Bio-chemico-physio-behavioro-environmento being

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“Why didn’t the brain go to the party? Because he had no body to go with!” – My 6.8 yr old.
There is only one thing. There is no disconnect. It is all connected, as in, related. Interacting, melding, smushing, giving and taking and trading.
There only reason you think that Chemistry is separate from Biology is because we, as humans, divided up the information in to chunks. There is no actual divide. You cannot have biology without chemistry. You cannot have either without physics, and physics is nothing without matter (chemical, particle or biological). Thusly, there is no divide, it simply depends on where you point your lens. What do you choose to “pull out” as important?

For those that get focused on the brain as the great interactor, the great computer switch-board control center, I have news for you. There is no separation of brain from body. (Unless your capi has been detated, as in: decapitated). There is only one. Yes we have phantom feeling (feeling a limb that is not there) and numbness/flaccidity (not feeling a limb that is there) and a lot of that is moderated via CNS synapses. But those synapses have been influenced by the feedback loops (positive and negative) and responses from the system. The give and take.

Additionally, there is no separation of your body (and that brain) from the environment. You don’t exist without one. You (as in you) can be inspired, mood altered, chilled, pressured and on… all from environmental factors. The environment can give you the sense that there is no way out. And then that becomes how it is. This is not separate from the you that is you.
Each is a dynamical system within the other, influencing the other, non-existent without the other.
Think of that little muscle cell, way off in that thigh muscle group. Her environment is chemistry and biology and physics and everything. That muscle can live in a toxic environment of increased CO2 in the blood due to COPD, perhaps the muscle lacks adequate C6H12O6 due to Diabetes or other factors. You cannot separate the cell, or the RNA, or the quark from the homeostatic realism of being in a body.
Thus, when you learn of a new thing, keep it in the context of the whole. This is no “butterfly affect” type of thing. This is the real world. The present.
See your patient as a cell, grouped as tissues, grouped as organs, grouped as organ systems, grouped as an organism, grouped as a whole, grouped into a family, a community, an environment, a world. (Yes I just used verbage describing these as separate, sorry)
We don’t treat body parts. We treat people. But people are just part of the whole.
See the whole.
Matt Dancigers, DPT
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

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Exercise Effects of Treating Low Back Pain

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Exercise and physical activity has been known to effectively treat low back pain. Recent studies demonstrate that over 12 months, researchers who carried out range of motion exercises had decreased the risk of low back pain by 35 percent!

Additionally, those that were taught to lift with proper ergonomics reduced their risk of low back pain by 35 percent.

In the UK, 1.6 million people suffer from chronic back pain and 25% of those are at risk of losing their jobs due to chronic back pain. Research contradicts staying in bed and demonstrates the benefits of exercising in addition to reducing rates of heart disease and diabetes.

Physiotherapy has been shown to effectively treat and prevent low back pain by decreasing fear and avoidant behaviors and maintaining movement.

Read More Here

Kinesio taping in musculoskeletal pain and disability that lasts for more than 4 weeks: is it time to peel off the tape and throw it out with the sweat? A systematic review with meta-analysis focused on pain and also methods of tape application.

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In recent years, Kinesio tape has been used to support injured muscle and joints, and relieve pain. We compared the pain and disability in individuals with chronic musculoskeletal pain who were treated with Kinesio taping with those using minimal or other treatment approaches. Searches of eight major electronic databases were conducted. Data for pain and disability scores were extracted. Meta-analyses (wherever possible) with either a fixed or random effect(s) model, standardised mean differences (SMDs) and tests of heterogeneity were performed. Seventeen clinical-controlled trials were identified and included in the meta-analyses. When compared to minimal intervention, Kinesio taping provided superior pain relief (pooled SMD=-0.36, 95% CI -0.64 to -0.09, p=0.009) but the pooled disability scores were not significantly different (pooled SMD=-0.41, 95% CI -0.83 to 0.01, p=0.05). No significant differences were found when comparing Kinesio taping to other treatment approaches for pain (pooled SMD=-0.44, 95% CI -1.69 to 0.82, p=0.49) and disability (pooled SMD=0.08, 95% CI -0.27 to 0.43, p=0.65).

Kinesio taping is superior to minimal intervention for pain relief. Existing evidence does not establish the superiority of Kinesio taping to other treatment approaches to reduce pain and disability for individuals with chronic musculoskeletal pain.

