Death of Vertical Tibia, Usain Bolt, Complex Patients, and More – Movement Debrief Episode 13

Movement Debrief Episode 13 yesterday involved quite a few rants. Must’ve been the ketones talking.

Here’s what we talked about:

  • Restoring sensation with my patient with low back pain
  • Why it’s okay to have an angled tibia during squatting
  • Would any intervention help/hurt Usain Bolt?
  • The complexity of Usain Bolt
  • Struggling with a complex patient
  • Dealing with uncertainty
  • Embracing the struggle

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


Here were some of the links I mentioned in this Debrief.

How to Deadlift – A Movement Deep Dive

Squatting Bar Reach – A Movement Deep Dive

The Sensitive Nervous System – Read my book notes here

Clinical Neurodynamics- Read my book notes here

A Study of Neurodynamics: The Body’s Living Alarm

Mobilisation of the Neuroimmune System – Read the course notes here

Explain Pain– Read the course notes here

Extreme Ownership

The Obstacle is the Way

Ego is the Enemy

The Subtle Art of Not Giving a F*ck

Continuing Education: The Complete Guide to Mastery


That’s my number.

No, not that number.



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”

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

Only one wears glasses but both are alternating and reciprocal warriors.
Only one wears glasses but both are alternating and reciprocal warriors.

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 is not the enemy. Teaching patients that their pain is normal and it doesn’t always mean that they are damaging themselves can be challenging as pain is often the reason patients seek out or are referred to PT. Some of the points we tried to teach patients were

  • Pain is there to keep you safe, which is good
  • Pain does not equal tissue injury
  • No pain, no gain is not what we’re looking for
  • Discomfort is okay
  • Knock on the door of pain, don’t try to kick it down

A large part of educating patients is helping them re-conceptualize why they are having pain. Most patients think of pain in terms of a pathoanatomical model (ie tissue abnormality=pain) and this is perpetuated by a lot of members in the medical community. The pathoanatomical language often causes a higher perception of threat and induces greater feelings of being broken, hopeless, and unfixable.

Re-educating the patients that what they are experiencing is normal and teaching them why it is normal helps decrease their perception of threat. We do not want to use language that will make patients more threatened, like telling a 20 year old that they have the spine of an 80 year old (numerous times our patients have been told that by other medical professionals). Getting them out of a mindset that if they move a “faulty tissue” they will make their situation worse is one step in this process.

Regardless of whether the patient is dealing with a more acute injury or one that has become chronic, there are three things we taught each patient that we would do in PT to help decrease some of the sensitivity they may be dealing with. Those three things are movement, space, and blood flow. These three things require the patient to be active in their therapy which gives them control.

Many of the patients with chronic conditions had stopped doing the things they enjoyed. Giving them activities which they can do without perceiving pain, or that can help decrease their pain, shows patients that they do not need to rely on external passive interventions to feel better. Getting patients to believe/understand that they have the control and power to make themselves feel better is one of the most important things a PT can do.

Mirror therapy, sensory discrimination, and PRI

Learning how to use different interventions to help decrease sensitivity and pain was huge for me. We used mirror therapy with different types of patients whether they had chronic pain or were post-surgical. The mirror activities usually started with the patient moving their unaffected limb while watching their affected limb move in the mirror. For example, if you right arm hurts you’d move your left arm while looking at the mirror because it would appear that your right arm is moving. We would progress patients to where they were moving their affected limb behind the mirror while still watching the reflection of their unaffected limb moving in front of the mirror. With the example above, you would still be watching the reflection of your left arm in the mirror making it look like your right arm is moving but would also be moving your right arm behind the mirror. This helped introduce patients to moving a sensitive area without experiencing pain, thus decreasing the threat of movement.

Numerous RCTs have shown this to be true.
Numerous RCTs have shown this to be true.

Another intervention I had not used before was sensory discrimination. We used this mostly in our post-surgical or more acute population to help decrease the local sensitivity after an injury and to try de-smudgify (that may or may not be an actual word) their homunculus [note from Zac: Totally is].

Sharp-dull discrimination was used first, then we progressed to two-point discrimination and usually ended with graphesthesia. The progress for patients from not being able to discriminate between sharp-dull to having graphesthesia showed me how powerful the role of the somatosensory homunculus is in the pain experience.

And of course, I learned more PRI from Zac. He challenged me to use more integrated non-manual techniques with patients while also limiting the number of cues I used. This was great because it is very easy for me to over coach these techniques. He also gave me a better understanding of some of the big concepts in PRI, such as neutrality.

Neutrality vs Hypofrontality

Neutral is a huge word in PRI that is often thought of as the end game when in reality it is just the beginning of a PRI treatment. The end goal is to get someone alternating and reciprocal. The idea of neutral always made sense to me as a good goal for performance as “neutral” joint positions is where the greatest force would be able to be produced. Talking to Zac about this he brought up what Bill Hartman Grandpa 🙂 has said: Neutral is a neurologically prefrontal state in which learning can occur, as the prefrontal cortex (PFC) is active during tasks that require attention. However, this is not a state you want an athlete performing in.

An active PFC is good when athletes or patients are in rehab because their cerebellum and basal ganglia are learning new movements that can then be used with less activity from higher cortical areas during performance. The movements used during these activities can become reactive after enough learning, practice, and repetition (those 3 things go hand in hand).

