you want to learn how to design a comprehensive strength training program for general population to athletes alike.

Mike also hosts one of the best podcasts in performance, in which he interviews a bunch of people in the fitness industry, including this joker. 

Eric Cressey – Been a big fan of Eric for a very long time. His book, Maximum Strength, was one of the first training programs I used that led to appreciable gains in strength. His knowledge of the upper extremity and shoulder is unparalleled, and that includes the rehabilitation

Darkside Strength – This is a good compilation site for a wide variety of performance topics. Ranging from med ball throws, to thorax rotation, to posture, you’ll find just about anything you’d like to learn about on this site.

YLM Sports Science – Yann Le Meur is awesome. What he does is takes important research articles, and disseminates them into useful infographics. If you want to get a quick summary of relevant research articles, here’s the site.

Joel Jamieson – Joel is the foremost expert on all things conditioning. I love how he integrates sports science (namely heart rate variability) and many other measures to make logical programming decisions.

Lance Goyke – Lance is one of my dear friends who writes on a wide variety of topics; ranging from building mass, to how overrated stretching is, to excellent physiology lessons. I love his 4 point Friday that he sends to his newsletter peeps, as he exposes you to very cool reads and listens on a wide variety of topics.

TD Athletes Edge – The place my boy Tim Difrancesco built. Here, Tim discusses all factors that are relevant to performance, such as diet, sleep, stress management, and movement. I really like the stuff Tim puts out because we have very aligning philosophies.

Tony Gentilcore – Tony is a guy who I refer to quite a bit regarding coaching cues and the like. Cat has one of the prettiest deadlifts in the game, so have to throw mad respek his way.

Dean Somerset – Dean is my go-to guy for post-rehab training. Love how he incorporates a wide variety of things into his training, and he always writes posts that make me think.

Bret Contreras – I admire how much Bret is a steward of the science and all things evidence-based. He’s also the guy who pioneered the hip thrust exercise. While not something I incorporate much in my training, definitely a great move if gluteal hypertrophy is your goal.

Chaos & Pain (NSFW, or most anyone) – With many of us emphasizing recovery, high/low methods, and not going too hard, sometimes you need a swift kick in the teeth and someone to tell you to get after it. That’s why I go to Jamie Lewis. The guy is also an encyclopedia when it comes to old time strength people and cooking stew. Definitely an underrated site.

Apps & Technology

Polar Beat – If you play with heart rate training, this app is a must. Here it’ll track your heart rate, time spent exercising, and so much more.

Tabata Pro – My favorite app for interval training. Simple, easy to use, and effective in both visual and auditory cues for when to go!

Books

All Gain, No Pain – Yeah, I’m a little biased (I did write the foreword after all), but Bill Hartman’s first book is an instant classic. I love how all-encompassing this book is. You’ll get an understanding of pain, stress, performance. But most importantly, you’ll be able to design a program that is specifically built for you. If you are post-rehab and looking for a way to get back into training, this book is a must.

Ultimate MMA Conditioning – Aka energy systems and application made ridiculously simple. Joel Jamieson’s classic book teaches you most of what you need to know when designing effective conditioning programs. It’s an essential read.

Starting Strength – If you want to enhance your understanding of the mechanics of basic lifts, this book is essential. My favorite section is the squat chapter.

New Functional Training for Sports – Mike Boyle has some of the best progressions that are simple and easy to execute. I like this book a lot because it is all practical application. His jump progression makes up a bulk of how I introduce the concept of jumping to my clients.

Essentials of Strength and Conditioning – Yeah, the exercise and nutrition sections are lackluster, but you’d be hard pressed to find a better overview of all things S&C. Some of the basic science chapters are easy to understand, which is incredibly valuable to me.

Spark – This book will make you rethink just how powerful aerobic exercise is.

Courses

Resilient Movement Foundations – An essential class to attend if you want to master the basic movements. I also like how if a movement cannot be performed, the boys at Resilient give you methods to assist in performance.  If you want an overview, check out my course notes.

FMS Level 2 – While I’m not an avid FMS/SFMA practitioner, I thoroughly enjoy their intelligent exercise progressions and coaching styles. Some of the variants taught at the level 2 in particular are things I readily incorporate into my practice.

Derek Hansen – One of the best sprinting coaches I’ve ever come across. His seminar that I attended was all about practice application, and his simple coaching cues to improve sprinting have made a huge impact in my clientele. Want to learn sprinting? Here’s the guy.

Tim Gabbett – The acute:chronic workload is a fundamental principle that we must all consider in both the rehabilitation and performance realms. No one teaches it better from an application standpoint than Tim Gabbett.

ALTIS Apprentice Coach Program – How does getting to learn from the likes of world class track coaches Dan Pfaff and Stu McGill for a week sound? One of the best investments I’ve ever made, you learn basically what you want to learn from this apprenticeship program. The biggest takeaways I got involved the art of coaching, resiliency training, plyometric programming, and that’s just a small taste.

Certified Speed and Agility Coach – Lee Taft is the foremost expert when it comes to multidirectional training. This online cert provides a great overview of all the skills one must possess when playing a multidirectional sport.

Nutrition, Functional Medicine, Sleep, & Wellness

Blogs & Podcasts

Mike Roussell – Mike is one of my favorite nutrition peeps in the land. Responsible for the great book the Metashred Diet, a diet I used to drop my first 20 pounds, Mike is all about practical application in regards to dieting. His steps are simple, easy to use, and require easy changes in behavior. Definitely a guy to learn from.

Chris Kresser – Chris hosts one of the most comprehensive functional medicine combined with ancestral diet resources I have ever seen. Many of the things he has posted on my site have helped me a great deal with some of the health issues I have experienced, and his practioner program is very intriguing to me. You will not be disappointed by what he has to say.

The Paleo Solution Podcast – Hosted by Paleo extraordinaire Robb Wolf, I amazed at how well versed he is in the wide variety of topics discussed in this podcast. Whether he’s interviewing a sleep expert, paleo enthusiast, or

Rhonda Patrick – RP (#bae) has gotten me so much into genetics, fasting, sauna use, and many other topics.  The papers she puts out for her newsletter peeps are beyond comprehensive. Definitely check out her site, listen to her podcast, and consume as much as possible.

Peter Attia – This blog is technically retired, but Dr. Peter Attia is a wealth of information when it comes to all things functional medicine. I admire his approach and emphasis on blood sugar management, hormones, and many more things. If I were ever to go to medical school, I’d want to turn out like this guy did.

Apps & Technology

Zero – This is the go-to app to use if you are experimenting with fasting. It times how long you’ve gone without eating, and keep you on target with the desired duration you wish to fast.

The Oura Ring – By far my favorite tracking device, and I’ve experimented with the best of them. The Oura ring is by far the most accurate sleep tracker you can buy. It also measures HRV, body temperature, activity levels, and the newer model do things for finding your circadian rhythm. All within a sleek looking ring. You’d be amazed at what you can learn from wearing this ring, especially in terms of what late night behaviors can impact sleep.

BrainWave – The best white noise app in the land. Also combines calming sounds with various waves that supposedly stimulate various brain states. Does it work? Who knows, but I’ll hedge my bets.

F.lux – An app that blocks blue light, the stuff that keeps you awake at night, on your screens. Essential for anyone who has to work on their computer late.

Books

The Metashred Diet – Just do it. That could be the mantra for this great read by Mike Roussell. Here, he just lays out a plan of attack to execute an all-out war on fat loss, and it is quite effective. I was able to drop close to 20 pounds staying militant on the 56 day plan, and I’ve kept up with many of the principles on a consistent basis.

Sleep Smarter – A little bit heavier on the esoteric sleep strategies, but I was blown away by how effective implementing these strategies have been. The biggest takeaway for me from this book was the importance of light exposure. A great read.

Take a Nap! Change Your Life – Who knew effective napping could be so scientific? If you want to get the most out of your naps, or question just how important napping is, let this be the answer.

Sleep for Success! Everything you Must Know About Sleep but are Too Tired to Ask – This book provides a little bit of background knowledge regarding sleep, and some easy strategies to implement to enhance your sleep quality. It’s a little salesman-heavy at times, but still a solid read nonetheless.