After-hours or weekend rehabilitation improves outcomes and increases physical activity but does not affect length of stay: a systematic review.

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In adults undergoing inpatient rehabilitation, does additional after-hours rehabilitation decrease length of stay and improve functional outcome, activities of daily living performance and physical activity? This was a systematic review with meta-analysis of randomised trials. Additional rehabilitation provided after hours (evening or weekend) was provided to the participants of these studies. Function was measured with tests such as the Motor Assessment Scale, 10-m walk test, the Timed Up and Go test, and Berg Balance Scale. Performance on activities of daily living was measured with the Barthel index or the Functional Independence Measure were all outcome measures used within the studies included. Length of stay was measured in days. Physical activity levels were measured as number of steps or time spent upright. Standardised mean differences (SMD) or mean differences (MD) were used to combine these outcomes. Adverse events were summarised using relative risks (RR). Study quality was assessed using PEDro scores. Seven trials were included in the review. All trials had strong methodological quality, scoring 8/10 on the PEDro scale. Among the measures of function, only balance showed a significant effect: the MD was 14 points better (95% CI 5 to 23) with additional after-hours rehabilitation on a 0-to-56-point scale. The improvement in activities of daily living performance with additional after-hours rehabilitation was of borderline statistical significance (SMD 0.10, 95% CI 0.00 to 0.21). Hospital length of stay did not differ significantly (MD -1.8 days, 95% CI -5.1 to 1.6). Those receiving additional rehabilitation had significantly higher step counts and spent significantly more time upright. Overall, the risk of adverse events was not increased by the provision of after-hours or weekend rehabilitation (RR 0.87, 95% CI 0.70 to 1.10).

Additional after-hours rehabilitation can increase physical activity and may improve activities of daily living, but does not seem to affect the hospital length of stay.

Where Do You Place Your Responsibilities?


Where should we place our responsibilities– with our patient/customer or our referral source?


As physios, we sometimes walk a fine line between wanting to do what’s best for our patients while not disrupting relationships with our referral sources. For most of us, physicians remain the primary referral source for physio. With improvements to direct access in many states, and the gradually changing landscape in health care delivery, I see a future (hopefully not too distant), where our patients/customers and clients will become our principal referral source. In the meantime, however, this can be a challenging dilemma that many of us, if not already, will likely face.

I posed this question to Dr. Jeff Moore (@jeffmooredpt) on the 12/31/15 “open mic” episode of #PTonICE. Jeff argued that we (both us and the referral source) should be acting as a team together to help the patient. In many cases, depending on the relationship we have with the referral source, I agree that that would be the ideal scenario. However, we don’t often always have the luxury of those kind of relationships with all our referral sources. So what to we do in those situations where some gray area exists? Sometimes we can view this situation as an opportunity to try to get in front of that particular physician, provide some education, discuss concepts on equal professional ground, and perhaps form a new or better relationship as a result.

Regardless, there are times when patients receive unintended, yet “harmful,” and even incorrect information from physicians, which then needs to be made clear and/or re-framed. This is especially true when common diagnoses such as “degenerative disc disease” are given, and more specifically in regards to the challenging concepts within pain neuroscience. Now, there is certainly a way to go about addressing conflicting information without directly stating that the physician is “wrong,” (I would advise looking elsewhere for advice on how to specifically do that as it is not my strong suit). Still, the time may arise when establishing our knowledge, expertise, and value may fly directly in opposition of a referral source.

I see a lot of chatter, especially on Twitter, to #disruPT. While there are many ways to go about this, one clear way that I can identify is working physio out from under the proverbial thumb of the medical establishment. We are the rehabilitation experts. We are working towards being the movement system experts. We may even be the experts at reducing risk (I don’t like the absolute implication of the term “prevention”). Bottom line, if we are the health care practitioner providing the bulk of the care, and it is within our field of study which we are the experts in, and the information may directly relate to patient buy-in to a plan of care or treatment approach, then I have little reservation about making that point clear.

Just this past week I had a county police officer present to me with a diagnosis of DeQuervain’s tenosynovitis. He recalls feeling a snap and immediate pain while pulling his gun from the holster during firearms training in mid-December. In October, he had developed discomfort in that same area without any specific mechanism. When the department found out, he was compelled to see a specialist.  After a reportedly very minimal exam from the orthopedist, he was given a cortisone injection in the area.