During performance or training we would not want an athlete using the higher cortical areas that elicit attention as this would make them slow and inefficient. Instead, we would want them fast and efficient (ie reactive and reflexive). A transient state of hypofrontality allows an athlete to reach a state of “flow”, which Mihaly Csikszentmihalyi describes in his book Flow, which is where the highest levels of performance occurs. This would allow the lower reactive (cerebellum and basal ganglia) and reflexive (brain stem) centers of the brain to essentially take over making them fast and efficient.

So from a theoretical neurologic stand point you do not want an athlete in a prefrontal state during performance. Good rehab and programming can help them become alternating and reciprocal through graded exposure and relearning of certain movement patterns in a neutral (prefrontal) neurologic state. Once this foundation is there, power and capacity can be added through training (which Zac talks more about here ). This may allow an athlete to stay alternating and reciprocal during transient states of hypofrontality when performing, not “neutral”.

Another concept that stood out to me from talking with Zac is the difference between extensor tone and extension. Extensor tone is necessary for power production during performance but it does not necessarily mean that the athlete is going into a position of extension. When someone is in extension they limit their degrees of freedom for movement and thus their movement variability. Using extensor tone from a neutral position, for lack of a better term, would allow them to display power while maintaining their potential movement variability (be alternating and reciprocal). This idea was something that made things click for me.

In summary…

I learned a lot from Zac and want to thank him for all his help and time he spent teaching me. Needless to say, this was an amazing clinical internship for me and I cannot recommend enough that other students should try to get Zac as their CI or for patients to get treated by Zac. He is the real.

Zac Cupples and Iron Sheik same thing
Zac Cupples and Iron Sheik same thing

And now what everyone has been waiting for… Zac quotes

Help for cueing exercises

  • “Shakin’ like a polaroid picture”
  • “We don’t want Fat Joe and the lean back”
  • “Do you remember the three little pigs? I want you to be the big bad wolf and blow their house down”
  • “Do you have the big 3? Jordan (L abs), Pippen (L adductor), and Rodman (L glute med)?”
  • “We like a tight right butt and we cannot lie, the other therapists can’t deny”
  • “I’ll start calling him Buffalo Bill, cause he’s abducting like crazy”
  • “We don’t want you to have hamstrings like Goldmember”
Hamstrings like Goldmember = POTS
Hamstrings like Goldmember = POTS

Zac after getting his wisdom teeth out, he doesn’t remember saying these things

  • “I have lateral trusion!”
  • “Check out this IR” and then he self-tested his own HG IR
  • “I ain’t got time to bleed”
  • “Nobody makes me bleed my own blood”

Other favorites

  • “If you ain’t assesin’ you guessin’”
  • “There’s 45 miles of nerves in the human body if you put them all in a straight line, but don’t try it at home cause you’ll die.”
  • “…hmm..interesting” in Bill Hartman Grandpa’s voice
  • “…sure about that?” in grandpa’s voice
  • “Her teeth told me she had bunions”
  • “I don’t know why he told us the same diagnosis five times.”
  • “Breathing is really important. The research has shown if you don’t do it you will die”
  • “How about this word, variability. How about this word, salience. How about this word, anti-fragile. How about this word, POTS.”

Trevor Rappa is a student at Columbia University and will graduate this May with his DPT. He has clinical experience with Lori Thomsen at the Hruska Clinic and with Zac Cupples at East Valley Spine and Sports. Upon graduation, he will be working at Peak Performance in NYC. You can get in touch with Trevor by email at or on twitter @TrevorRappa.


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!


PRI and Pain Science: Yes You Can Do It


You may have noticed that my blogging frequency has been a little slower than the usual, and I would like to apologize for that. I am in the midst of creating my first course that I am presenting to my coworkers. It has been a very exciting yet time-consuming process. It makes me excited and more motivated to someday start teaching more on the reg.

Ever since I started blogging people started asking me questions. These range from many topics regarding physical therapy, career advice, and the like. Some of the more frequent ones include:

  1. What courses should I look at?
  2. Any advice for a new grad?
  3. Seriously, Bane. What’s the deal?
Some questions are best left unanswered.
Some questions are best left unanswered brother.

But the one I get asked more often then not is as follows:

“Zac, how do you integrate PRI into a pain science model?”

A great question indeed, especially to those who are relatively unfamiliar with PRI. With all the HG, GH, AF, FA, and FU’s, it’s easy to get lost in the anatomical explanations.

Hell, the company even has the word (gasp) “posture” in the title. Surely they cannot think that posture and pain are correlated.

One of my favorite actors of all time. RIP
One of my favorite actors of all time. RIP

I think there is a lot of misinformation regarding PRI’s methodology and framework. What needs to be understood is that PRI is a systematic, biopsychosocial approach that predominately (though not exclusively) deals with the autonomic nervous system. The ANS is very much linked into pain states, though not a causative factor.

But of course, that may not be enough. Perhaps we can dig a little deeper into what may be going on. My hope with this blog is to make a guide to integrating two very effective paradigms which I feel are not mutually exclusive.

PRI Patterns and Nociception

 David Butler discusses many nociceptive processes, including mechanically-induced pain, inflammation, and ischemia.

I feel that the PRI patterns, albeit normal, could contribute to nociceptive processes. Mechanical pain makes the most sense. We could think of this process as typical anatomy/biomechanics. If one is in a right-lateralized and extended position, certain areas are going to be more prone to mechanical deformation than others.

