Physical Therapy for Neurological Conditions in Geriatric Populations.

Physiotherapy rehabilitation sessions for people with geriatric conditions.

With more of the world’s population surviving longer, individuals often face age-related neurology disorders and decline of function that can affect lifestyle and well-being. Despite neurophysiological changes affecting the brain function and structure, the aged brain, in some degree, can learn and relearn due to neuroplasticity. Recent advances in rehabilitation techniques have produced better functional outcomes in age-related neurological conditions. Physical therapy (PT) of the elderly individual focuses in particular on sensory-motor impairments, postural control coordination, and prevention of sarcopenia. Geriatric PT has a significant influence on quality of life, independent living, and life expectancy. However, in many developed and developing countries, the profession of PT is underfunded and understaffed. This article provides a brief overview on (a) age-related disease of central nervous system and (b) the principles, approaches, and doctrines of motor skill learning and point out the most common treatment models that PTs use for neurological patients.


Untold Physio Stories (S7:E10) – Jason Doesn’t Care Part 2

Untold Physio Stories is sponsored by the EDGE Mobility System, featuring the EDGE Mobility Tool for IASTM, EDGE Mobility Bands, webinars, ebooks, Pain Science Education products and more! Check it out at .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Jason Shane at Shane 

Keeping it Eclectic…

Consider the Power of Habit in Rehab

Personal trainer teaching to man in suspension training

I treat a number of patients who have difficult diagnoses or have not succeeded with previous treatments.  It can be, at times, stressful and difficult.  All of us at one time or another have had a difficult case.  Maybe there were a ton of comorbidities complicating the presentation.  Maybe the presentation was complicated by multiple impairments.  Whatever the cause, we all encounter these cases and the only way to be consistently successful is habit.

What do I mean by habit?

One of my favorite books, The Power of Habit by Charles Duhigg, discusses how our automatic brain works.¹  It’s on a completely different wavelength and processing pattern than when we have to think and make a decision.  In the book, Duhigg talks about Tony Dungy, Super Bowl winning coach with the Indianapolis Colts.  Duhigg discusses Dungy’s methods of training his players to react.  He repeats the same thing over and over until it becomes a habit so when the players are on the field, they react instead of think.  When it is the end of the game and the pressure is on, those who are thinking feel the stress.  Those who are reacting just do…..and they do just like they have 1,000 times before.  Here’s the key.  Because they have run that specific play until they perfected all the patterns, when something goes wrong, they know it and can adapt.  They snap out of the pattern and are able to adlib.

Treating patients is exactly the same.  Great clinicians follow a system and recognize patterns they have seen thousands of times.  The key for the complicated patients is that the clinician is able to see where the patterns don’t fit and where they do!

I co-founded an education company, The Association of Clinical Excellence, where everything we do revolves around 2 simple principles.  The principles help us to establish and reinforce patterns.  The first of these is our Treatment Philosophy and at the heart of the Treatment Philosophy is a simple, test, treat, retest method.  It allows us to recognize patterns in our practice and because we are constantly reassessing, we can quickly recognize when an outlier exists.  Best of all, we can quickly change because of it.

If I am treating a patient for a gluteal tendinopathy and notice that their lumbar screen turns up (+) or screen the hip joint and see pathologic findings, I know I need to shift gears.  I put tendon loading progressions² on hold and determine whether an intervention at the hip or lumbar spine can change a patient’s pain or impairment.  If it can, then the tendon loading is likely still important, but I need to address the other issues to drive the patient outcomes we are all looking for!

This method of treating allows us to establish methods for quick decision making based on both the literature and our personal experiences.  It also allows us to follow habits, but also snap out of the habit to allow us to treat the individual patient’s variance.


  1. Duhig C. The power of habit:  Why we do what we do in life and business. Random House.  2012.
  2. Grimaldi A, Fearon A. Gluteal Tendinopathy: Integrating Pathomechanics and Cliinical Features in Its Management.  J Orthop Sports Phys Ther.  2015;45(11):910-922.

Feedback Leads to Better Exercise Quality in Adolescents with Patellofemoral Pain.

Adolescent Knee Pain

Adolescents with patellofemoral pain (PFP) do not comply with their exercise prescription, performing too few and too fast repetitions, compromising recovery. The authors investigated if real-time feedback on contraction time would improve the ability of adolescents with PFP to perform exercises as prescribed.

A randomized, controlled, participant-blinded, superiority trial with a 6-wk intervention of three weekly sessions of three elastic band exercises was undertaken. Forty 15- to 19-yr-old adolescents with PFP were randomized to real-time BandCizer™-iPad feedback on contraction time or not by a physiotherapist. The primary outcome was the mean deviation from the prescribed contraction time of 8 s per repetition. Secondary outcomes included isometric hip and knee strength, Kujala Patellofemoral Scale, and Global Rating of Change.