Courses

Precision Nutrition Level 1 – An excellent combination of overview, depth, and application of nutritional coaching. The emphasis on behavior change is critical, and I admire how that makes up the backbone of this great certification.

Personal Development & Entrepreneurship

Blogs & Podcasts

Barking up the Wrong Tree – Probably my favorite blog on the internet. Like…for real. Why are you still here??? Eric Barker is a guy who researches many different topics, and breaks down the information into 3-5 applicable points. My favorite? How to be James Bond of course!

The Tim Ferriss Show – One of the most popular bloggers of all time, Tim goes around interviewing a wide variety of people, seeking answers on how to get the most out of life in the fastest manner possible.  He also has great q&a’s and talks on building business and more. An essential listen.

Jocko Podcast – The podcast of former Navy Seal Jocko Willink. My favorite podcasts are his Q&As, where he problem solves listener questions with incredibly practical advice that you probably don’t want to hear, but need to hear. Definitely a life changing person to learn from.

Seth Godin – He writes a short blog every day that will either inspire you, make you rethink what you are doing, or be just the thing you need to hear.

I Will Teach You to Be Rich – Ramit Sethi promotes a message that really resonates with me. He writes profoundly on topics ranging from personal finance, entrepreneurship, and marketing. Definitely check this cat out.

Books

Extreme Ownership – One of the most impactful books I have ever read in my life. Consider it the practical guide for controlling the things that you can control. You’ll be amazed at what making this shift in mindset can do for you.

The Obstacle is the Way – I read this book during a rough patch in life, and it helped me appreciate how impactful adversity can become. It can break us or shape us. Use those hard things in life as opportunities to grow. This will help you along the way.

The Ego is the Enemy – Something I’ve struggled with through much of my life is squashing ego. This book was essential for doing that. Realize that you aren’t that important, keep a beginner’s mindset, and be humble. Understanding these three concepts will get you far in life.

The Subtle Art of not Giving a F*ck – After you’ve squashed your ego, read this bad boy to bring it up to appropriate levels. This book is essential in helping you understand just how frivolous most things in life are. I sweat so many fewer things thanks to this phenomenal read.

The Millionaire Fastlane – This book will forever change how you think about running your business, running your life, and why it is important to strive for a business that makes you millions. It’s more of a selfless reason than you think.

Unscripted – Another great in-your-face book by MJ DeMarco. This one makes you really think about striving for that 40 hour work week until your dead. Another life changing book.

The 4-Hour Work Week – Elimination, automation, and many more outstanding principles occur in this book. The biggest key I got from this was a guide on streamlining many of the processes I have in place from a business standpoint. It’ll definitely make you think about how you are currently running your life.

Discipline Equals Freedom Field Manual – On those days you lack motivation, or when you feel like blaming others for problems, or are experiencing tough times, just read one page. Never did a book exist that helped me refocus as well as this one.

The Definitive Book of Body Language – Nonverbal communication is essential to effectively communicating with a wide variety of people. You will be amazed at some of the relative nonverbal “mistakes” we make when interacting with others. Mastering this book will enhance your relatability to a high degree.

How to Talk to Anyone – Another great key read in maximizing verbal and nonverbal strategies to  become an effective communicator. One of my favorite tips? Taffy eyes. Get it to learn more.

Apps & Technology

Evernote – My go-to note taking app. Syncs with most every tech device you own, and is pretty easy to use. Love how easy it is to categorize things, and you can even copy paper notes onto this bad boy. Essential for tracking many of my upcoming projects.

AllTrails – If you are an avid hiker, this app is a must have. I can’t tell you how many times this app saved me on questionable hikes, or given me access to hikes that I didn’t know about. In a class of its own.

Freedom – For those times you need to be immensely productive and the internet does nothing but distract you. This app will kick you off the internet for however long you so desire.

Deathclock – Another procrastination killer. Download this Chrome extension, and each time you open a new page you’ll see how many days you approximately have left to live. Morbid? Yes. Effective? Absolutely.

Photo Credits

Pixabay 

 

 

Hypermobility, Pushups Over Quad Sets, and Lat Dominance – Movement Debrief Episode 28

Movement Debrief Episode 28 is in the books. Here is a copy of the video and audio for your listening pleasure.

Here is the set list:

  • How do testing considerations differ for people with joint hypermobility syndromes?
  • What does treatment look like for the hypermobile client?
  • Why I like pushups and other upper body exercises can be effective selections for lower body problems
  • What “pain science” courses do I recommend
  • What’s the deal with overbracing and cueing abdominal coordination?
  • How can you reduce lat overactivity
  • The clinical reasoning model that I am thinking of

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

Enjoy. (sorry about the audio delay, still making some tweaks on my new computer)

Zac Cupples iTunes                

Here were the links I mentioned:

Here is the first way I assess coordinative variability

 

The next test assess coordination, power, and fatigability of joint variability:

Noi Group

Explain Pain Course Notes

Graded Motor Imagery Course Notes

Mobilisation of the Nervous System  Course Notes

Therapeutic Neuroscience Education Course Notes

International Spine and Pain Institute

“All Gain No Pain” by Bill Hartman

Enhancing Life

Method Strength

Andy Mccloy 

Trevor LaSarre

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

Continuing Education: The Complete Guide to Mastery

75

That’s my number.

No, not that number.

 

Pervert

75 is the number of continuing education classes, conferences, home studies, etc that I’ve completed since physical therapy school.

Though the courses are many, it was probably too much in a short period of time. When quantity is pursued, quality suffers. Sadly, I didn’t figure out how to get the most out of each class until the latter end of my career.

Two classes in particular stand out: Mobilisation of the Nervous System by the NOI Group, and ART lower extremity.

Yes, the content was great, but these classes stood out for a different reason. You see, instead of just doing a little bit of prep work, I kicked it up a notch. I extensively reviewed supportive material, took impeccable notes, and hit all the other essentials needed to effectively learn.

I was prepared, and because I was prepared I got so much more out of these classes than my typical fair.  The lessons learned in those courses stick with me to this day.

For the stuff you really want to learn, I’ll encourage you to do the same. Here is the way to get the most out of your continuing education. By the time you are done reading this post, you’ll understand why I now recommend a more focused learning approach and fewer courses.

Let’s see how to do it.

 

Continue reading “Continuing Education: The Complete Guide to Mastery”

The Post Wonderful Time of the Year: 2014 Edition

And That’s a Wrap

It’s that time of the year that we get to look back and reflect and what posts killed it (and which bombed).

It seems as though my fine fans be on a pain science kick this year, and rightfully so. It’s some of the best stuff on the PT market right now. It’s definitely a topic I hope to write about more in the coming year, and one I will be speaking on at this year’s PRC conference.

But without further ado, here are the top 10 posts of 2014.

10. Treatment at the Hruska Clinic: PRI Dentistry and Vision

Lift scores 6/5 with the Bane mask on. #alternatingandreciprocalwarrior
Lift scores 6/5 with the Bane mask on. #alternatingandreciprocalwarrior

Going through the treatment process as a patient has really upped my game in terms of knowing when to integrate with my patients. It has also been a life-changing experience for my health and well-being. Learn how they did it for me.

9. Course Notes: THE Jen Poulin’s Myokinematic Restoration

She's a myokinematic beast!
She’s a myokinematic beast!

So much fine tuning occured the second time around. I love how Jen acknowledged the primitive reflex origin of the patterns, as well as fine tuning both lift tests. She’s an excellent instructor (and fun to party with)!

8. Treatment at the Hruska Clinic: Initial Evaluation

Producing so much saliva
Producing so much saliva

The start of my alternating and reciprocal saga. Made for one of the most fascinating evaluations I have ever experienced. Ron Hruska is otherworldly.

7. Course Notes: PRI Postural Respiration

Chiari malformation waiting to happen.
Chiari malformation waiting to happen.

I love a good foundational course taught by the Ronimal. You always get a few easter eggs that allude to higher level courses and concepts. A must-take course.

6. Course Notes: PRI Craniocervical Mandibular Restoration

Ron looks even better in person with the meat suit.
Ron looks even better in person with the meat suit.