Inflammatory processes could be caused by acute injuries secondary to position. The easiest example I could give would be an ankle sprain. If someone is in a right lateralized pattern (a la Left AIC), the right ankle/foot complex would be more supinated, thus being more at risk to sustain an ankle sprain. So in these cases, a right lateralized pattern could be one of many risk factors for leading to an injury.

Ischemic nociception is where things get interesting. There are two ischemic features that Butler mentions in “The Sensitive Nervous System” that stood out to me:

  1. Symptoms after prolonged or unusual postures.
  2. Rapid ease of symptoms after a change of posture.

If I am right lateralized and unable to leave right stance, this position could become ischemic after a prolonged period. Less movement, less axoplamsic activity, less blood flow.

You can't feel the flow when you can't move.
You can’t feel the flow when you can’t move.

Moreover, symptoms would be much more challenging to relieve. If I am unable to adduct and internally rotate my hip maximally, then I effectively limit what movement planes I am capable of utilizing. This concept is what Bill Hartman calls movement variability. When a position becomes nociceptive, movement must occur to reduce danger signals and restore axoplasmic and blood flow. I am looking for freedom. But triplanar activity is unachievable, movement freedom becomes a limited resource.

I simply lose the ability to change posture, which limits my ability to relieve ischemia.

 PRI Patterns and Peripheral Neuropathic Pain

 When I am in right or left stance, the nervous system slides and glides to accommodate position. Suppose I am in right stance. Right stance would require my right hip to be more extended, adducted, and internally rotated. My left hip would be flexed, abducted, and externally rotated.

When my hips are positioned as above, the sciatic nerve would be more taut on the right and slacked on the left. Now if I never leave right stance (aka left AIC), then I could potentially be more at risk for tension impairments on the right.

Another example would involve spinal position. Research demonstrates that humans have a naturally right oriented spine (here & here) which is precisely what PRI advocates. This orientation may bias more compression on the right nerve root than the left. If we have someone who presents with a dominant PEC i.e. spinal hyperextension, we could potentially see increased compression bilaterally.

Here we go yo, it's just a potential scenario.
Here we go yo, it’s just a potential scenario.

PRI, What a Great Defense

Now of course, we know very well that nociception and peripheral neuropathic issues are neither necessary nor sufficient for a pain experience. So how does PRI relate to pain?

Simple, the PRI patterns are the perfect protective postures for us to assume when we are threatened.

We drive these patterns via our autonomic nervous system. If you read Stephen Porges work, he discusses the concept of neuroception. Neuroception is how our nervous system’s evaluates risk. We take all sensory information in regarding our environment and determine if we should fight, flight, freeze, or relax and socialize.

When we neurocept (is that a word??) something as a threat, we will become more sympathetically driven and likely use our most efficient processes to respond to the threat. We use what we know.

Play Scrabble with me and you'll find I make up words all the time.
Play Scrabble with me and you’ll find I make up words all the time.

We bias ourselves to the right because motor planning occurs in the left hemisphere regardless of hand-dominance. If I stand on my right leg, I simply am better able to make my next move than if I were to stand on my left.

We will increase activity of our anti-gravity muscles, our extensors. To defend against a threat, it probably makes sense to stay upright. This function has governors present in the reticular formation. The pontine reticulospinal tract controls extensor tone, and the medullary reticulospinal tract inhibits this tone. One of these is spontaneously active and the other is not. Guess which one? Extension is the norm to keep upright. Thus, extensor tone is the brain’s reflex-driven path of least resistance. Perhaps if I am under threat long enough, I become a PEC?

Breathing will become faster and shallower. Take a look at the diaphragm. Which side is larger?

Would you look at that.
Would you look at that.

The right hemidiaphragm is larger and more powerful than the left. If I am already biased to the right and have a stronger muscle on the right, breathing becomes a less conscious process.

My point of listing these plausible changes in response to theat is to demonstrate that we are fairly similar creatures. Bill again, helped me realize this on a post he made at Somasimple.

If a lion were to walk in the room, what physiological changes would we undergo? Our heart rate would increase, pupils would dilate, HRV decreases, we sweat, etc. Are these responses not the same for all humans? These physiological changes are a common human pattern. Could it be possible there is a common threat response in postural and muscular activity as well? This pattern of positioning and neurological bias is what I feel PRI has put together more completely than anyone else.

Granted, we can still account for individual differences, but realize these changes are likely minor variations off the normal response.

When under threat, your heart rate increases 20 beats per minute, mine increases 10.

When under threat, your sweat accumulates on your brow, mine on my palms.

When under threat, your left anterior hip capsule becomes lax via compensatory external rotation, mine stays intact after compensatory external rotation.

Similar responses occur through varying degrees.

We're not so different, you and I.
We’re not so different, you and I.

Treating Pain Through PRI Approaches

I think PRI can influence the pain experience by altering autonomics via the vagus nerve. Paced breathing can positively influence pain states, and PRI breathing-style is very much paced.

The positions utilized are the farthest removed from the typical protective response when we perceive threat. If right stance with increased extension is what we do when we are threatened, then I am going to get you into left stance and flex you until the cows come home.

PRI essentially is graded exposure into left stance and parasympathetic paradise.

That doesn’t mean that PRI is going to eliminate the entire pain experience in all cases. There are some people who have injuries that are producing nociception, and may take time to heal. There are some people who have enough neural sensitivity requiring a hands-on or neurodynamic approach. There are some people who have centrally-maintained pain experience that requires graded exposure, pacing, and homuncular refreshments. The autonomic protective response is one piece of the puzzle, and altering that piece is the only way one can know if it is contributing to one’s complaint.