The mean deviation from prescribed 8 s per repetition contraction time was 1.5 ± 0.5 s for the feedback group, compared with 4.3 ± 1.0 s for the control group (mean difference: 2.7 s (95% confidence interval = 2.2-3.2, P < 0.001). On the basis of total contraction time during the intervention, the feedback group received 35.4% of the prescribed exercise dose whereas the control group received 20.3%. Isometric hip and knee strength increased significantly more in the feedback group compared with controls (mean difference = 1.35 N·kg, 95% confidence interval = 0.02-2.68, P = 0.047). There were no significant differences in Kujala Patellofemoral Scale and Global Rating of Change between groups, but the study was not powered for this. Real-time feedback on contraction time resulted in the ability to perform exercises closer to the prescribed dose and also induced larger strength gains.

Effects of progressive muscle relaxation training on sleep and QoL in patients with pulmonary resection.

The inadequate quality and nature of sleep is a commonly reported problem among hospitalized patients. The purpose of this study is to examine the effects of progressive muscle relaxation training program on sleep quality, sleep state, pain, and quality of life in patients who underwent pulmonary resection.

The study was planned as a single-blind prospective randomized controlled trial. The study was conducted on 26 patients who underwent surgery by using posterolateral thoracotomy method. Progressive muscle relaxation training were given to the training group with a therapist two times a day. Sleep quality, daytime sleeping, pain, and quality of life were respectively evaluated in the morning before the surgery and 1 week after the surgery by using Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, visual analogue scale, and Euro Quality of Life-5D (EQ-5D).

There is no significant difference between preoperative groups in the total Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Euro Quality of Life-5D, and visual analogue scale scores (p > 0.05). The intra-group change in the study group showed a significant deterioration in the Euro Quality of Life-5D and visual analogue scale scores (p < 0.05). There was a significant deterioration in the total Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, EQ-5D, and visual analogue scale scores in the control group (p < 0.05). The Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Euro Quality of Life-5D scores showed significant improvements in the relaxation training group after treatment at 1 week (p < 0.05). Progressive muscle relaxation prevents a decline in patient-reported sleep quality following pulmonary resection.

A Novel Mobilization for Acute Ankle Inversion Sprains

The case in the video was a severe ankle inversion sprain on the left and moderate on the right. The patient is a high level gymnast who injured herself tumbling during a floor routine.

The video below was taken almost a week after the sprain. She had significantly decreased mobility with pain in all planes. Normally I would try a posterior glide to the lateral malleolus and ankle inversion/plantarflexion, which has worked on her in the past with great results. This time, that was too painful as was lateral malleolus contact. 
Instead, I tried slacking the irritated skin and ligaments while gradually moving the forefoot/ankle into dorsiflexion and eversion. This was pain free and after working my way to end range, her active/passive NWB range was much better and her gait was nearly pain free. This got her started with loading and was easily replicated for an hourly home exercise program to modulate pain. Videos of various motor control drills will be posted soon!
A Novel Mobilization for Acute Ankle Inversion Sprains

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Keeping it Eclectic…

Meta-analysis of transcutaneous electrical nerve stimulation for relief of spinal pain.

Patient Applying Electrical Stimulation Therapy ( Tens ) On His

The authors conducted a systematic review and meta-analysis analysing the existing data on transcutaneous electrical nerve stimulation (TENS) or interferential current (IFC) for chronic low back pain (CLBP) and/or neck pain (CNP) taking into account intensity and timing of stimulation, examining pain, function and disability. Seven electronic databases were searched for TENS or IFC treatment in non-specific CLBP or CNP. Four reviewers independently selected randomized controlled trials (RCTs) of TENS or IFC intervention in adult individuals with non-specific CLBP or CNP.

Primary outcomes were for self-reported pain intensity and back-specific disability. Two reviewers performed quality assessment, and two reviewers extracted data using a standardized form. Nine RCTs were selected (eight CLBP; one CNP), and seven studies with complete data sets were included for meta-analysis (655 participants). For CLBP, meta-analysis shows TENS/IFC intervention, independent of time of assessment, was significantly different from placebo/control (p < 0.02). TENS/IFC intervention was better than placebo/control, during therapy (p = 0.02), but not immediately after therapy (p = 0.08), or 1-3 months after therapy (p = 0.99). Analysis for adequate stimulation parameters was not significantly different, and there was no effect on disability.

This systematic review provides inconclusive evidence of TENS benefits in low back pain patients because the quality of the studies was low, and adequate parameters and timing of assessment were not uniformly used or reported. Without additional high-quality clinical trials using sufficient sample sizes and adequate parameters and outcome assessments, the outcomes of this review are likely to remain unchanged. These data highlight the need for additional high-quality RCTs to examine the effects of TENS in CLBP. Trials should consider intensity of stimulation, timing of outcome assessment and assessment of pain, disability and function.