One of the most powerful and humbling courses I have ever been to. Ron goes all out on this course, as it is his baby. What dental integration can do to a system under threat is a concept that I hope is further explored in medicine. We can’t do it alone folks.

5. The End of Pain

Still verklempt by the overwhelmingly positive response.
Still verklempt by the overwhelmingly positive response.

This post marked a shift in my thought process and a realization of the possibilities that an integrated health system can accomplish. I have high hopes for our profession, and feel excited that an original post had so many views.

4. Course Notes: PRI Pelvis Restoration

A good group to learn from and with.
A good group to learn from and with.

It seems that with each PRI course you take you go another layer down the rabbit hole. Pelvis is a great course to link up Myokin and Respiration; especially with Lori and Jesse at the helm.

3. Course Notes: Dermoneuromodulation

Diane is bullseye with her neuroscience.
Diane is bullseye with her neuroscience.

Couple the best manual therapy explanation I have come across and a gentle technique and you get a rock solid course. The only downside is that now Diane has tarnished any other manual therapy course for me, as I can’t rationalize any other explanatory model given.

Fine by me.

2. Course Notes: Therapeutic Neuroscience Education

Stayed hungry to learn ever since this course.
Stayed hungry to learn ever since this course.

I love Adriaan’s practical application of pain education to patients, and he is one of the best speakers in the biz. There’s a reason why I am hosting him again next year.

1. Course Notes: Explain Pain

A legend
A legend

A great neuroscience course, a great practical course, and getting to learn from a PT legend? Sign me up.

Game Over!

And that marks the last post of 2014. Which were your favorites? Which are you hatin’ on? Comment below and let’s hope to even better content in 2015!

496d30611f94277eee71b80e3cd0f24cb9

Course Notes: Explain Pain

A Whirlwind

I finally had the opportunity to meet my personal Jesus, David Butler, and learn the way that he explains the pain experience to patients.

Don't even ask who the father and holy spirit are...
Don’t even ask who the father and holy spirit are…

It was an interesting weekend to say the least. The course started off with a smash…literally.

Good thing they wrote that, I couldn't tell.
Good thing they wrote that, I couldn’t tell.

We had the unfortunate experience of someone breaking into our car to start the trip off. Then once we arrived to the course, we were informed that Dave was going to be 2 hours late. He was staying in Philly (where I also experienced flight troubles last week) and a snowstorm with a name no one cares about stopped his flight.

So Dave drives all the way from Philadelphia, “tilting his head back to rest” for 1 hour, and then what happens?

He, along with the other instructors, drive to the wrong campus.

So after all these crazy things happen, Dave finally makes it to the course, sets up his presentation, plays a little Bob Marley, and………………

Kills it.

I mean, absolutely kills it.

To see Dave present this topic under the above circumstances and be on the entire time is a testament to the type of speaker and professional he is.

David Butler is one of, if not the best speaker I have ever heard.

So I’d like to thank you, Dave, for making an otherwise stressful weekend memorable and exciting. I look forward to applying what I have learned.

If you haven’t taken a course from the NOI Group, please do so yesterday!

So what did me and my friends blossums learn this past weekend? Read on brothers and sisters, read on.

Some of my favorite blossums out there.
Some of my favorite blossums out there.

A Paradigm Shift

Conceptually understanding what pain is can be quite powerful. And pain science itself has grown by leaps and bounds.

The number needed to treat (NNT) values of explaining pain to patients is about three. That means that it takes explaining pain to 3 patients before 1 will have a successful outcome (pain relief after 12 months).

To put this value in perspective, most pain medications have a NNT over 10. Taking aspirin in hopes of preventing a heart attack is 50. Knowledge is powerful stuff.

We know lots of powerful things to tell patients regarding pain states. Take the following points as an example:

  • Pain is a critical protective device.
  • Pain depends on how much danger your brain thinks you are in, not how much you are really in.
  • Tissue damage and pain often do not relate.
  • As pain persists, the nervous system becomes better at producing pain.

Great educational pieces that patients ought to know. The problem arises in dispelling this knowledge.

Think about who educates patients on their complaints. How many people do we know are given the death sentence of a bulging disc? How many people say “look at my x-ray!!?” How many people say “There’s nothing I can do. It’s bone on bone?”

There is an obvious disconnect between what is known about pain and what healthcare practitioners educate patients on. It is a constant battle, so how do we combat this problem? As Dave so eloquently put it:

“You have to meet the patient at their story.”

Let’s face it, changing the way one perceives pain is changing a thought process and belief system; something very challenging regarding any belief.

Changing one’s pain beliefs involves first reconceptualizing pain, then translating this message to the audience, and finally altering the narrative to address misconceptions. But the quote above reigns supreme. If you start by barraging someone with pain science when they are so far away from that paradigm, you run the risk of losing them.

You must build a bridge in order to cross a chasm.

Whatever it takes.
Whatever it takes.

Two Models

If you have not been living under a rock for the past 5 years or so, there are currently two combating models in the medical realm.

  • Biomedical (BM…not bowel movement)
  • Biopsychosocial (BPS)

The BM model is still the overwhelming favorite and where most of the world thinks. It combines knowing anatomy, biomechanics, and tissue pathology in order to treat conditions.

If you want a signed print of my work, shoot me an email. For a small fee, you too, can own my wonderful artwork.
If you want a signed print of my work, shoot me an email. For a small fee, you too, can own my wonderful artwork.

One key thing regarding this model is that it is still useful. If I have someone who is having complaints that resemble cancer, I want to utilize this model to determine if that is indeed the case.

The BPS model encompasses the above and much more. Here we take into account the neuromatrix, pain mechanisms, the onion skin model, fears, threats, and challenges, and evolutionary biology.

This one will cost double due to the enriching color scheme.
This one will cost double due to the enriching color scheme.

The important thing to realize is that the biomedical aspects are still present in this model, and can play a role in one’s pain experience. So please, do not forget them.

The BPS model’s goal is to enrich patient’s knowledge and create a conceptual change along with addressing potential problems.

However, each patient we interact with may possess many different misconceptions that we may have to address. The range goes from missing pieces of understanding all the way to lacking the requisite mental framework for understanding pain science.

We can see how sometimes teaching someone pain science can be incredibly challenging. If a patient cannot think in the way you are educating, you may not be able to alter their perceptions on the pain experience. They may lack the neurosignature necessary to understand what you are saying.

To understand pain, one must realize it is an emergent process. Many people conceptualize pain as a linear process – I pinch myself, and I feel pain. But as we know, pain is complex and results from the interaction of many variables. This process is like baking a cake. Small ingredients combine to form an end product that bears no resemblance to the individual parts.

Let’s Build Us a Nervous System, or even Better, a Neuroimmune System

While the periphery is extremely important, more emphasis ought to be put on the neuroimmune system and how it works, especially in pain states. As suggested by Butler, the nervous system works by being:

  • Complex – The hardware and wetware
  • Self-constructing
  • Distributed
  • Representational

I won’t go into great detail into these points, as I have talked about them ad nauseum here , but here are some interesting factoids regarding your nervous system:

  • The anatomy and chemistry of the brain do not match.
  • Over 80% of the brain are glial cells with an immune function and have a bidirectional relationship with neurons.
  • 25% of the brain’s neurons are mirror neurons.
  • The entire brain is replaced every few weeks.
You serious bro?
You serious bro?

Ion channels, your body’s sensors, change every two days and reflect the individual’s needs.

Now if we want to look at the brain itself, the big kahuna, there are some key points Dave discussed with us regarding this magnificent organ:

  • Although pain experiences are distributed and can vary among people, common areas do activate.
  • The neurotag composes the areas that activate together in a particular experience. Hence, those active during pain would be the pain neurotag.
  • Brain representations do not indicate specific tissues, but more so areas.
  • Emotional and physical pain look similar. Moreover, pain and pleasure have similar neurotags.
  • Brain representations can be modified by cognition.
  • Smudging of key areas can occur.
  • If no problems whatsoever exist in your body tissues, nerves, or immune system, you may still feel pain if the brain thinks you are in danger.