Therapeutic Neuroscience Education…PRI Style

So usually when I educate patients I just run through the above as quickly as possible…

download (2)

Okay that’s not 100% true.

I actually use the concept of a home security system to explain how PRI patterns are a part of the pain experience. Go ahead, watch the video, I’ll wait.

So as you can see, I do not go into nitty gritty detail of PRI methodology. It is mostly not necessary and could potentially increase threat perception. But framing the system as done above can help the patient understand why we may work at areas far away from the pain experience. We are treating what area of the system continues driving the protective response. We are treating the person.

In Summation

PRI is a very powerful system that does not have to go against current pain research, not that it ever did. But the above may be a potential framework and justification as to how PRI affects the pain experience.  It is the framework that I operate on, and will continue operating on until I am shown otherwise.

I hope that I am.

Who knows where the rabbit hole goes next.
Who knows where the rabbit hole goes next.

Course Notes: Therapeutic Neuroscience Education

How’s Your Pain How’s Your Pain How’s Your Pain How’s Your Pain?

To purge onward with developing some semblance of chronic pain mastery (ha), my employer had the pleasure of hosting a mentor and good friend Adriaan Louw.

I first heard Adriaan speak in 2010 when I was in PT school. I was amazed at his speaking prowess and the subject matter. Unfortunately, my class could only stay for a little while in his course, and onward life went.

I went on with my career focusing on structure and biomechanics and forgetting about pain. It wasn’t until I ran into Adriaan again two years later. He was teaching me Explain Pain (EP), and forever changed how I approached patient care.

It’s funny how things have come full circle.  Here we are, Adriaan teaching Therapeutic Neuroscience Education (TNE) through The International Spine and Pain Institute (ISPI), and me promoting his work to my colleagues.

A lot has changed in two years. EP and TNE are quite different courses, and I learned so much this weekend that I continue to become more engrossed with what I do.

So thank you, Adriaan, for playing a huge role shaping me into who I am today.  I have now become very much more interested in what ISPI has to offer, and I think you should too. And no worries Adriaan, I will stay hungry 🙂

Inside joke...So can't believe I forgot to take a pic with this guy.
Inside joke…So can’t believe I forgot to take a pic with this guy.

So without further ado, here is what I learned.

The Power of Words

 It’s getting worse. One person out of 3.5 has chronic pain.  Many of these people have tried many treatments, heard many explanations, and lost all hope.

And here they are, in your office. The patient thinks you are going to be another statistic.  Another failure. Another person who can’t help them.

So what do you do?

The answer: Apologize, and tell them they are going to be okay.

These are some of the most powerful words in medicine, and likely words that these people with chronic pain have never heard. Most importantly, they satisfy the ultimate goal of TNE:

Reduce the perception of threat

That, my friends, is what all physical therapy interventions do. Exercise, manual therapy, and education all reduce threat perception.  These simple words can often jump start the process.

Changing Cognition

Fear and catastrophization are often the big components that we have to battle with the above patients.  When these beliefs regarding pain are present, a cycle of avoidance and disuse occurs.  These factors can continually perpetuate the pain cycle.

When experiencing pain, we can go one of two routes.

I was inspired by the class to detail this artwork with blue arrows, contrasting to Adriaan's black. I feel the blue juxtaposes quite nicely against the white backdrop
I was inspired by the class to detail this artwork with blue arrows, contrasting to Adriaan’s black. I feel the blue juxtaposes quite nicely against the white backdrop

We can see how understanding pain can have profound impacts regarding recovery, yet the converse can lead to a debilitating cycle. Our goal is to steer people towards confronting their experience as quickly as possible. Knowledge can be powerful at reducing chronic pain.

Realize that there are many other factors that go into which path one will travel. These factors may include pain beliefs, sleep, behaviors, family, social circle, job, etc. These examples are a few of many variables that make pain as complex as it is.

The best that can be done is to manage the threats you are able to influence and educate the patient on understanding other possible factors.

Psychologist Wannabe

Now some of you psychology fans might be thinking that this strategy may be stepping into areas outside of our scope. But think of how we treat impairments that may be impacting one’s movement:

  • Stiff joints – manual therapy
  • Altered muscle recruitment – motor control
  • Muscle stiffness –manual therapy

What if the impairment impacting one’s movement is one’s thoughts and beliefs? What intervention would you utilize to address this area?

Clockwise ultrasound of course.

The brand I use. Combo only baby!
The brand I use. Combo only baby!

The logical choice of course, would be educating the patient that these thoughts and beliefs do not relate to the pain experience. Successful education may affect the impairment shackling that person.


Why is it that when patients come to us in pain we teach them anatomy? This was a question Adriaan posed to the class that summed up my frustration with much of traditional orthopedics in a way I never could.

There are a few studies (here and here) that have demonstrated that educating patients on anatomy and biomechanics has limited efficacy and may increase fear.  Moreover, using degenerative terms are associated with poorer prognosis (here).

The problem with this strategy is that it does not adequately address what the patient is seeing you for–pain.  Fortunately, the evidence for TNE is becoming quite compelling (check it).

