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Having low self efficacy has been linked to having things like increased pain, presence of tender points and more. For our first post on High Self Efficacy, click here. Read the awesome infographic by Brad Beer below on 5 Things Low Self Efficacy Increases.



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[LACK OF BELIEF IN OUR ABILITY:LOW SELF EFFICACY] 🧠 _ 👉🏻Last week I posted on how an individual’s self-efficacy plays a major role in how goals, tasks, and challenges including injuries are approached 👀 _ 👉🏻I outlined how higher levels of self efficacy have been associated with better rehabilitation outcomes (where self-efficacy = a person’s belief in his or her ability to succeed in a particular situation) 🎯 _ 👉🏻Individuals who have high self-efficacy will exert sufficient effort that, if well executed, leads to successful outcomes, whereas those with low self-efficacy are likely to cease effort early and fail ⚠️ _ 👉🏻 A 2018 published systematic review* which looked at the role of self-efficacy on the prognosis of chronic musculoskeletal pain found that low levels of self efficacy increased 1-5 listed in the infographic above☝🏻 _ 💻*Ref: The Role of Self-Efficacy on the Prognosis of Chronic Musculoskeletal Pain: A Systematic Review. Martinez-Calderon, Javier et al. The Journal of Pain, Volume 19, Issue 1, 10 - 34 _ 👉🏻Big thanks to @shoulder_physio for bringing this paper to my attention at recent ‘Shoulder Rehabilitation’ workshop 💡 _ 📌TAKE HOME: if inured be aware that your beliefs in your ability to contribute to a positive rehabilitation outcome matters. It’s important to work with a practitioner who promotes & fosters higher levels of self efficacy through their language & guidance 🗣✅ . #training #running #fitness #health #rehabilitation #marathontraining #runners #physio #sportsphysio #sportsscience
A post shared by Brad_Beer Running.Physio 🏃‍♂️ (@brad_beer) on Jul 2, 2019 at 4:40am PDT


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Loss of rotation or unilateral upper cervical headaches could benefit from an Upper Cervical Rotation Mobilization.
No need for uncomfortable and repeated oscillations into the barrier. Try this quick and comfortable Upper Cervical Rotation Variation and instruct on repeated retraction and rotation with ipsilateral eye gaze and isometrics for a home reset.
A Better Upper Cervical Rotation Mobilization - YouTube


Be sure to check out our full online seminar Modern Manual Therapy: The Eclectic Approach to UQ and LQ Assessment and Tx! - new modules being added for Upper Quarter Closed Chain Patterns soon - 12 hours and 27 modules!

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Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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When a clinician thinks of dizziness from the neck, or Cervicogenic Dizziness or Cervicogenic Vertigo, typically the zygapophyseal joints come to mind as a proprioceptive and nocioceptive abnormal afferent input.
In fact, most authors agree that the following order, C1-2, C2-3, C0-1 and C3-4, are the most often influenced in cervical symptoms following mTBI due to high influence of proprioceptive activity from these levels.
Moreover, the muscles of the posterior cervical spine, the suboccipital musculature, have an abundance of muscle spindles and are high in mechanoreceptor concentrations.  These deep, short intervertebral neck muscles are also typically involved in proprioceptive and nocioceptive abnormal afferent input.
Interesting enough, a recent case report in 2018 and literature review appeared in Medicine Journal with title, “Vertigo caused by longus colli tendonitis“.
For us with anatomical training, we know the longus colli is anterior to the cervical spine and doesn’t typically come to mind with proprioceptive activity.  However, we do know it has proprioceptive distribution (albeit less) and commonly injurious after whiplash injuries.
This case report of a 38 year old male with vertigo arising from longus colli tendonitis is interesting as there was no description of trauma (other than running).  The authors hypothesize that the swollen longus colli muscle stimulated the cervical sympathetic ganglia, resulting in symptoms, which were then alleviated by corticosteriod injection and acupotomy.
The hypothesis of Cervicogenic Dizziness as a cause of vertigo / dizziness has a strong trend towards the proprioceptive pathogenesis and less of a trend towards sympathetic dysfunction.  In fact, stimulation of the cervical sympathetic ganglia is now becoming discarded in the literature.
This case report, albeit n=1, brings back to life this hypothesis and although rare, could be a cause of vertigo in your patients when all other medical causes are ruled out.  Even though in this report by Shen et al 2018 found 0% of previous cases (n=278) exhibited symptoms of vertigo or dizziness, there could be some anatomical variations in the longus colli muscle and if the perfect storm was created (i.e. trauma, stress, weakness, etc), the individual could be symptomatic.
I would liked to have seen conservative treatments (i.e. physical therapy) introduced prior to invasive procedures but nevertheless, was successful for the patient and worth a read.
You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to the assessment of Cervicogenic Dizziness, which includes the appropriate ruling-out process and cervical examination of the articular and non-articular systems. Also pertinent to this blog post, the 1st day includes the “Optimal Sequence Algorithm”, a multi-faceted physiotherapist approach to diagnosis of Cervicogenic Dizziness while ruling out other causes.
If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.
AUTHORS
Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Danielle N. Vaughan, PT, DPT, Vestibular Specialist  
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

