MedBridge Go

Are you having issues with patient adherence to HEP? MedBridge’s new application may be the next big solution. 

No matter the dialect, we have all heard this statement!

Everyone knows the importance of what is prescribed for patients outside of the clinic but we also all know the low adherence rate.  From personal experience, correlation with medication intake research and word of mouth from other clinicians, I would suggest adherence rate ranges around 30 percent.  I think this number is alarming on how effective what we prescribe as HEP can really be to help others maximize benefit from our in-session services.

Do you think the lack of compliance with your HEP is affecting your outcomes and results in your clinic?

I know for sure that the extent of adherence varies greatly amongst patients including their diagnosis and prognosis—with special attention at our various generations.  Honestly, I find the Traditionalists are the most adherence whilst Millennials and even Centennials have the worse compliance rate.  In my clinical opinion, the focus of our younger patients is the most challenging as paper handouts just don’t do the trick.

It could be the combination of morals, work ethic and simply lack of hustle, but needless to say, clinicians need to find savvy ways to make our HEP more appealing.

The MedBridge GO application does just this.

Just like the MedBridge online continuing education site, you will not be disappointed by the simple to use interface combined with eye pleasing visuals.  The application runs seamless allowing the patient to follow along with the specific HEP from the prescribing physical therapist just like a video.

It reminds me of the very common and popular exercise DVDs from Tony Horton and Shaun T —including repetition and set count, as well as a timer to make sure you hold each exercise for the correct amount of time.

The application can be easily downloaded to your patient’s phone for portable use to use at home or the office.  The therapist can create the personalized home program so the patient can follow along in the correct order, timing, frequency and duration to maximize results.  Additionally, the reminder option can cue your patient to perform exercises based off of your recommendation.

Nothing like positive reinforcement and goals to help your patients stay on track and consistent with rehabilitation through a difficult time in his or her life.

 

Could this application be the next phase to bring HEP up to speed with today’s generations?  It just may.

MedBridge is more than a continuing education company but also includes HEP and Patient Education Modules.  This application just came out so be sure to take a few minutes to review it yourself and see if it will improve the experience and outcomes for your patients.

For now, join to get hundreds of continuing education courses.  Use code inTOUCH for over 50% off on the annual subscription! Not a bad deal at all!

 

 

Cervicogenic Dizziness – Excerpt from Maitland 1979

Cervicogenic Dizziness, Cervical Vertigo
Courtesy: http://www.imta.ch/

I am a big believer of standing on the shoulders of giants.  Even though I am not “Maitland trained”—I use his constructs of concordant sign, sensitivity/irritability and several other clinical reasoning aspects in my examination and treatment approaches.  You cannot deny the impact he had on our profession.

I am reaching a decade now (old man status!) of treating in clinical practice and feel like I am seeing more and more that our predecessors are being put down, bashed, exonerated by writings and teachings of that time.   Maybe this is not everyone of course, but through the pits of social media, the bubble is expanding.  I am all about growth and science, but the concepts and principles behind assessing and treatment can still stand strong.  I always remember this foundation and add research on top of it—-to make things positive overall for us, keep reading and pounding out knowledge as the PT profession continues to grow as the best team in musculoskeletal conservative care with updates in research as the “why” of “what” we do is better explained.

Remember—it is always easier to critique than create.

We build off of each other and grow with decades of research, clinical practice and self reflection.  The way I see it—the time line of growth and education is not linear, but builds off like tree rings.

With that being said, it brings me to this excerpt from Maitland in 1979 about differentiating dizziness from arterial dysfunction (i.e. vertebrobasilar insufficiency) to cervical spine dysfunction.

Cervicogenic Dizziness

Of course by just reading this, we can mock the lack of clinical metrics behind this thought process (where are the sensitivity and specificity values!?), where is the research citation, how many of your dizziness folks can just go and lie prone??—- However, it is a concept based off of standardized thought processes in our field—-looking at effects of gravity, loaded/unloaded positions, reactions in latency and duration of symptoms, etc.

I would second guess this thought process by saying first we need to evaluate blood pressure, heart rate and appreciate the entire haemodynamic system!  We need to do a thorough screen prior to putting the neck at a risk for mechanical thrombus if the patient walks in with a spontaneous dissection!  We need to rule out a higher probability of dizziness through other benign conditions, such as through a canalith repositioning manuever!  Bam Bam Bam!

The previous paragraph is partly what I teach in my Optimal Sequence Algorithm to diagnose Cerviogenic Dizziness. I feel the components of the examination are the most sound, evidence-based approach based off of concept of diagnosis of exclusion, other reasonable reasons for symptoms, epidemiological data and prevalence/incidence of cervicogenic dizziness in the population.

Interesting enough….DeKlyne first spoke about the VBI test over 75 years ago and this wasn’t mentioned in Maitland’s work from 1979….Maybe he already knew the limitations behind it before we had clinical guidelines and clinical metrics.  I’m certainly glad he didn’t say drop the patient’s head off the edge of the table and see what happens.