Taking into account the above, the therapeutic goal is to alter representations, deactivate painful neurotags, and reduce the perception of threat.

Nociception

Nociception is basically a danger message that comes in from the periphery. This “danger” signal is not the same as a “pain” signal, as pain is a brain output. These fibers send quantitative data as opposed to qualitative. So when you hear someone saying pain feels achy, gnawing, tearing, ripping; know that these descriptors are CNS outputs.

Nociception is neither necessary nor sufficient for a pain experience.

There are two basic nociceptive processes:

  • Ischemia: occurs at the end of day and when little movement is applied; address by education and movement.
  • Inflammation: neurogenic and non-neurogenic.

Lets break down inflammation further. The non-neurogenic side contains chemicals from cells of damaged tissues, specialized inflammatory cells, and plasma. We also see the immune system releasing pro inflammatory cytokines to help with the response.

Understanding the neurogenic side requires understanding C fibers. C fibers, peripheral nerve components, are able to send information both towards the brain (orthodromic) and periphery (antidromic). The orthodromic impulses are the danger signals sent to the brain, whereas the antidromic impulses create inflammation via peptides such as substance P.  This release  leads to immune activity, capillary leakage, and increased enzymatic responses.

Aside from the above mechanisms, the periphery also has the ability to become hypersensitive by increasing the ease at which nociceptive fibers fire.  This increase can occur in transient receptor protein channels as well as ion channels.
All of the aforementioned changes are a normal protective mechanism that the body uses to keep us safe. Inflammation helps you heal, and ischemia prevents further tissue damage from occurring. What becomes problematic is when these processes, either by central regulation or potential re-injury, perpetuate.

Stop…Nerve Time

Nerves...You can touch them.
Nerves…You can touch them.

Nervous tissue, like all other tissue, can become injured or unhealthy. However, nerves do not necessarily have to hurt. In fact, cadaveric studies demonstrate that 50% of people who never complained of symptoms undergo connective tissue and nerve fiber changes at vulnerable places.  Moreover, 20-30% of the population has abnormally compressed nerve roots.

Like nociception, nerve sensitivity is neither necessary nor sufficient for a pain experience.

When a peripheral nerve is injured, changes occur at the injury site and centrally. Ion channels begin flooding the injured area, creating an Abnormal Impulse Generating Site (AIGS). These sites do not fire right away, but oftentimes after 3 to 21 days…quite a long time indeed.

The immune system also plays a critical role in neural sensitivity.  A peripheral nerve injury turns on local immune cells and encourages further cell recruitment toward the injured site.

What is crazy about these immune cells is that they can stay active for 25 years. So recurrent pains may not be re-injury, but a helpful survival tool. It’s the body testing the fire alarm.

Good thing yours works.
Good thing yours works.

So how does one treat these problems? The overarching goal is reduce threat by whatever the nervous system requires. This could include unloading structures, movement, education, drug therapies, etc.

Central Sensitization

With the CNS as the overall governor of our experience, it will create responses depending on the value of received inputs. A fixed response does not occur.

In central sensitization, we see an abnormal responses to the nociceptive system by altered sensory responses to inputs and increased pain sensitivity.  This state is most often present when pain occurs past normal healing duration.

There are three states in which the nervous system responds to information:

  • Input = output
  • Input > output (think injured athlete finishing a game)
  • Output > Input (folks with chronic pain)

The last option is the one we will deal with the most. Many changes occur to include decreased central inhibitory control, ion channel flooding by the immune system, C-fiber uncoupling and A-beta fibers (light touch) becoming nociceptive, inhibitory neuron cell death, and nociceptive fibers turning on more easily.

Dave gave us some key points on this condition to think about:

  • No diagnostic test can visualize these changes.
  • Deeper tissues injured lead to greater up-regulation.
  • Contributing factors (e.g. coping strategies) are strongly linked.
  • Sensitivity changes affect all outputs.
  • These changes are more reversible than previously thought.
  • Can occur instantaneously.
  • Tissues can heal though still be unhealthy.
  • Can see changes in 2-point discrimination.
  • Mirror pains may occur, which is an immune response.

Ya Other Systems

We have predominately been discussing the neuroimmune system, but realize multiple systems are involved in and respond to a pain experience. Our ultimate goal is to provide expressive freedom to these systems which creates better brain construction of all our experiences. 

Think motor freedom, pain freedom, output freedom.

Here are some different responses that various systems produce:

Emotions – Anxiety and fear to increase attention, vigilance, and pain intensity.

Thoughts – Nerve impulses that could elicit a threat response.

Sympathetic nervous system – Response system to get us out of trouble by affecting many systems; it is connected to almost every body tissue after all. It can increase inflammation, cause AIGS to fire, initiate an immune response, create nociception via vasoconstriction, and potentially be compromised at the thorax.

Endocrine system –  Working along with the sympathetic nervous system, the endocrine system produces ACTH via the hypothalamus in response to threats. This hormone stimulates the adrenal cortex to produce cortisol, which powers ups defensive systems necessary for survival and turns off unnecessary systems.

Parasympathetic Nervous System: Not much is known about this system, but it is thought to help with recharging and calming. With the heart as an exception however, the parasympathetic and sympathetic systems have discreet actions.
The vagus nerve is a major player here, and along with the hypoglossal nerve is linked to the immune system. These nerves accept immune compounds in the blood because they don’t have to deal with the blood brain barrier; allowing for easy access to the CNS.

Motor System: Chronic pain states are usually accompanied with unhealthy, unfit muscles that may be a nociceptive source. We can also see protective changes to include altered vocalization, muscle imbalances, spasms, and impaired recruitment.

The Immune System: The show of the course. Three components make up this system:

  • Innate: We are born with it (molded by it); kills microbes and stops infection
  • Adaptive – learns, recognizes, and remembers how to ward of disease and illness (immunizations).
  • Immune-like – Immune cells in the nervous system.
Ohhhhh...You think the immune system is your ally?
Ohhhhh…You think the immune system is your ally?

In relation to the nervous system, microglia in particular are capable of stripping synaptic connections and may play a role in learning. These compounds are able to move up to 3/4 of an inch to areas in need.

The immune system is also composed of pro inflammatory and anti-inflammatory components; the cytokines and chemokines. These cells are capable of increasing local inflammation, sensitizing AIGS, and decreasing opioid responsiveness. They also play a huge role in CNS plasticity, hence being a major component to learned behavior.

Therapeutic Knowledge Bombs for Patients

So with all the immense knowledge garnered previously, the challenge becomes teaching this information  in a patient-friendly manner.

Rarely do patients truly change their thought process when pain is explained. Dave mentioned that only 8% of patients will undergo a true conceptual change when learning pain science. So it is of utmost importance to tailor your educational style in a manner that the patient will understand and relate to.

The process begins right at the subjective. Let the patient talk and capture their story. This part will help you understand what the patient’s pain perception is like, and give you insight to where your education must focus.

The therapeutic process via both the patient and clinician is often communicated through metaphor. This method is oftentimes the only way patients are able to enrich our understanding of their experience. Knowing which metaphors a patient will use can provide options for educational strategies:

Simple metaphors

Example: “My knee is a rusty hinge.”

The Response: Don’t respond with a metaphor.

Embedded metaphors

Example: “Pins and needles” “Pelvic floor”

The Response: Have them flesh out the descriptors more. Or strengthen what they say. Instead of pelvic floor (something unchanging), call it a pelvic diaphragm (something always changing).

Ontological metaphors

Example: “It hurts like hell” “Pain is a killer”

The Response: these metaphors give abstract pain some structure. Help by telling stories and helping with goal setting (a better structure).

Orientational metaphors

Example: “The pain goes around” “My back has gone out.”

The Response: These are examples of disembodiment, so the goal is to get them to re-embody. Humor can be used here. Ask them “where did your back go?”

Invasive metaphors

Example: “There’s a knife in my back.”

The Response: An immunological response. Often there is a representation in the brain of a knife for example. Tell a story which lets them know these thoughts are unhealthy.

Prognostic metaphors

Example: “I’m riddled with arthritis.” “I’m ready for the scrap heap.”