It’s All in the Delivery

So TNE sounds all well and good, but the question must be posited: how? There are several ways to skin this cat (as long as the cat gets skinned):

  • Research demonstrates only performed by PTs currently.
  • Sessions can last from 30 minutes to 4 hours, but Adriaan suggested 10-minute increments.
  • 1on1 is best, but groups of 8-10 people are also good.
  • Use props – pictures, drawings, metaphors, etc.

The research also demonstrates that certain content must be covered:

  • Pain neurophysiology.
  • No reference to anatomical or patho-anatomical models.
  • No discussion of emotional or behavioral aspects to pain.
  • Nociception and nociceptive pathways.
  • Neurons.
  • Synapses.
  • Action potentials.
  • Spinal inhibition/facilitation.
  • Peripheral sensitization.
  • Central sensitization.
  • Plasticity of the nervous system.

One phenomenal way to gauge if patients understand your education is by having them fill out the Pain Neurophysiology Questionnaire (PNQ). This tool covers a large portion of TNE, and can give you talking points on where your education ought to be targeted.

I have been having patients fill this out for a few weeks now, and it is amazing how many people have pain misconceptions even after I perform TNE. Most of the learning that was occurring was superficial. This tool gives you reason to reinforce your education, as well as a way to have evidence of learning.

Now I have been talking a lot about education, and the common misconception is that all you do is talk to your patients. This thought is far from true. Most of the study designs in Adriaan’s systematic review had other interventions along with education. So it is only one piece of the puzzle. You do not have to completely change how you treat patients, you must only change the framework at which you educate and think.

Pain Neuroscience…Learn It!!

If you are going to explain pain to patients, you have to know more about it then they do. To enhance our knowledge base, we can discuss the PNQ in detail. So fill it out before reading on.

Go ahead, I’ll wait.

Did you fill it out yet?

Fill it out. It's right there!!! Do it now!!!!!!
Fill it out. It’s right there!!! Do it now!!!!!!

Okay, here we go:

Pain receptors convey the pain message to your brain: FALSE

Why – Tissues only send danger messages. Compare suffering an ankle sprain on a sidewalk versus a busy street. The latter would not necessarily hurt.

Fun fact – There are no unmyelinated nerves in the body. Every axon wears a coat; it just depends on what degree

Pain only occurs when you are injured: FALSE

Why – Injury and pain are not synonymous. Think about when you get a bruise and are not aware of it.

Fun fact – Tissues heal in 3-6 months. This includes your bulging discs.

The timing and intensity of pain matches the timing and number of signals in danger messages: FALSE

Why –  This statement predominately deals with descending modulation and interneurons.  In acute pains that end quickly, danger messages make their way up to the spinal cord and then the brain, but the brain sends endogenous opioids down the system to turn the dial down on danger messages.

There are many other fibers that that send messages to the brain, one example being A-betas. These sensors carry information regarding light touch for example.  If you occasionally feel that you are wearing pants (unless you are not), you can thank these fibers.

Stopped wearing pants ever since this course.
Stopped wearing pants ever since this course.

However, you don’t have to constantly be reminded that you are wearing pants, so an interneuron in the spinal cord will prevent this information from reaching the brain. The interneuron is like a club bouncer; only the VIPs pass.

However, if danger messages (via A-delta and C-fibers) continue firing to the spinal cord, the interneuron could potentially die from amino acid overload. When this change occurs, the club called your spinal cord has no bouncer, thus all information from the periphery will make it to the brain. This input barrage can significantly impact your body’s ability to modulate danger messages, and eventually pain.

Fortunately, interneuronal death takes months to years in most cases except when someone gets struck by lightning, electrically shocked, or in whiplash. But the message is clear; we must do what we can to modulate nociception and pain so this change does not occur.

The best way to treat chronic pain is to prevent it.

Nerves have to connect to a body part in order for that part to be in pain: FALSE

Why – Phantom limb pain, duh! The somatosensory homunculus is what allows for this phenomenon to occur.

He runs the show.
He runs the show.

When areas are used less, such as in pain states, the area of that body part becomes less clear. These changes can occur as fast as 30 minutes. The research shows the more “smudging” of these areas you have, the more pain you have.

So in phantom limb pain, the body part is gone, but the brain representation of that area remains.

In chronic pain, the central nervous system becomes more sensitive to danger messages from tissues: TRUE

Why – Interneuron death plays a role, but also descending influences from the brain contribute.  Because more danger messages are occurring, the brain is less likely to utilize endogenous opioids to calm the system down.

From a survival standpoint this makes sense. In chronic pain, the future becomes less certain, and your top priority is to stay alive. If I can make you more sensitive to your environment, I can better protect you.

The body tells the brain when it is in pain: FALSE

Why – The brain is what produces pain. The body can only produce danger.  The brain activates many areas in the pain experience, making pain multi-sensory.  And the more this pain map is run, the more efficient your brain becomes at producing it.

Fun fact: The amygdala’s role in pain could be why females have more chronic pain than males.

The brain can send danger messages down your spinal cord that can increase the danger messages going up the spinal cord: TRUE

Why – If there are enough danger signals reaching the brain, the brain will want to know more; thus impacting the periphery.

Nerves can adapt by increasing their resting level of excitement: TRUE

Why – Action potential are key. Every nerve has a resting amount of activity, and a certain amount of stimulus is necessary before this action potential occurs.

When someone is extra sensitive, the nerves increase their resting excitement level so action potentials more readily occur. Adding more ion channels to less myelinated areas can further compound this sensitivity.

Fun fact – Ion channels change every 48 hours, and therapy can positively influence the change.

