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

Read More

Master the Fundamentals of PT, Neurodynamic Tricks, & Check Your Ego – Movement Debrief Episode 7

Episode 7 of the Movement Debrief (aka The Movement Awakens) occurred last night. I can only imagine how devastated you are that you missed it. But hey, though I think it’s way more fun live, I have a copy of the video below, where we discussed the following topics: Why fundamental PT skills are still relevant Why the basic clinical exam is incredibly important Determining if you can or cannot help your patients A simple trick to making any movement a neurodynamic test Doing what is best for the patient, not your ego or agenda If you want to watch these live, add me on Facebook or Youtube. They air every Wednesday at 8:30pm CST. Enjoy. Master the Fundamentals of PT Neurodynamic Tricks Check Your Ego

Read More

Movement Debrief Episode 1: Meet the Patient at Their Story

A Live Movement Video Series Hey party people. I recently started doing some live feeds on the interwebz. You can check me out on Facebook and Youtube if you want to see me live. Otherwise, I thought I’d share with the very first episode of “Movement Debrief.” Here we dive into the following topics: The importance of reflection Using similar language to the patient. De-threatening that language Restoring sagittal plane control A case for manual therapy Enjoy!

Read More

Manual Therapy Musings

When I think About You… Prompted by some mentee questions and blog comments, I wondered where manual therapy fits in the rehab process. To satisfy my curiosity, I calculated how much time I spend performing manual interventions. Looking at last month’s patient numbers to acquire data, I found these numbers based on billing one patient every 45 minutes (subtracting out evals and reassessments): Nonmanual (including exercise and education) = 80% Manual = 20% Modalities = 0%!!!!!!!!!!!! Delving a bit further, here’s my time spent using PRI manual techniques versus my other manual therapy skill-set: PRI manual = 14% Other manual = 6% As you can see, I use manual therapy a ridiculously low amount; skills that I used to employ liberally with decent success There’s a reason for the shift I want my patients to independently improve at all cost and as quickly as possible. The learning process is the critical piece needed to create necessary neuroplastic change; and consequently a successful rehab program. Rarely is learning involved in manual therapy.

Read More

Course Notes: Spinal Manipulation Institute’s Dry Needling 1

You Mean Zac Didn’t go to a PRI Course? Yes. From time to time I occasionally take a gander at what else is out there in PT land. It was probably about time I check out this whole dry needling thing and see what the fuss is about. I took the Spinal Manipulation Institute’s version based on some recommendations from a few colleagues I trust. Ray Butts was MC’ing for the weekend. I know needling is quite the controversial topic, but I was amazed at the sheer quantity of evidence supporting this modality. Like, an insane amount. I am not sure what the “haterz” found their criticisms on, so please comment if you have some ammo (I am a noob to this after all). And Ray’s lecture on dry needling mechanisms? Oooohhh lawwwwd. Easily one of the best foundational science lectures I have ever heard. Period. The passion this group has not only for science but the physical therapy profession is inspiring. They made me excited to be a PT. Perhaps even inspired me to contemplate the PhD route. All that said, I am unsure as to where needling will fit into my practice. The assessment that would point you toward needling someone was sorely lacking. I’ve noticed this problem to be quite common in manual therapy courses. It’s pretty much you hurt here/have this diagnosis, then use this protocol.

Read More

It’s the Salient Detection System, Stupid

 Can you tell the difference among pain, depression, and pleasure? From a neurotransmitter perspective, the answer is no (see here and here). How is it that three very different states can be so neurologically similar? I feel the commonality that the nervous system purports reflects a system that responds to stimuli that are deviations from the norm. We call these instances by this word: Salient. Doesn’t that make your loins quiver? Let’s discuss how it works. Here’s your recommended reading. 1. The pain matrix reloaded: a salience detection system for the body (Thanks Sigurd) 2. Stress signalling pathways that impair prefrontal cortex structure and function (Thanks Son) 3. From the neuromatrix to the pain matrix (and back) [Note: Most of this article is an amalgamation of the three articles that I cited above and my own thoughts. Rather then cite every sentence AMA-style, I’ll give the credit to these guys above. Read ‘em and figure out how I put this together. For those who are sticklers for proper reference formatting, the type I am using is KMA-style citation.*] The Pain Neuromatrix Myth Hate to break it to you, but pain ain’t so special. Here’s why. If you follow modern pain science, you may often hear the term pain neurosignature or neurotag. This phrase is meant to describe a cluster of brain areas that are active during a pain experience. Information that can contribute to a pain experience travels to several areas. Some of the big players are the primary and secondary somatosensory cortices (all the

Read More

9 weeks with Bane, I mean Zac…Oops Sorry Wrong CI

Note from Zac: This is my first guest post, and to start things up is the one and only Trevor Rappa. Trevor was my intern for the past 9 weeks and he absolutely killed it. Here is his story. It’s very exciting for me to get to write a guest post for Zac’s blog that I have read so many times and learned so much from. The experience I have had with him over these past 9 weeks has been incredible and I hope to share some of it with all of you that read this. He challenged me to think critically in every aspect of patient interaction: how I first greet them, which side of them I sit on, the words I use, and how I explain to the patient why I chose the exercises they’ll go home with. All of this was to create a non-threatening environment to help to patient achieve the best results they can. He also taught me how to educate patients with a TNE approach, incorporate other interventions such as mirror therapy into a PRI based treatment model, and deepened my understanding of the neurologic concepts behind performance. Therapeutic Neuroscience Education Perception of threat can lead to a painful experience which will cause a change in behavior. It’s the PT’s role to introduce a salient stimulus to attenuate the perception of threat in order to cause a positive change in experience and behavior (Zac and I came up with that, I really like it). Pain