The Response: These create a permanence to the condition. Let them know nothing is permanent in biology.

Disembodiment metaphors

Example: “It”

The Response: GMI to re-embody the individual. Also eliminate the good part/bad part dichotomy, as well as using “we’re” going to  do xyz. These can reinforce the disembodiment.

Therapeutic metaphors

example: “Motion is lotion”

How-to: make sure to add stories to give the metaphors context. Humor is also good because it provides an immune boost.

A Great Story Teller

There are many way to explain pain to patients, but stories are often the most common. Here were some of my favorites with one common rule:

If you can give one example, give two.

Favorite strategies:

  • Dermatomal pain: Show the dermatome map.
  • Mirror pains: It is an immune response to protect you.
  • Night pains: Blood pressure drops, so blood has a hard time entering capillaries.
  • Phantom pains: The brain has a template of the affected area.
  • Smudging: Think use it or lose it. The brain will change to look after you and help you do what you need to do.
  • Imaging issues: The kisses of time. We grow like trees, so branches don’t always grow straight.

And to finish this blog, I will show you in video format, two of my favorite explanatory stories:

Neurodynamic findings – The theratube trick works wonders

And one of my personal favorites, David’s drug cabinet.

Read with Dave

On Patients

  • “Meet the patient at their story.”
  • “What is the person trying to protect with chronic pain? What are they escaping from?”
  • “Humans are inhibitory animals.”
  • “Humans are not bilateral animals.”

On Pain

  • “Pain treatment, not pain management.”
  • “Take away the threat value of a defense.”
  • “All pain descriptors are metaphors.”
  • “Treating acute pain shouldn’t be different than chronic pain. What changes is the story.”

Sayings for patients

  • “Well done, that’s a great inflammatory response.”
  • “You little self-healer you.”
  • “Well done, what a great defense.”
  • “Well done, you’ve gotten the best protective response.”
  • “Nerves take up only 1/3 of space in the intervertebral foramen.”

On Therapy and movement

  • “Therapy is re-inhibition.”
  • “It’s easier to change brains than rotten shoulders.”
  • “Distraction disassembles the pain neurotag.”
  • “Anytime you can do a movement and look at it is analgesic.”
  • “Knowledge is the richest context you can offer movement.”
  • “Total-knee arthroplasty is only limited by nociception and swelling. You don’t need to jump on knees because you have full ROM after surgery.”
  • “Faulty movement can be caused by faulty knowledge.”
  • “Give a license to move.”
  • “Forward head posture is an avoiding posture.”
  • “Repetitive movements lift your body’s serotonin”
  • “You are immunotherapists.”

On the brain and body

  • “Your brain will change to look after you.”
  • “When we’re in trouble, our brains weigh the world and judge whether pain is appropriate.”
  • “Your body tells your brain about danger, not about pain.”
  • “The immune system knows who you are from experience and genetics. It will react when you are not you.”
  • “Performance is an output of the brain.”

Funny shit

  • “Alright duckies, grab this”
  • “Neuroimmune. Doesn’t that make your loins tingle?”
  • “Lorimer Moseley. He’s a smart little shit.”
  • “You’ve got the same number of neurons as Albert Einstein…You might want to tell patients that.”
  • [On a sprained ankle] “I had one of those. Worse than childbirth.”
  • “I’d rather a shark bite my ass off than a paper cut.”
  • “The only cure for pain is decapitation.”
  • “Trigger points are clearly cultural because you have way more than we do.” 
  • [On trigger points, which are AIGS] “Get the needles out of it.”
If you insist Dave.
If you insist Dave.

The Year of the Nervous System: 2014 Preview

It’s All Part of the Plan

And if you see my course schedule this year, the plan is indeed horrifying.

joker

I wanted to write a post today to somewhat compose my thoughts and plans for this year, as well as what I am hoping to achieve from the below listed courses.

Because of the course load and some of my goals for the year, I am not sure what my blogging frequency will look like. I have begun to pick up some extra work so I am able to attend as much con ed as I do.

Yes, this will be me from time to time for now.
Yes, this will be me from time to time for now.

The Amazon affiliate links that I don’t get money for because I live in Illinois simply cannot pay for classes :). I am just putting these links up here because I want to encourage you to read these books on your own. Use my site as a guide through them.

Big Goals

My biggest goal for this year is to successfully become Postural Restoration Certified (PRC), and my course schedule below supports this goal.

The amount that I use this material and the successes that have come along with it simply compel me to become a PRI Jedi. I see the PRC as a means to achieving this goal.

The application thus far has been quite time-consuming. There are a total of 3 case studies, 5 journal article reviews, and tons of other writing that has to be done. Couple that with studying the material, and I have had a very busy year.

I also hope this year to start offering some online training at some point. I do some personal training on my own in my free time (ha), and would like to extend my services to people who are not near me. This would come complete with a full skype evaluation and unlimited access to me via email for all your questions, comments, concerns, and complaints.  If anyone is interested, please contact me at cupplesperformance@gmail.com

This will NOT be you on my programs.
This will NOT be you on my programs.

Without further ado, here is the course list.

Course List 2015 aka “The Year of the Nervous System”

I have dedicated this year to maximizing my understanding of the most powerful way to get into my patients, here is the lowdown

January 17th-18th – PRI Pelvis Restoration, St. Louis, MO

Been so looking forward to this class. Here I hope to learn about decreasing extensor tone in those people who use it as their protective pattern. Extension is what gives us power in response to defend from threat, this course will help you turn it off when you need to.

February 8th-9th – PRI Cervical-Cranio-Mandibular Restoration, Pitman, NJ

There are several patients that I just seem to have a harder time with. People with neck pain are one of them. Moreover, there are some patients who I just can’t seem to get fully neutral from a PRI perspective. I am hoping to learn to what extent I can affect the neck and above to help my patients achieve better function.

February 15th-16th – Explain Pain, Atlanta, GA

I have already taken this course once, but the man, myth, and legend David Butler is teaching this version. EP is his baby, his muse. If I won’t ever be able to see Led Zeppelin live, interacting with Butler would be the next best thing.

Total rockstar in my eyes.
Total rockstar in my eyes.

March 1st-2nd – Therapeutic Neuroscience Education: Educating Patients About Pain, Naperville, IL

I have been fortunate enough to chat with Adriaan on multiple occasions, and have the pleasure of hosting him where I work. It will be nice to get his perspective towards pain education. Adriaan was who I took Explain Pain with, and I will be curious to see how his thought process has changed since a couple years ago.

March 29th-30th – PRI Postural Respiration, New York, NY

Another re-take course for me. But this time, I have much more experience with the system. I hope my understanding will be so much more enriched. Plus, I get to learn it from Ron. Anytime you can learn from this man please do.

April 26th-27th – PRI Vision, Grayslake, IL

The motor system is not the only thing that can put up defense mechanisms in response to threat. The visual system changes as well, and in many cases can drive one’s protective postures. I need to know why and how.

May 2nd-4th – Dermoneuromodulation, Chicago, IL

The skin is such a sensory-rich organ that I need to learn more about it. And who better to learn it from then the master-ectodermalist Diane Jacobs. I have yet to take a true hands-on course, and if I can learn a pain-free way into the nervous system, then sign me up.

Hopefully I can teach her some therapeutic Microsoft paint techniques in return 🙂

True dat
True dat

June 7th-8th – PRI Integration for the Home, Lincoln, NE

Sometimes the PRI movements can be very challenging for those who are older. I want to know how my man James Anderson gets this population to perform at the high level he does. I want the baked goods!

Also during this week I plan on netting some observation time at the Hruska clinic. Details to follow.

August 9th-10th – PRI Myokinematic Restoration, Indianapolis, IN

I took this class last year, and want to be as prepped as possible for the PRC. Besides, Indy is my Mecca. I have so many good friends there that I cannot pass up a chance to hang at IFAST.

October 18th-19th – Neurodynamics and the Neuromatrix, Buffalo, NY

With two rounds of Explain Pain and Mobilisation of the Nervous System under my belt, what better way to put the classes together? Plus I am hoping to get my man Erson Religioso to come so we can hang out (hint hint).