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Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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Part 1 of this Post Op Progression Series is here - 5 Considerations for Post-Op Patients

Over my years of practicing, I’ve realized that many clinicians have no criteria for progressing/regressing their post-surgical patient's rehab programs.  They seem to do it randomly or solely based on time or “just because.” And if you’re anything like me, those reasons (especially the “just because”) doesn’t fly.


So here are the thoughts, criteria, etc. that go through my head when deciding on when/how to progress (or regress) patients rehab programs.  I’m not saying these criteria are the only way to do things, the only factors to consider or that they are set in stone, rather these are guidelines I use/consider to safely progress my treatments.  Anything has to be better than nothing.

The two main areas I will touch upon are range of motion and exercises (i.e. strengthening, neuromuscular, dynamic stability, etc). This post focuses on ROM and in particular end-feels and their relevance to progression.

Range of Motion

First, let me say that if a surgeon wants certain ROM limitations, then you follow them.  And yes, I’m well aware many surgeons are behind the times and put silly, many times counterproductive, limitations on their patients.

If you feel that it would be detrimental to the patient if you follow the limitations, then I highly recommend speaking with the surgeon.  Maybe there was a reason you weren’t aware of as to why the restricted ROM. And if there isn’t a good reason and they’re just stuck in the ’90s, I’ll leave that up to you to make the call.  I know that in those instances, many of us “obey” the limitations appropriately with our patient’s best interest in mind.

If there are no restrictions placed on the patient by the surgeon, then the #1 thing I use to gauge ROM progression is end-feel.  It’s really that simple (and complex at the same time). When assessing someone’s motion, it’s not only important to quantify the amount, but also the quality of the movement and the type of end-feel.

The type of end-feel you get will dictate how you go about your ROM work for that session.  Here are common end-feels and how they affect my progression. For some joints these end-feels are normal and for others, they aren’t - the following rationales are for when that particular end-feel is abnormal for a joint:

1) Bony and 2) Springy:  don’t push into these end-feels or try to go past it.  It’s bony or springy for a reason that you can’t “fix.”  Instead, you can just irritate and potentially worsen, causing more pain for your patient by going ham on them.  It’s like trying to slam a door that has a rock in the way. You can’t progress this type of end-feel unless the underlying physical restriction is removed.  
  • Example - bone chip(s) in a joint limiting motion, meniscal fragment in the knee.

3) Soft tissue approximation: the only times I’ve thought of this as “abnormal” for a joint is in obese people. That extra mass ain’t goin’ anywhere anytime soon, so no sense in trying to progress that motion.  I know some people will put motion limited by edema in this category but I think of that as more firm.
  • Example - hip flexion limited by their gut.