Read More

Favorable Inputs: A Model for Achieving Outcomes

One Hot Model  Louis Gifford’s Topical Issues in Pain has an amazing amount of quality information, and has really inspired many thoughts. I’ve only read book 1 thus far, but this book can generate material to expand upon much like Supertraining does for fitness writers. I’m sure many of you folks have seen this picture before. Gifford called this schematic the “Mature Organism Model” (MOM) to illustrate how pain works. Inputs from the tissues and the environment travel up the spinal cord to the brain. The brain processes these inputs and samples information from itself to generate a corresponding output. These outputs are perceived as new inputs which reset the cycle. MOM was of course used to illustrate the three pain types (read here and here), but it is so much more than that. The MOM is a schematic for how the nervous system works. Any input that is processed by the brain may or may not lead to outputs of altered physiology and/or behavior. Viewing (your) MOM (ha) made me think a lot about working with individuals who are dealing with a threat response. How exactly are we helping these folks? I’ve come to believe that we do not treat outputs. At best we can only provide inputs that we hope are exchanged for new, desirable outputs. In patient care, we are hoping to alter perceived threat. We attenuate threat by giving an individual favorable inputs, which we hope leads to favorable behavior and physiological changes. Let’s look at what these

Read More

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 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 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 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 I love a good foundational course taught by the Ronimal. You always get a few easter eggs that allude to

Read More

Post 100: Sexifying Upper Quadrant Post-Op

I Wrote a Lot It’s interesting to think how much this blog has changed since I started writing in February 2013. We’ve gone from cliff notes of books, to cliff notes of courses, to the occasional self-musing. While I still plan on reviewing and assimilating courses I take, my hope is to expand and reflect upon whatever is in my brain a smidge more. It makes sense to start this trend with post 100. And today, postoperative care is piquing my interest.   Yes, post-op intervention is a guilty pleasure of mine. And it’s not because it’s easy. Far from easy. Post op treatment gives you a license to create under various constraints. Meaning you have to dig a little deeper to achieve desired goals. I think it can be way sexier, and effective, than your typical post-op protocol BS. So let’s create some successful post-op fun. The First Constraint Before we even talk about specific patients, we have to first look at the largest constraint yet: available tools. At my current digs, I don’t have much of anything in terms of heavyweights. So here is what I have at my disposal that I can implement: 1-on-1 care for 60 minutes Kettlebells: 10, 15, 25 pounds Therabands and theratubes of various sizes Cook bands of various resistances PRI trial orthotics (mouth splints, arch supports, reading glasses, yada) Steps Tape IPAD 3D stretch cage (aka very expensive equipment to tie therabands to) Access to higher level brain centers Heart of gold

Read More

The End of Pain

I’m Done Treating Pain. Yes. You read that correctly. I’m over it. Several different thoughts have crept into to my mind sparked by what I have read and conversations I have had. I would like to share these insights with you. I remember when I was visiting Bill Hartman Dad a few months ago and we were talking about a specific treatment that is quite controversial in therapy today. He said something that really resonated with me: “Maybe they measured the wrong thing.” This sentiment was echoed in “Topical Issues in Pain 1” by Louis Gifford. Check out this fantastic excerpt: “Thus, pain can be viewed as a single perceptual component of the stress response whose prime adaptive purpose is to powerfully motivate the organism to alter behavior in order to aid recovery and survive.” Notice what I bolded there. Pain is a single component of the stress response. Not the stress response. Not a necessary component of the stress response. Just one possibility. Why do we place so much importance on pain? Many proponents of modern pain science (myself included) often use this statement against individuals who are over-biomedically inclined: “Nociception is neither necessary nor sufficient for a pain experience.” Agreed, pain is not always the occurring output when nociception is present. That said, pain is only one of several outputs that may occur when a tissue is injured. Just because pain is absent does not mean other outputs are also absent. Many different outputs can occur when an individual is

Read More

A Fly on the Wall of the Hruska Clinic

The Saga Continues  This post is way overdue, but a lot has been going on in life. I have just moved to Arizona to start anew, and the change is bittersweet. The Midwest is all that I have known for the past 27 years. I’m leaving a lot of loved ones behind that I will miss dearly. However, getting out of the Midwest to a warmer place has always been a dream for me, and I finally got that opportunity. I also get to work at an awesome clinic alongside like-minded clinicians. One of my good friends will even be there. Plus, summer forevaaaaaaaaaaaahhhhh!!!!!! So with this transition in my life marks a good time to reflect on one of my many experiences at the Hruska Clinic. This time, I will show you how the clinic itself operates. And their operation is a beautiful thing. The General Feel You walk in the door and can immediately shift into your left hip. That’s what this place is like upon entering. With various shades of purple and tan, you just feel at ease being there. It screams parasympathetic. This build was no accident of course. Purple is a calming color, giving those at the clinic a huge home-field advantage. I bet there is also a reason why you walk left to check-in at the front desk. The clinic is an interdisciplinary dream. The staff includes 5 physical therapists, an optometrist, a dentist, and a podiatrist. This setup allows for great communication among

Read More