Maybe its the history buff in me, but I enjoy looking back at these old articles.  They really can be considered blogs of modern times—-written by 1 author, 3-4 references and straight clinical interpretations.  Don’t give up on our past—but use it positively to build our future.

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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 first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

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 prices and discounts.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

Cervicogenic Dizziness – HINTS Exam

Cervicogenic Dizziness, Cervical Vertigo

The ability to differentiate between central and peripheral causes of dizziness went to another level by the work of Kattah et al in 2009.  The three-step bedside oculomotor examination was found to be more sensitive than early MRI diffusion-weighted imaging and really opened up the eyes (no pun intended) in regards to clinical diagnostic accuracy to the plinth vs imaging examination approach.

Since then, the works of Chen et al 2011 and especially the passion and agenda of several literary pieces by Newman-Toker, have further examined the diagnostic accuracy of the HINTS examination with highly powerful clinical metrics as a screening tool and potentially need for less imaging.

With a sensitivity ranging from 96.8% to 100%, the 3 step process is phenomenal for clinicians!  It definitely beats any of the PT so called clinical decision rules.

However, I wouldn’t hang my hat on this solely, especially if you’re a PT.  Three main points are made below:

Firstly, unless you have been trained in neuro-otology or neuro-opthalmology, then you may not be as reliable as these guys/gals.  Most of the studies involve an extensive training program and know what to look for in regards to a pathological sign.

Secondly, unless you pound out Direct Access (and most of us seeing dizziness aren’t….), then you aren’t seeing the patients under inclusion criteria set forth in the studies: which is typically a time frame of symptoms less than 7 days. 

Thirdly, all of the studies used a strict inclusion criteria—-resulting in studying moderate to high risk populations—ones with risk factors such as hypertension, diabetes, nausea/vomiting.  Therefore, if you are examining a low risk population, then the HINTS diagnostic sequence may not be as applicable or powerful in its accuracy.

HINTS is a fantastic sequence of objective clinical measures that individually, do not have much influence on a clinical decision, but combined, can be very powerful. Of course we do not rely on one test for diagnoses of other conditions, but a combination of tests/measures highly increases the diagnostic credibility.  I wrote about this with SIJ testing several years ago and more of common practice now in SIJ dysfunction diagnostics.

We teach the HINTS examination, but in context with other clinical features, risk factors and statements in the Subjective Examination and only in combination with other Objective clinical tests that are conceptual to cervicogenic dizziness.  This is what I do in my Optimal Sequence Algorithm.

cervical vertigo, cervicogenic dizziness, manual therapy, cervical spine
Rights Reserved: Harrison N. Vaughan, DPT, FAAOMPT

If you want to learn more how to screen your patients and feel MOST confidently in addressing dizziness from a cervical origin, we have it all in our Optimal Sequence Algorithm.  Sign up here for more emails!

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 first day provides the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” to assist in ruling out disorders and ruling in cervical spine, including determining if single or double entity exists.  

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 prices and discounts.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

Cervicogenic Dizziness – Controversial Entity between Professions

Cervicogenic Dizziness, Cervical Vertigo

There is controversy between professions.


Gonzalez and Palacios in 2001 wrote an article, “Cervical Dizziness: A Scientific Controversy” in Fisiotherapia Journal.  The final wording in the manuscript, albeit translated from Spanish to English, basically sums of the controversy that surrounds the diagnosis and treatment of cervicogenic dizziness in one sentence.

For practitioners of physiotherapy and manual medicine, the vertigo of cervical origin is almost unquestioned, treatable and solvable entity mostly, while for professionals otolaryngology and scholars of the vestibular apparatus and balance, their relationship remains hypothetical and in many cases questionable.

Gonzales and Palacios 2001


There is controversy between professions.


To those in the professions of manual medicine and rehab—osteopathy, acupuncture, chiropractic and physical therapy—the diagnosis and treatment of cervicogenic dizziness obviously occurs and can be present in many subsets of different populations.  To anyone who has dealt with this in their office, this seems to be a no brainer as results speak for themselves.  However, outside the manual medicines, including otoneurology and audiology; the diagnosis of exclusion stands concrete and likelihood of referring out is much less likely.  In fact, most of the literature denotes less than a 10% prevalence rate with dizziness from cervical origin and majority of studies consistently outside of the rehabilitation and manual realm do not list it at all under differential diagnosis.

Could cervicogenic dizziness be embellished in the manual medicine fields and neglected in the allopathic medical field?

cervical vertigo, cervicogenic dizziness
Cheever et al 2016

The question remains, what makes the incidence and prevalence so different between the professions?

Is it a business argument?  Obviously manual medicine and rehab can benefit from treating these patients, where medication and imaging does not work.

Is it science?  The diagnosis of dizziness from a cervical origin continues to be under debate and scrutinized (Brandt 1996, Brandt/Bronstein 2001).  There is a discrepancy in the pathophysiology, lack of diagnostic criteria including a well established clinical test or a specific laboratory test, and many other diagnoses can be a convincing alternative reason for symptoms.

Is it ethical?  With a lack of a true diagnostic test, unknown epidemiological data points and prognostic time line of improvement—could the manual medicine fields provide unethical treatments— scientific implausible treatments or even fraud?