4) Firm/hard: due to increased tone, soft tissue (capsule, ligament, tendon) shortening; decreased tissue mobility (i.e. from an incision).  Many patients will have this type of abnormal end-feel once that initial surgical pain subsides.

This end-feel is where you can perform your manual therapy magic and improve motion, many times without actually stretching them into the limited motion - i.e. myofascial work, IASTM, PNF, MET, repeated motions, etc.  I will “stretch” and progress these joints up to (and sometimes a little past) the firm end feel - making sure to never cause pain.  
  • Example: doing some myofascial work on the pecs, then ranging their shoulder into external (or internal) rotation until you hit the new end-feel, then repeating/or switching to another technique, ranging again, etc.

5) Empty: this is where the vast majority of post-op patients fall, especially in the early phase after surgery and the end-feel that many clinicians have a hard time progressing.  Mechanically there is no limitation, rather it’s the pain preventing the joint from going farther. So if you push through the empty-end feel and crank away, you might get some temporary increase in motion, but it will come with the costly trade-off of increased pain/soreness (and probable fear of movement).  And that increased pain/soreness and fear of movement typically causes the patient to not use the joint, guard it, etc - thereby negating the “gains” you just got.

The way to improve motion with an empty end-feel is to modulate the pain and address any underlying restrictions (i.e. joint mobility, increased tone) and then guide the joint through its pain-free range - stopping at the new end-feel.  It sounds simple and cheesy, but use pain as your guide when progressing this end-feel.
  • Example - using something like IASTM or rocktape or Gr I/II joint mobs to modulate shoulder pain and then guiding it through the new pain-free motion, stopping when it starts to hurt again.
  • ** education plays a huge role in empty end feels as well - no use in increasing motion at the expense of increasing fear avoidance

Important Note: Early on in my career, I use to do aggressive joint mobs and crank the shit out of some patients, thinking that “no pain, no gain” method was the way to go.  After a few years of that, I realized that that method wasn’t nearly as effective as I thought it was and in many cases it was actually making people worse...not to mention me tired.  I have gotten to the point now where I don’t want to cause pain with my manual treatments - some discomfort I’m ok with. If you’re one of those clinicians who is sweating after working on a patient and that patient is near tears during the treatment and super sore afterward, I challenge you to improve their ROM without ever “stretching” them into that motion - it’s easily doable and, in my opinion, more effective.

via Dr. Dennis Treubig, DPT - Modern Sports PT and creator of The Knee Terminator

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Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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On this episode, Modern Rehab Mastery mentee Dr. Dana Palmer goes over how some education changed many lives and helped save countless limbs in a small island country she decided to work at just because it looked nice.

Search for Untold Physio Stories on your favorite music/podcast apps!  

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 edgemobilitysystem.com .  Be sure to also connect with Dr. Erson Religioso at Modern Manual Therapy and Andrew Rothschild at Modern Patient Education.

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Today, I want to give you my two proven strategies for raising your rates in your cash-based practice. Check it out below!




Raise Your Rates Today! - YouTube

Raising your rates can be really scary, I get it. But that doesn’t mean it won’t work. It doesn’t mean your patients will run away screaming or new ones won’t show up. Here are the two ways I suggest:
  1. Raise your rates just a little bit. Maybe $10 to $25 per visit.
  2. Don’t just sell one visit at a time, sell the plan of care, a.k.a. the transformation.
I’ve done both, and I’m going to share how to accomplish both of them.
When it comes to the first strategy, all new patients get the new rate. Old patients can keep the old rate until they finish their plan of care. If you need to raise your rates on people who come in regularly, say once a week or month, just inform them of the date it will change. Don’t ever say “price” or “cost”—focus on using the words “investment” or “rates.” You don’t need to make any excuses. Tell them that if they pay up front for the rest of their plan of care they can stay on the old rate!

Whatever you do, don’t post about raising your rates. Instead, deal with it on a patient-by-patient basis. Don't email to everyone that you're raising rates because people who are not your patients don’t know otherwise. You're likely to turn off those people who don't need to know yet.