From a clinical decision making perspective, that’s a quick leap from examination to diagnosis to an invasive treatment with questionable efficacy. But how else is the poor physician to get paid? Reimbursement, sorry, Jerry (@Jerry_DurhamPT), payment,  too often is the driving force of clinical practice. Perhaps it’s a cynical view, but it’s what I see. The unknown question in this particular case is did the injection potentially lead to a partial tendon rupture (which I think he has). Now consider the impact– a more serious tissue injury with a potentially longer rehabilitation time, a police officer unable to work full duty and out on worker’s compensation, all which results in increased health care expenditure. Who’s affected by all of this? Well, the patient is, the police department is, the community is, the local economy potentially is, and the health care system is.

Bottom line, it should first and foremost be about the patient in front of us. If we are a customer service-first provider, shouldn’t the customer in front of us take precedent? And with the growing impact of direct access and the health care consumer, they will start to take on a bigger role as the decision makers, transitioning away from the traditional model. And, as I hopefully illustrated, I feel that our responsibilities also lie beyond just the patient or the referral source. Our responsibilities are also to our employer, our profession, and society. After all, a healthy society is a productive society. There’s a reason why in other countries such as Australia, physio is the first option.

Now, you might argue that upsetting a referral source has the potential to be bad for business and therefore have a negative impact on the clinic/employer. Yes, maybe in the short term. But in taking the long view, each individual patient is a possible referral source in their own right. Don’t we all want patients/customers who choose to come see us (internal motivation), rather than are told (external motivation)?


When your organization becomes more human, more remarkable. faster on its feet and more likely to connect directly with customers, it becomes indispensable— Seth Godin

I will conclude that Jeff’s point mentioned earlier is well-taken. The better our relationships are with all our referral sources, and the more of them that we can accumulate, the better overall the health care delivery will be. A team approach with a unified message is of course a preferred option. But in the absence of that, I view each patient/customer as an opportunity to establish our expertise, our knowledge, and ultimately our value, not only to that individual sitting in front of us, but eventually to society as a whole.

Thanks for reading.

-Andrew

opening photo credit courtesy stokpic



Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic…

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Isometric Flexion Pattern to Improve Toe Touch

Here is another easy way to improve toe touch and reduce perception of stretch and tightness in the LQ posterior chain.

Isometric Flexion Pattern to Improve Toe Touch


Why does this work? My thoughts are activating the previously flexion pattern without the “bad feeling” in your hamstrings/calves. Do this enough and the association of that perception with that movement pattern is now disassociated.
 If there is still some discomfort with the active straight leg raise, you can add an EDGE Mobility Band to further decrease stretch perception. Make sure with the ASLR that you do not perform it too slowly as this tends to fatigue the hip flexors prior to completing the pattern.
Interested in live cases where I apply this approach and integrate it with pain science, manual therapy, repeated motions, IASTM, with emphasis on patient education? Check out Modern Manual Therapy!

Keeping it Eclectic…

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The clinical reasoning processes of extended scope physiotherapists assessing patients with low back pain

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Employing allied health professionals in extended scope roles has developed relatively recently in health-care. Within physiotherapy, the extended role has provided clinicians with autonomy to use knowledge and clinical acumen to request investigations such as Magnetic Resonance Imaging (MRI) and X-ray as part of the diagnostic process, a practice beyond the traditional scope of physiotherapy. In these advancing roles, little is written about the clinical reasoning processes that clinicians use in managing patients with musculoskeletal pain and knowledge of these processes would advance training for new recruits to this arena. This qualitative study has explored the processes by which extended scope physiotherapists (ESPs) clinically reason their decisions regarding patients reporting low back pain in a musculoskeletal outpatient setting. The study used a multiple case study design informed by grounded theory methodology, using focus groups (involving ESPs and non-ESPs/musculoskeletal physiotherapists) and semi-structured interviews with a think-aloud method (ESPs only) to investigate these processes.

The themes identified include: prior thinking; patient interaction; formal testing; time; safety and accountability; external and internal factors; and gut-feeling (which challenges current physiotherapy models of reasoning). Extended scope physiotherapists reported experiencing greater stress due to higher levels of perceived accountability, safety requirements and internal drivers for competence than non-ESPs. Further research is indicated to explore the role of gut-feeling in musculoskeletal physiotherapy clinical reasoning.