Chronic pain means an injury hasn’t healed properly: FALSE

Why – Read, like, everything I have ever written ever. Pain and injury are not the same thing.  Tissues heal, tissues heal, tissues heal.

Receptors on nerves work by opening ion channels in the wall of the nerve: TRUE

Why – See above.

The brain decides when you will experience pain: TRUE

Why – Pain is a brain construct. Tissues can only send danger messages.

Fun fact – Laughing at a joke requires 5 different areas to be active in the brain.

And not a single of these areas have been active during this blog.
And not a single of these areas have been active during this blog.

Worse injuries result in worse pain: FALSE

Why – See video below

When you are injured, the environment that you are in will not have an effect on the amount of pain that you experience: FALSE

Why – Injuries and pain occur in an environment, not a vacuum. An ankle sprain may hurt on a sidewalk, but likely won’t if a bus is about the hit you.

Fun facts – Injuries in high stress environments are 7-8 times more likely to produce chronic pain. Also, kids who play contact sports early in life have less chance of developing chronic pain.

It is possible to have pain and not know about it: FALSE

Why – Pain is a conscious decision by the brain.  No brain, no pain.

Nerves can adapt by making more ion channels: TRUE

Why – I already answered it duuuuude.

Second order messenger nerves post-synaptic membrane potential is dependent on descending modulation: TRUE

What did I just say? – I don’t know.

Why – The brain has the abilty to inhibit information coming up from the periphery via endogenous mechanisms.  This is how placebo works.

Nerves adapt by making ion channels stay open longer: TRUE

Why – Because I said so…directly above. The brain will also make g protein ion channels, which can stay open for several minutes. This type allows for more danger messages to fire.

When you are injured, chemicals in your tissue can make nerves more sensitive: TRUE

Why – Much was previously mentioned, but the stress response plays a huge role here.  When you go into a more sympathetic state, adrenaline, cytokines, and cortisol pump throughout the body. This change increases sensitivity of nerves throughout the body systems, and those in chronic pain are more geared toward this state.

Put it all together, and what do you got???

So with all the above information, we can see there are many misconceptions regarding pain. So it becomes very important to define what pain is. Here is a great definition:

“Pain is a multiple system output activated by an individual’s specific pain neural signature. The neural signature is activated whenever the brain concludes that body tissues are in danger and action is required.”


So Let’s Do Something about It

While we do need to know all the nitty-gritty regarding pain physiology, your patients and clients will not know what the heck you are talking about. Thus, you have to teach this information in a patient-friendly manner. Here were some of my favorite ways Adriaan used for TNE.

You can also mention to patients in chronic pain that one in three people keep their nerves elevated past normal healing times.

With this example, there are usually three questions that arise:

  1. How do you know this?
  2. Why did my nerves stay/become so sensitive?
  3. What can be done to calm them down?

Number one can be answered by the following points:

  • You told me – it takes less activity for pain to arise.
  • Your tests told me – physical exam and neurodynamic tests.
  • Your doctor told – any anti-depressants or drugs like Cymbalta or Lyrica can calm the nervous system down.

We can answer number two by having them think about the many factors that could enhance sensitivity. These factors could be failed treatments, hearing different explanations, pain chronicity, life worries; basically anything that could make you feel threatened.

Number three is easily answered by explaining the powers of education, exercise, and medication.

The Old Speeding Bus Trick

Say you sprain your ankle. Would it hurt? How about if a bus was about to run you over? This tactic demonstrates that the brain makes a conscious decision as to whether or not pain should be experienced; and the greater threat always wins.

I Hate Having Neighbors

Here is a great way to explain spreading pain to patients.

Say your alarm goes off and you begin to feel pain. If your alarm stays on long enough, the noise may wake up your neighbors.  If the neighbors stay awake because your alarm keeps going, eventually they will get agitated. It wouldn’t be surprising to see neighbors even farther away waking up if the alarm stays on too long.

And there are many ways your neighbors can be agitated.
And there are many ways your neighbors can be agitated.

You can also tie in the immune system in to this example. Immune molecules are like little police men that check out everyone and make sure the situation is okay. Nearby neighborhoods might also be checked out just to be safe.

The police watch the area until the problem is taken care of. But as is customary, a few months later the police may check-in to make sure everything is okay. This analogy can explain why pains you once had can reoccur.

The Road Often Traveled By

This analogy is a great way to show how chronic pain allows for neural pathways to turn on more efficiently.

Think of a neural pathway that would lead to a pain experience as a dirt road. If  you get a lot of traffic along that pathway, eventually the road is going to have to get bigger to accommodate. So perhaps the road is widened.  Maybe the next step is the road getting paved, then making the roads 2-laned, etc.

The more that pain pathways run, the more fluidly they do so.  The pain experience is created faster and faster with the more traffic encountered.

Just the thought sends my amygdala crazy.
The analogy alone makes my amygdala go crazy

The Top 5 Reasons Why a Bulging Disc Ain’t a Big Deal

 You are inevitably going to run into someone who thinks having a bulging disc is a death sentence. Here are the 5 facts (in order) that you should mention to them:

  1. 6 weeks after a scan is performed bulging discs become smaller.
  2. You can get completely different results depending on the time of day the MRI was taken; early am is more likely to show disc bulges.
  3. Position MRI was taken in affects results.
  4. Levels that swell don’t move much; thus laying still or moving can impact results.
  5. 40% of asymptomatic individuals have bulging discs.