November 1st-2nd – NOI Clinical Applications: Lower Limb and Lumbar Spine, Chicago, IL

I am going to this one mainly to cleanup my techniques and though process, as well as learn a little more about the less talked about nerve tracts (that darn saphenous nerve).

November 21st-22nd – PRI Integration for Baseball, Clearwater, FL

Florida in November…no brainer 🙂

But seriously, getting little snippets throughout my previous classes about what they will be teaching here has me intrigued.

Most of PRI deals with gait, which if we talk DNS is a contralateral pattern. Here my understanding is how PRI will approach the ipsilateral patterns. They will also introduce a test for the thorax, hopefully giving me a nice adjunct to the Hruska Adduction lift test.

December 4th-9th – Advanced Integration and PRC testing, Lincoln, NE

AI was such a game changer for me this year that I cannot wait to take it again. There are so many nuances I want reinforced and so many questions answered.

Moreover, the PRC test is going to happen, and learning in close proximity with Ron, James, and Mike is an opportunity I simply cannot pass up.

C’est Fini

So there’s the plan for this year. What thoughts do you have? What’s on your con ed radar for the year? Comment below.

What I use to find the best con ed courses there are.
What I use to find the best con ed courses there are.

The Post Wonderful Time of the Year: Top Posts of 2013

The Best…Around

Time is fun when you are having flies. It seems like just yesterday that I started up this blog, and I am excited and humbled by the response I have gotten.

Hearing praise from my audience keeps me hungry to learn and educate more.

I am always curious to see which pages you enjoyed, and which were not so enjoyable; as it helps me tailor my writing a little bit more.

And I’d have to say, I have a bunch of readers who like the nervous system 🙂

Like porn for my readers.
Yeah, it’s pretty cool

I am not sure what the next year will bring in terms of content, as I think the first year anyone starts a blog it is more about the writing process and finding your voice.

Regardless of what is written, I hope to spread information that I think will benefit those of you who read my stuff. The more I can help you, the better off all our patients and clients will be.

So without further ado, let’s review which posts were the top dogs for this year (and some of my favorite pics of course).

10.  Lessons from a Student: The Interaction

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Actually, I have found I now have more success setting up my interactions like this.

This was probably one of my favorite posts to write this year, as I think this area is sooooooo underdiscussed. Expect to be hearing more on patient interaction from me in the future.

9) Clinical Neurodynamics Chapter 1: General Neurodynamics

Any post with Predator in it has been shown to increase T levels by 300%
Any post with Predator in it has been shown to increase T levels by 300%

Shacklock was an excellent technical read. In this post we lay out some nervous system basics, and why we call neurodynamics what we call it.

8) Course Notes: Graded Motor Imagery

Drawing skillz unparalleled.
Drawing skillz unparalleled.

It seems like I took this course forever ago, but reviewing this post reminded me why I love the NOI group so much. I feel as though their message is one you cannot get enough of.

As for GMI itself, I find that it is great for people who most every movement hurts, as well as an educational piece. From a PRI perspective, it is also useful. I have had patients imagine contracting their glute max and go neutral. Crazy stuff.

7) Explain Pain Section 6: Management Essentials

I totally recall how awesome this post was...Just see the movie
I totally recall how awesome this post was…Just see the movie

Hopefully after following this blog you have a better understanding of pain than the average bear, so here are some basic ways we can manage the pain experience.

6) The Sensitive Nervous System Chapter III: Pain Mechanisms and Peripheral Sensitivity

When I see someone stub their toe, I'm not thinking a stubbed toe.
When I see someone stub their toe, I’m not thinking a stubbed toe.

One of my very first posts, so maybe a Cupples classic?

Anyway, here we explore in great detail what nociception and peripheral neuropathic pain are; and why you should go to the emergency room when you stub your toe 🙂

5) Course Notes: PRI Myokinematic Restoration

Because why not?
Because why not?

I am very glad this post got many views, as I feel the message these guys send is some of the best on the market. Here is PRI 101, and expect to hear a lot more about their work this upcoming year.

4) The Sensitive Nervous System Chapter VIII: Palpation and Orientation of the Peripheral Nervous System

There was a time in which I didn't post funny pics...Besides, who doesn't like Led Zeppelin?
There was a time in which I didn’t post funny pics…Besides, who doesn’t like Led Zeppelin?

One underrated way to assess the nervous system is via palpation. You can get a lot of interesting responses on people. Here we learn how.

3) Clinical Neurodynamics Chapter 2: Specific Neurodynamics

I really feel like my artistic endeavors became their own once I started drawing in color.
I really feel like my artistic endeavors became their own once I started drawing in color.

In this post we learn a lot of local nervous system tidbits, and more information on my future Therapeutic Microsoft Paint Course 🙂

2) Course Notes: Mobilisation of the Nervous System

That my writing pace has slowed down.
That my writing pace has slowed down.

Such a great class. Here we see updates to the science behind “The Sensitive Nervous System”, as well as some neat tweaks to our neurodynamic testing. My favorite pieces were on the immune system and genetics.

1) Explain Pain Section 1: Intro to Pain

Because what's a post on my site without a Bane reference?
Because what’s a post on my site without a Bane reference?

This section could be a manifesto for this blog. Learning and understanding pain has been one of the biggest game changers for me as a clinician and writer.

Simply put, if you work with people in pain, this section is a must-read.

C’est Fini

So there you have it. Which posts were your favorite? Which would you like to see more/less of? Comment below and let a brother know.

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Course Notes: Mobilisation of the Nervous System

I Have an Addiction

It seems the more and more that I read the more and more and read the more and more addicted I become to appreciating the nervous system and all its glory. To satisfy this addiction, I took Mobilisation of the Nervous System with my good friend Bob Johnson of the NOI Group.

This was the second time I have taken this course in a year’s span and got so much more value this time around. I think the reason for this enrichment has been the fact that I have taken many of their courses prior and that I prepared by reading all the NOI Group’s books. A course is meant to clarify and expand on what you have already read. So if you are not reading the coursework prior, you are not maximizing your learning experience.

This really isn't too far off from how I feel regarding reading at this point.
This really isn’t too far off from how I feel regarding reading at this point.

What made this course so much more meaningful was being surrounded by a group of like-minded and intelligent individuals. As many of you know, I learned much of my training through Bill Hartman. Myself, Bill, the brilliant Eric Oetter and Matt Nickerson, my good friend Scott, and my current intern Stephanie, all attended. When you surround yourself with folks smarter than you, the course understanding becomes much greater. This course was so much more with the above individuals, so thank you. Try to attend courses with like-minded folks. Here are the highlights of what I learned. If you would like a more in-depth explanation of these concepts, check out my blogs on “The Sensitive Nervous System.”

Neurodynamics, Clinical Reasoning, and Neuroscience

When discussing clinical reasoning and neuroscience, we have to discuss processing. The pain processes are what we end up treating in rehabilitation, so we have to know where our patient’s problem occurs along the process:

  • Input – Issues in the tissues; typical therapeutic approaches.
  • Processessing – How the brain interprets inputs.
  • Output – The experiences and emotions we feel.

Processes, as opposed to structures, are what we really treat. We can define processes as changes in the physiology. These changes can include degeneration, ischemia, stiffness, inflammation, etc.

The T800 cat sums motor learning up nicely.
The T800 cat sums motor learning up nicely.

In terms of inputs, the two types of input processes that may lead to a pain mechanism include nociception (the firing of A delta and C fibers from tissues) and peripheral neuropathic (involving the neural tissues outside the dorsal horn). The above mechanisms have predictable stimulation responses.

Understand that all injuries to structures are the same, but the context and environment affect processing and output. We have all experienced this phenomenon. A paper cut can hurt like hell, but a cut from a branch while hiking in the forest may not even be noticed. Context makes all the difference.

The pain mechanism related to processing occurs in the central nervous system. With processing problems, the stimulation-response relationship is unpredictable. Thoughts, feelings, past experiences, knowledge, and other states can affect responses here. These components are designed to help us survive our environment.

Lastly, there are several outputs related to pain mechanisms. These outputs involve all our body systems, with the central nervous system acting as the driver.