Here’s the deal about raising your rates: Even if your clinic has only been open for four days and you realize your rates are too low… raise them! If you feel like you are undercharging in any way, raise them! That’s how we did it. I realized $147/visit wasn’t enough to turn a profit in the business while hiring on employees. So I raised them to $247.

I can’t tell you what to charge, but I do know you can’t be charging $50 per visit If you want to grow and scale your business.



The second method involves a mindset shift. Stop selling the treatment and start selling the transformation. Stop selling one visit at a time and start selling the plan of care.

Explain to people, “So, Mrs. Jones, my recommendation for you is our ‘back to running’ program. It’s only 1998 when you decide to move forward. I’m going to finish the evaluation, do some treatment on you, and send you home with a few exercises to do over the weekend. Then I’ll give you a customized plan of care so you can get back to running in order to compete in that 5K. I want you to feel like you’re competent and capable and a great role model for your daughter without feeling like you’re doing permanent damage to your body. How does that sound?”

Most people speak that language and will immediately see it’s what they want.
You can also create an ongoing wellness program for patients who have phased out of their plans of care. It’s recurring revenue for you and helps your patients stay patients for life.

Remember: we’re not selling a commodity. We’re selling a custom solution they can’t price-shop for.

Bottom line… if you’re undervaluing yourself and what you know you can provide to patients, RAISE YOUR RATES TODAY!
If you’re interested in some more specifics on this topic, check out this video!





Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

Learn more online!


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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What qualities do you prefer in your patients? Motivation, having a growth mindset are two I prefer. Having high self efficacy is also important and has been associated with more positive rehab outcomes. Here's another awesome infographic via Brad Beer on Self Efficacy.

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[BELIEF IN OUR ABILITY: SELF EFFICACY] 🧠 _ 👉🏻What Is Self-Efficacy? It has been defined as ‘the belief in one’s abilities to organise and execute the courses of action required to manage prospective situations’ 🧐 _ 👉🏻More simply self-efficacy is a person’s belief in his or her ability to succeed in a particular situation. This belief in turn determines how we in turn can think, behave, and feel 👀 _ 👉🏻An individual’s self-efficacy plays a major role in how goals, tasks, and challenges including injuries are approached 🎯 _ 👉🏻 People with a strong sense or high levels of self-efficacy: . ▶️View challenging problems as tasks to be mastered . ▶️ Develop deeper interest in the activities in which they participate . ▶️ Form a stronger sense of commitment to their interests and activities . ▶️ Recover quickly from setbacks and disappointments _ 👉🏻People with high efficacy approach difficult tasks as challenges to be ‘mastered’ rather than as threats to be ‘avoided’ which in turn lowers vulnerability to depression ⬇️⬇️ _ 👉🏻Not surprisingly higher levels of self efficacy have been associated with better rehabilitation outcomes ⬆️💪🏻 _ 👉🏻Evidence suggests that self-efficacy can play an essential role as a protective factor + a ‘mediator’ in the relationship between pain & disability 🔁 _ 👉🏻 A 2018 published systematic review* which looked at the role of self-efficacy on the prognosis of chronic musculoskeletal pain concluded that high levels of self efficacy increased 1-5 listed in the infographic above☝🏻 _ 💻*Ref: The Role of Self-Efficacy on the Prognosis of Chronic Musculoskeletal Pain: A Systematic Review. Martinez-Calderon, Javier et al. The Journal of Pain, Volume 19, Issue 1, 10 - 34 _ 👉🏻Big thanks to @shoulder_physio for bringing this paper to my attention at recent ‘Shoulder Rehabilitation’ workshop 💡 _ 📌TAKE HOME: if injured be aware that your beliefs in your ability to contribute to a positive rehabilitation outcome matter. It’s important to work with a practitioner who promotes & fosters higher levels of self efficacy through their language & guidance 🗣✅
A post shared by Brad_Beer Running.Physio 🏃‍♂️ (@brad_beer) on Jun 26, 2019 at 2:09am PDT



Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

Learn more online!