Two Lions Walk into a Bar…

This analogy is a great way to explain the stress response. Imagine you are watching television minding your business when a big African lion walks in the room. What happens to your body systems?

  • Adrenaline pumps through the bloodstream, increasing heart rate, breathing, alertness, etc.
  • Big strong muscles turn on; smaller muscles turn off.
  • Raise voice and speak short and sharp.
  • Shallow and fast breathing.
  • Digrestion slows.
  • Memory fogs.
  • Reproductive systems stop (unless you dig lions)
  • Many other things.

When the lion leaves the room, the body returns to its previous resting state.  Chronic pain states is akin to having this lion following you at all times.  This state, which can be perpetuated by many factors, can keep the above changes going relentlessly.  Our goal with therapy, is to make that lion less threatening.


While we have been exposed to great science and metaphor, the practical component was what did it for me. Adriaan had so many wonderful suggestions for implementation that I had to list some of my favorites:

  • Train the entire staff on TNE; including front office.
  • Designate particular days as TNE days.
  • Can teach in 10 minute increments.
  • Carefully use the word pain. Asking patients pain rating repeatedly may increase pain ratings.
  • Have a strict cancel/no show policy: Adriaan likes one cancel; >10 minutes late leads to a reschedule.
  • No more than 5 exercises for HEP.
  • Aerobic exercise is huge for chronic pain. Perform at >50% VO2 max and >10 minutes.

A big one for me regards coping skills. Before a patients calls in on a bad day to see a therapist, 5 strategies should be performed first:

  1. Problem solve – find a cause/relationship.
  2. Ice/heat/TENS.
  3. Perform your exercises.
  4. Get away – walk for a little bit, then relax and take a cleansing breath.
  5. Do not cancel all activities. Do as much as you can.

Quotes from Adriaan

  • “Light a candle, watch Oprah.”
  • “The holy grail to chronic pain is prevention.”
  • Take that patient. Own that patient. Fight for that patient.”
  • “Your challenge is to be so good a these [chronic pain] patients that the other stuff will become mundane.”
  • “If you are a PT and have not had back pain you are dead to me.”
  • “Aerobic exercise is gold standard for chronic pain.”
  • “Parenting sets up pain later on.”
  • “The biggest boost for the immune system is social interaction.”
  • “Low back pain is the common cold of the musculoskeletal system.”
  • “Your job is to make your patient so smart that pain decreases.”
  • “30% of pain is insidious onset”
  • “You are not treating evidence, you are treating a patient.”
  • “The best clinical question you can ask is ‘what do you think is going on with your x.’”
  • “Pain protects.”
  • “Make patients responsible for their own care.”
  • “The bigger threat wins.”
  • “The biggest predictor of chronic pain is acute pain.”
  • “pain spreading is an expansion of receptor fields.”
  • “When pain is involved motor control becomes 2nd.”
  • “Pain is a unique human experience.”
  • “If you live your pain, you become very good at living your pain.”
  • “Don’t forget the human being.”
  • “You are a walking placebo pill.”
  • “Lyme disease is the new fibromyalgia.”
  • “A brain that doesn’t know is the most dangerous thing on the planet. Make the unknowns known.”
  • “Pain is what I think.”
  • “You own your pain.”
  • “If you teach about pain and they feel worse, you got them.”
  • “Chronic pain patients are not weak, they are deconditioned.”
Any social interaction is better than nothing.
Any social interaction is better than nothing.

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 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.


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

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

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.


Course Notes: PRI Impingement and Instability

Soooooooooo Dense

It has been a long, busy, and great few weeks for me. After attending a cluster of courses, playing around with some new jobs, moving, and working, I got some time to settle down and review PRI’s I&I material.

I traveled to Phoenix to take this course. My man James Anderson taught and several good friends attended. James did not disappoint.

I&I was easily one of, if not the best course I have ever taken. You did it again PRI!


The only real disappointment was leaving Arizona. The temperature was in the 80’s and the sun was shining. Now here I am in the Midwest with the temp in the mid-20’s. Why did I stay here again? 🙂

This course combined and fleshed out the concepts of respiration and myokin, and added so many more layers onto what we previously learned.

I&I was what DNS C should have been.

Take notes Prague School. You have potential.
Take notes Prague School. You have potential.

I left the course with many answers, but double the questions. You truly cannot appreciate how complex the nervous system is, and how the total body responds to perceived threat until you delve into this material. I am so excited to learn more.

This course had so much information regarding the entire body that there is no way I could post all the relevant info and do it justice. It really was a 4 day course done in 2. So here are a few of the gems I got from this weekend.

The PRI Basis

The course started off with a lovely frontal-plane slice of the thoracic cavity.


Pay attention to how much stuff is there. This area is money for the body. You will notice the yellow sympathetic ganglia’s proximity to the spine and ribs.

Suppose we alter spinal position. If the thoracic spine is extended and rotated, increased pressure via the ribs and vertebrae occurs to the sympathetic trunk. Thus, when you have someone with a flat and twisted thoracic spine, you may overstimulate the sympathetic ganglia, driving one into sympathetic overdrive.

Depending on which pattern one presents with, different anatomy will press upon the ganglia. A LAIC patterned individual will have the ribs compress against the ganglia due to the rotational component. Whereas the PEC individual’s spine will compress this structure due to the gross extensor pattern.