You tellin' me pain doesn't come from the brain? You tellin' me?
You tellin’ me pain doesn’t come from the brain? You tellin’ me?

All these pain mechanisms–input, processing, and output—are involved in some way during a pain state or sensory alteration. One can be more dominant than the others, but all areas are active. It is similar to energy systems. The aerobic, lactic, and alactic energy systems are always active with one often as the primary driver. So too are the involved pain mechanisms.

Genetics

Often, genetics is the biggest contributing factor to chronic pain development. It is strongly hereditary, like having blue eyes. Here were some values given in the course as to what percentage of pain is genetic:

  • 50% of migraines.
  • 55% of menstrual pain.
  • 35-68% of lower back or neck pain.
  • 50% of shoulder and elbow pain.
  • 40% of pain with carpal tunnel syndrome.

The Nervous System is a Continuum

The nervous system is one of three continuous systems, the other being vascular and fascial. If you move the nervous system at any one place, the entire system moves. It is like moving a tree branch and creating motion throughout the whole tree. Continuum concepts cannot be enhanced by tissue dominant approaches.

There are four ways in which the nervous system is continuous:

1)      Mechanically

2)      Electrically

3)      Chemically

4)      Emotionally

Discussing nerves often puts people at unease. However, this feeling should not be the case. Nerves are like any other tissue. Therefore, they live under the same rules as all other tissues. They can bend, twist, and slide transversely. Nerves can also take on increased pressure by loading.

You can even get your nerves with lotion.
You can even get your nerves with lotion.

This interconnected quality often confounds traditional segmental-based testing such as myotomes and dermatomes. The nervous system ought to be thought of instead as a continuous piece with multiple reference points.

Moreover, everyone has a different nervous system. Therefore, each person may require a different sequence when performing neurodynamic tests.

Ion Channels

Ion channels are the molecular targets for manual therapy. These channels go where no myelin is present:

  • Dorsal root ganglion
  • Nodes of Ranvier
  • Injured nerve

There are six points to describe these ion channels:

1)      They are proteins with holes in the middle.

2)      They have holes that open or close.

3)      Some stay open for longer.

4)      There are different kinds of channels.

5)      They have a half-life of 2-7 days.

6)      They represent needs and perceived needs.

Neurodynamic Testing

I will not go over all the neurodynamic tests in this post, but there were some different variations that I liked in this course compared to what I was doing. The biggest thing when performing these tests is to have a consistent starting position every time. And if you are doing a straight leg raise, pay attention to potential responses on the contralateral leg.

Here is a radial neurodynamic test…proximal to distal style.

Nociceptive Highlights

The biggest thing that I got out of the nociception section involved inflammation. First off there are two types of inflammation:

1)      Non-neurogenic – occurs with tissue damage; creating bleeding and fluid buildup. NSAIDs work well on non-neurogenic inflammation.

2)      Neurogenic – Created via C-fibers, which is driven by changes in peripheral tissues and threat perception. It can occur even if the nervous system was not fully involved in the injury. Pregabalin,Gabapentin, Cymbalta, and other similar drugs work well with these.

Peripheral Neuropathic Highlights

Injury to peripheral nerves involves blood flow, axoplasmic flow, and development of abnormal impulse generating sites (AIGS) along the nerve. There are also three different issues that can occur in the nervous system:

  • Physiologic conduction blocks – local circulatory changes
  • Neuropraxia – Local conduction block where axon is okay and conduction returns in weeks to months.
  • Axonotmesis – Axon continuity loss with intact endoneurial tubes; Wallerian degeneration occurs.

Central Sensitivity Highlights

It is important to understand with central sensitization is that it occurs with all injuries. The difference between those with and without chronic pain is that the sensitivity stays turned on.

The CNS utilizes opiate components to combat nociception. There are three major endogenous opioids produced in the central nervous system to create an anti-nociceptive response:

  • Endorphins – produced in the periaqueductal gray matter
  • Enkephalins – Produced in the Nucleus raphe magnus
  • Dynorphins – produced in the spinal cord.

There are also exogenous opioids, which include epidurals, TENS units, and counter-irritants. However, if the endogenous piece is not present first, these opioids will not work.

Arguably the most important part of the entire course was Bob’s talk on the immune system and glia. Research is starting to show that glia runs the central nervous system. They are the gate and clean up synapses. Inflammation can activate glial activity via the vagus nerve, and when glia activates are opioid systems become much less effective. Nitric oxide is also released, which can sensitize receptive fields in the periphery.

Glia is going to be really sexy in the next 10 years I bet.
Glia is going to be really sexy in the next 10 years I bet.

A Side Note

One area that I struggle with in pain education is patients who either dislike pain or have huge functional changes but still have some pain. Bob suggested with these folks that this problem deals with the patient’s beliefs. The best thing to do is to talk around the beliefs or find methods to get them to detach from the pain. This could involve meditation or other similar outlets.

Great Bob Johnson Quotes

  • “Pain is your brain loving you too much!”
  • “Spreading pain is connecting the dots in the nervous system.”
  • “We are good at gathering data, but we are not good at determining what is relevant. Gather the data and make it tell a story.”
  • “Ask the patient what they think the issue is.”
  • “Showing the patient how they are better is a central component.”
  • “All we do is move people.”
  • “We want pain freedom, not pain control.”
  • “If I save a patient a day, I did something good.”
  • “When you treat the container, you treat the nervous system.”
  • “Sensitivity is plastic.”
  • “A 30-35 degree SLR is needed for normal gait.”
  • “We rarely see true nerve root compression.”
  • “Sliders are like grade I & II mobilizations.”
  • “Nerves love space, movement, and bloodflow.”
  • “Cardiovascular health has everything to do with nervous system health.”
  • “The better cardiovascular fitness, the less pain people with chronic pain have.”
  • “Most patients have a spinal component to a peripheral piece.”
  • “Beliefs are a big deal.”
  • “A biochemical memory is left in the tissues…An immune marker.”
  • “Movement is Wolff’s law for the nervous system.”
  • “The pattern of central sensitivity is no pattern.”
  • “Everyone needs an apology.”
  • “Ask the patient what they think.”
  • “We are here to change your behaviors.”
Use the bear rug apology as a last resort.
Use the bear rug apology as a last resort.

 

Explain Pain Section 6: Management Essentials

This is a summary of section 6 of “Explain Pain” by David Butler and Lorimer Moseley.

Management 101

The most important thing you can understand is that no one has the answer for all pains. Pain is entirely individualistic, hence requiring different answers. There are several strategies which one can undertake to triumph over pain.

Tool 1: Education

Knowing how pain works is one of the most important components to overcoming pain. Instead of no pain, no gain, the authors like to use “know pain, or no gain.” Understanding pain is essential for squashing fear of pain, which leads best toward the road to recovery.

Here are some important concepts to be known about explaining pain.

  • Anyone can understand pain physiology.
  • Learning about pain physiology reduces pain’s threat value.
  • Combining pain education with movement approaches will increase physical capacity, reduce pain, and improve quality of life.
And I mean anyone.

Tool 2: Hurt ≠ Harm

It is important to understand that when someone feels pain it does not equate with damage. The same can be said with recurring pains. These pain types are often ways to prevent you from making the same mistake twice. If your brain sees similar cues that were present with a previous injury, the brain may make you experience pain as a way to check on you and make sure you are okay.

Just because hurt does not mean harm does not mean you can get crazy though. Because the nervous system is trying to protect you, it will take drastic measure to prevent re-injury. Therefore, the best option is to gradually increase activity levels without pressing past the nervous system’s threshold.

If only there was a neurosignature that helped me stop drinking Redline. So bad yet so good.

Tool 3: Pacing & Graded Exposure

All the body tissues are designed for movement, therefore this is how we will increase activity. Here are the steps to pacing and graded exposure.

  1. Select an activity you want to do more of.
  2. Find your baseline – The amount of activity you can do that you know will not cause a flare-up. A flare-up is an increase in pain that leaves you debilitated for hours to days.
  3. Plan your progressions.
  4. Don’t flare up, but don’t freak out if you do.
  5. It is a lifestyle change, requiring a little bit more planning.