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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In this video, I go over ways to desensitize a painful or irritated TMJ. There are 3 simple steps you can take that will go a long way toward pain relief. 


The more you avoid things that trigger or sensitize an area, the less sensitive it gets and you can handle more activity and load.
TMJ Pain Relief - 3 Ways to Self Treat - YouTube

My full online course in Temporomandibular Management is below!



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Typically when someone thinks of a concussion, a picture below comes to mind.


Cervicogenic Dizziness from Impact to Chest - YouTube
But, we also know sport-related concussion is just one type of injury that is associated with the diagnosis of concussion, or mTBI.  Prior to the recent build-up of information and data on concussion in sport over the last several years, we would treat similar symptoms in patients presenting with whiplash-associated disorders.
So, for those us treating whiplash, this type of image usually comes to mind.
One impact approach that typically doesn’t come to mind, but could potentially be more prevalent (although may require twice the rotational velocity) in contact sports (especially with changes in tackling rules) is the biomechanical response to the cervical spine from primary impact to the chest.
Potentially a picture like the one below can come to mind.
Instead of just helmet-to-helmet collisions, we can’t forget impulsive force transmitted to the head from a direct blow somewhere else.  This is in the definition from the 2012 consensus statement and considering the acceleration strain placed on the head and neck with this type of impact, we don’t want to forget this mechanism and potentially rehabilitation methods with this type of contact.
A recent study by Jadischke R et al in 2018 examined the biomechanical response and strain of the upper cervical spine and brainstem from chest impact in their study entitled, “Concussion with primary impact to the chest and the potential role of neck tension”.
Even though chest impact collisions causing concussion place lower stress on the neck, the authors did find that neck tension or strain along the axis of the upper cervical spine cord and brainstem is a possible mechanism of brain injury in concussion.


http://www.iccseminars.com
Don’t always imply a neck injury results in a brain injury, but also don’t imply lack of direct head collision means less stress to the cervical spine.  You may just be missing a key component in manual and/or sensorimotor rehabilitation to get maximal results in your patients.
You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes treatments of the articular and non-articular system of manual therapy and the most updated sensorimotor exercise regimen.
If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.
Authors
Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Danielle N. Vaughan, PT, DPT, Vestibular Specialist

Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

Learn more online!


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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I don’t think these will come as any surprise to people, but they are often overlooked by clinicians (especially those who work in really busy clinics) and they can play an important role in a session.





Other Factors I Consider

I don’t think these will come as any surprise to people, but they are often overlooked by clinicians (especially those who work in really busy clinics) and they can play an important role in a session.  I’m sure there are other factors that I think about but these are the ones that came to mind:
  • Mood - if someone is just having a bad day, you probably don’t want to add more challenging exercises or increase the intensity of exercises
  • General health - are they a little under the weather, did they have a bad night’s sleep, etc. - these all get factored into my thoughts
  • Stress - is the person always stressed out, then you’ll probably have to progress things slower because their body just won’t be able to adapt as well
  • Vacation/special event coming up - you don’t want to add in some new exercises if their daughter is getting married the next day, or they’re leaving for a much-needed vacation soon, etc.  You don’t want to be that guy that made them sore for an event they were looking forward to
  • Prior training experience - this can be a good thing (expect and understand DOMS, technique, etc) or a bad thing (have no clue what to expect afterward, set/rep schemes, etc)

Summary

So those are some of the factors/criteria I consider and the thought process that goes through my head when deciding how to progress/regress patients’ programs.  It’s not an exact science or set in stone, but it at least gives me some set of guidelines instead of doing things randomly at will.


Let me know what I missed or what other guidelines you use! Look for other post op considerations in part 2 of this post!

Want to learn in person? Attend a #manualtherapyparty! Check out our course calendar below!

Learn more online!


Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. Live cases, webinars, lectures, Q&A, hundreds of techniques and more! Check out Modern Manual Therapy!

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