I am sure that most of you will be wondering about people who present with hyperkyphotic thoracic regions. This posture is still an extended posture. The individual hyperinflates the lungs, while simultaneously flexing the spine to try and dome the diaphragm.

The rib flares are a dead giveaway
The rib flares are a dead giveaway

Now I may be discussing structure quite a bit, but this point must be re-iterated again and again. PRI is brain and autonomic therapy. We are working with a cycle between posture and the autonomic nervous system. Being stuck in the fight or flight state influences our postures, and being in these postures influences the autonomic nervous system.

As James so eloquently put it, preserving the space between the front of the thoracic vertebral body and the front of the back of the ribs will preserve neurology.

Impingement and Instability is Normal

Say what? Yes, you read it right. It is good to be impinging and unstable, as long as these positions are performed at the right time, sequence, and positioned in the right way.  As I step with my left leg, and swing with my right, favorable gait should allow for me to impinge into my left hip for support. That way the unstable right leg can move forward.

To take this concept further, we especially want instability of the nervous system and neutrality. As I defined here, neutrality is a slightly parasympathetic state but having the ability to go sympathetic when needed. We want to be able to phase in and out of neutrality when the situation warrants.

Balanced impingement and instability allows the nervous system to act favorably.

We run into problems when the nervous system creates instabilities to survive sympathetic states. When these defense mechanisms form, impingement occurs to provide stability. The surrounding joints further accommodate these protective patterns by altering position.

Your body will alter itself to keep you alive.
Your body will alter itself to keep you alive.

The Pattern

I could try to write this out for you, but if we look at the entire lower extremity you would lose your mind. Here is a video outlining what happens at every joint, along with how we will get out of that:

For Future Reference

If you can utilize one principle from this course, it is use your reference centers. These areas are where we are trying to create new impingement, new stability points, to shift us more towards a parasympathetic state. They include the following areas:

  1. Right medial longitudinal arch when the left leg is in acetabulofemoral (AF) internal rotation.
  2. The left posterior calcaneal tuberosity.
  3. The left ischial tuberosity.
  4. The left anterior hip capsule/right posterior hip.
  5. Left internal obliques/Transversus abdominis and left posterior lower ribcage (THE MOST IMPORTANT)
  6. Right lateral posterior upper ribs when in left  AF IR.

The goal is to feel as many of these points as possible when not only doing exercise, but through daily activities.

Calcaneal Instability

This portion discussed the subtalar joint’s importance, as its position governs what the entire foot complex does. Therefore, if you do not have good support here, you lose control of the foot.

The calcaneus is the window to achieving frontal plane support and control; a plane not often discussed when designing orthotics. But when you can utilize something like eversion on the right side, you are able to decrease activity of the right adductor magnus and right abdominal wall. Eversion begets increased glute max activity, a PNF concept if I ever saw one.

But not this kind of PNF
But not this kind of PNF

There was also a lot of talk regarding shoes and orthotics. These items are not presented from a support factor as typically done.  By using these devices, we instead are altering the proprioceptive input to the ground-foot interface; thus affecting the position the body is placed.

Femoral Instability

This section discussed correcting potential knee orientations as a result of the pattern. There were many different ways that the femur and tibia could orient or compensate position based on pelvic position. The most potentially nociceptive positions involve the femur rotating one direction and the tibia rotating the other.

The way these can be altered to decrease nociception is by typical PRI fair, with the added focusing on balancing out the hamstrings. Think of these muscles as reigns on a sled. Bias the medial or lateral hamstrings more, and the position of the femur on the tibia can be altered.

Practical Aspects

I got two major points regarding exercising my patients:

1)      Slow down

2)      It’s okay to stand

I had difficulty with progressions through PRI in terms of targeting certain movements/muscles, but also never getting to the point where someone was standing.

Regardless of what activities you choose, you have to be willing to slow movements down so the reference centers and muscles you are going after are felt.

To apply this to standing activity, a PRI-test purist would wait to stand someone until they scored Adduction lifts of 3/5 on both sides. But oftentimes this change can take a lot of time; especially for an inexperienced clinician such as myself. Moreover, people are typically out of painful states before you get to this point. But as long as your patient is feeling the reference centers in the position you are utilizing and your tests are changing…Do it.


We also had some great discussion regarding PEC patterns, which is demonstrated via positive Ober’s tests bilaterally and either positive or negative Thomas tests. A  left AIC patient would have only a left positive Ober’s. However, one fitting this pattern could still be a PEC functionally if adduction lift scores were low. You would be oriented in a left AIC pattern, but function as a PEC.

Great James Quotes

  • “The brain will always win.”
  • “There’s a new sheriff in town, it’s exhalation.”
  • “Keeping a patient on a table is great if they are only on a table their whole life.”
  • “Real life PRI is a person walking across the room.”
  • The PEC patterned individual is in bilateral swing phase. “
  • If you get reciprocally alternating gait, you won’t be mobing joints, joints will be mobing you.”
  • “You need the diaphragm in all planes or you will lose.”
  • “PRI is neurology, respiration, and biomechanics.”
  • “The feet are the interface between the brain and the ground.”
  • “In Impingement and Instability, hamstrings are trending on Twitter.”
  • “Airflow drives the nervous system.”
  • “This isn’t muscle training, it is brain training.”


Every time I take a course offered by this group I get more excited for my profession and what I do. I can’t wait until my next one. Take their stuff as soon as you can.

I do...Sometimes
I do…Sometimes