Take walking for example. Suppose you know you could walk for 5 minutes, but if you did 7 you would pay for it over the next couple days. You might walk for 5 the first day, then 5:15. Eventually, you would work up to past 7 minutes, then so on and so forth.

Access the Virtual Body

Just like the body, the virtual body can be exercised as well. Ways to work on the virtual body are as follows:

  1. Imagine movements – a la graded motor imagery.
  2. Alter gravitational influences or surfaces.
  3. Add varying balance challenges.
  4. Vary visual inputs – Eyes closed challenges the virtual body even more. Use a mirror to give the brain visual input and further decrease threat.
  5. Alter the activity environment.
  6. Move in different emotional states.
  7. Add distractions.
  8. Perform the desired movements in functional activities.
  9. Break down functional movements.
  10. Perform sliders.
  11. Perform movements with the surrounding tissues in relaxed positions that do not hurt.
  12. Work out of your glitches – If you walk with a limp from an ankle you sprained in 1962, try changing how you walk.
  13. Let your mind go.
Open your mind…Open your mind.

Explain Pain Section 3: The Damaged and Deconditioned Body

This is a summary of section 2 of “Explain Pain” by David Butler and Lorimer Moseley.

Tissue Injury 101

When a body is damaged, pain is often the best guide to promote optimal healing. Sometimes it is good for us to rest, other times it is better to move.

A similar healing process occurs for all tissue injuries. First, inflammation floods the injured area with immune and rebuilding cells. This reason is why inflammation is a good thing in early injury stages.

A scar forms once the inflammatory process is over. The tissue then remodels to attempt to become as good as the original. Blood supply and tissue requirements determine how fast the healing process occurs. For example, ligaments heal much slower than skin because the former has a lower blood supply than the latter. This may also be a reason why aerobic exercise may speed up the healing process.

If present, pain usually diminishes as the tissues heal. However, pain may persist if the nervous system still feels under threat.

Acid and Inflammation

The alarm sensors described here constantly work and often get us to move. Movement keeps our system flushed. When we don’t move or a physical obstruction is present (e.g. sitting), acid and by-products build up in the body tissues. Oftentimes we will start to feel aches and pains when we stay in a prolonged position, which is our body’s way of saying “get up and move.”

Much like the alarm system, inflammation is a primitive way for our body to continue the healing process. Inflammation is designed to hurt so the injured area has time to heal. There is no need to fret when swelling, redness, and pain are present; our internal systems are merely repairing us.

Not so bad after all!

We call swelling and its corresponding cells the “inflammatory soup.” This soup is a by-product of blood and chemical transportation, and sets off our body’s alarm system to increase sensitivity. All of these changes are essential to facilitating a healing environment.

Muscles

Everybody be hatin’ on muscles nowadays as the source of our aches and pains. However, the authors put muscles in perspective for us with the following points.

  • Muscles are loaded with sensors, so can impact the pain experience.
  • Muscles can become unhealthy and weak.
  • Muscles are very difficult to injure, they are just very responsive structures.
  • Muscles are well vascularized which allows for quick healing.
  • Muscle activity alters in response to threat and injury.
  • Muscles reflect what our brain is thinking.
Truf
Truf.

The Artist formerly known as disks – LAFTs

The reason the authors wish to change the name of these structures is because anatomically they do not resemble a disk at all. The new name is “living adaptable force transducers,” or LAFTs.

LAFTs are made up of the same material as your ear, and contain some very strong ligaments. In the medical world, we have many different treatment modalities that target the LAFT. We have McKenzie, traction, surgery, and injection to name a few. Because there are so many different treatments for these structures, it is fair to say that LAFT injuries are still not fully understood.

LAFTs also come with very strong language: slipped, bulging, herniated. Using such strong language can stop someone from moving, which is far from the ideal regarding low back pain.

Here are some LAFT facts.

  1. The LAFT outer layer has a nerve supply, so danger sensors can become activated easily. If the LAFT becomes injured, the surrounding structures will likely set off danger sensors as well. You want a lot of danger sensors if something is occurring near the spinal cord. It is kind of a big deal.
  2. LAFT injuries usually do not cause instant pain. Pain usually occurs 8-12 hours later.
  3. LAFTs naturally degenerate and do not have to contribute to a pain experience. At least 30% (and potentially up to 80%) of people without low back pain have LAFTs bulging.
  4. LAFTs never slip.
  5. LAFTs heal slowly, but they will always be a bit tatty around the edges. This attribute makes it hard to distinguish aging from injury.
  6. LAFTs, spinal joints, and nerves are built to withstand high forces.

Skin and Soft Tissues

Our knowledge of pain is based predominantly on the skin. The skin mirrors the nervous system’s state. Rarely is the case that skin injury leads to chronic pain however. On the flipside, painful skin zones; changes in skin health; and altered sweating or hair growth can all be indicators of damaged nerves.

How often have you seen or had your skin become increasingly sensitive to touch after an injury? This is a common phenomenon that occurs because cutaneous nerves increase sensitivity in order to protect an injured area. Here are some other skin and soft tissue facts.

  • Damaged skin heals very quickly.
  • Skin has a high danger sensor density.
  • Skin is very mobile and loves movement.
  • Fascia is a strong tissue that lies under the skin and also contains many danger sensors.
  • Massage moves tissues and sends impulses to the brain. Therefore, movement and touch are great ways to refresh the virtual and actual body.
Love skin, just not too much.

Bones and Joints

Most joints have lining known as synovium which keeps the joint contained and lubricated. This lining is loaded with danger sensors. Here are some other facts.

  • Joint pain seems to be dependent at which the speed damage occurs. Slow changes usually do not make the brain think there is danger. A dislocation however may lead to severe pain. Most people with worn joints never know about it.
  • Everyone has worn joints as we age. They are the wrinkles on the inside.
  • Joints love movement and compression.
  • Broken bones heal and are often stronger than before.
  • Joints in the back and neck can get injured, but may be too small to see on imaging. This may or may not set off the alarm bells.

Peripheral Nerves

Most of today’s neuroscientists agree that peripheral nerve problems are far more common than we think. Here are some fun facts regarding nerves.

  • Nerves have danger sensors.
  • Neurons can contribute to pain.
  • If a nerve becomes injured, it may become more sensitive to ensure you survive.
  • Nerves slide as we move. If a nerve cannot slide well, pain may occur while moving.
  • Nerves change as we age, just like everything else in our bodies.
  • Scans and nerve conduction tests cannot easily identify a damaged nerve.
  • Nerves can be injured but may not create a danger message for days to weeks.

The Dorsal Root Ganglion (DRG)

The DRG is like the brain of the peripheral nervous system. This is the first place that tissue messages are evaluated. Here are some facts for DRGs

  • Peripheral nerves have their nucleus in the DRG. It is here that sensors are made.
  • The DRG is extremely sensitive and changeable.
  • The DRG is very sensitive to blood chemicals, especially stress chemicals.
  • Sometimes the DRG fires just because. It is like your body’s car alarm. Sometimes the DRG can be hurt without having any pain too.

Backfiring Nerves

When a nerve is injured, oftentimes it will backfire. The reason for this is like a domino effect. If a nerve is stimulated at one end, it will send messages up the system to go to the other end.

Backfiring may not be an issue for the short term, but its persistence can lead to sustained inflammation. A less sensitive nervous system may lessen the amount of inflammation in the tissues.

Nerve Pain

Here are the common symptoms associated with peripheral nerve pain.

  • Pins & needles.
  • Burning.
  • Night pain.

Here are potential locations

  • Skin zones supplied by the damaged nerve.
  • Small sensitive hot spots known as trigger points.

There are also some other potential qualities

  • Movement often makes it worse, so you may adopt abnormal postures for relief (upper cross, elevated shoulders).
  • Stress makes it worse.
  • Unpredictable zings may occur.
  • Movement or a sustained posture may ignite an injured nerve which keeps ringing.
  • May not hurt for a few days or weeks.
  • Skin zones may become itchy.
  • Might just feel weird.

Just because you feel these symptoms does not mean it is the end of the world. Understand that nerves are just responding to signals from the brain that tell them to increase sensitivity and improve warning capacity.