Is it training?  Anyone in the physical therapy field knows the lack of training in the MSK field by physicians—we fuss about this all of the time.  We contend about their lack of knowledge to refer to us for even less controversial diagnoses.  You can imagine, considering even a small percentage of manual medicine that focuses on cervicogenic dizziness, that medical physicians do not have training or knowledge to refer out to us for this condition.  Just recently, Reneker et al 2015 found a distinct difference between professions regarding utility of clinically diagnostic tests for differentiating cervical and other causes of dizziness s/p concussion.  In fact, three tests, 1) passive joint mobilization, 2) palpation of cervical musculature and 3) joint position error testing were shown to have high utility to diagnose cervicogenic dizziness by PTs (62%, 53% and 47% respectively), but NONE of these were selected by a single neuro-otologist!


There is controversy between professions.


With such discrepancies between the philosophies and clinical approaches between the medical trades, it is no wonder there is never “cervicogenic dizziness / cervical vertigo” is not on a script.  We must meet on the same playing field here and see both sides of the argument with the manual and non-manual fields.

A fair result can only be obtained only by fully stating and balancing the facts and arguments on both sides of each question.

Charles Darwin

It can be challenging to go speak to physicians about this condition as we do not have the juice to provide in regards to evidence.  However, this is an emerging area of practice and the physical therapy field is gaining traction in RCTs by Susan Reid’s work to put more power to our trade.  With that being said, if you want to learn the evidence to present to physicians, either in the elderly, s/p concussion, s/p whiplash or some other head/neck insult—we got you covered because there is controversy between professions. 

 

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 entire weekend includes the most up-to-date evidence review from multiple disciplines to diagnose through the “Optimal Sequence Algorithm” and treat through the “Physio Blend”. 

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 prices and discounts.

Sign up for more emails on this topic by clicking here

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

 

 

Cervicogenic Dizziness – should you treat the upper trapezius?

Cervicogenic Dizziness, Cervical Vertigo

trap

Simons and Travel 1999 describe myofascial pain (MP) as a common symptom usually caused by myofascial trigger points (MTrPs). The MTrPs in the neck muscles have been associated with a possible source of referred facial and cranial pain and could contribute to the nocioceptive activity occurring with Cervicogenic Dizziness.  The muscle most often affected with the presence of MTrPs in the neck region is the trapezius muscle,  specifically the upper fibers, and this is the most hyperalgesic muscle of the neck and shoulder (Sciotti et al 2001, Melegar & Krivickas 2007, Fischer 1987).  In fact, it is well established that treating soft tissue dysfunction of the upper trapezius is effective in the management of nonspecific cervical pain (Cagnie et al 2015,  Montañez-Aguilera FJ et al 2010Aguilera FJ et al 2009).

The authors of this manuscript consider addressing MTrPs in the descending fibers of the upper trapezius to be an appropriate treatment for individuals suffering from Cervicogenic Dizziness, however, it may be incomplete and suboptimal location to maximize potential outcomes.   It can have an influence on the functional relevance of the neck in its relationship with the cervico-collic reflex and vestibulo-collic reflex, but may not be a significant factor in modulation of its effects on head-in-space and head-on-trunk posture. All things considered, even though it is a popular location to stretch or treat manually, it may not be as much of a contributing factor of nocioceptive input into dysfunction of head on neck proprioception and self-motion perception.

The following two scenarios are the theoretical concepts to this impression:

  1. Relative Abundance of Muscle Spindles

Neck muscles are richly endowed with muscle spindles and contribute greatly to proprioception of the neck (Voss 1958, Cooper 1963, Kuklarni et al 2001Liu et al 2003).  The high muscle spindle density and the special features of the muscle spindles in the deep neck muscles allow not only great precision of movement but also adequate proprioceptive information needed both for control of head position and movements and for eye/ head movement coordination.

The number of muscle spindles in relation to muscle mass in a recent anatomical study by Banks RW 2006 confirms the greatest abundance is in axial muscles, including those concerned with head position.  The upper trapezius muscle is a high contributor of muscle spindles, but comparably, it is far behind suboccipital musculature, being rated #31 and along the same relative abundance as the adductor pollicis, extensor digitorum brevis, obliquees internus abdominus, omohyoideus, pronator quadratrus and extensor digitorum.  These muscles, due to their location, are of course not primary influence on head-on-neck proprioception.

So, based off of this information and overall thoughts on a patient’s adherence to a home program (keeping 5 exercises or less)— does stretching the upper trapezius, as described in the literature & pictured below, appear to be the most optimal treatment & one we should encourage with patients having cervicogenic dizziness?

trap
Minguez-Zuazo, et al 2016, Malmström et al., 2007; Schenk et al., 2006; Wrisley et al., 2000

2. Influence based off of points of attachment on occiput (from Dvorak J. Manuelle Medizin. 1988)

points of attachment

Based off of the cross section of the occipital anatomy shown above, you can question the influence of the upper trapezius, as compared to suboccipital musculature, on the effect of head on neck posture/proprioception.  The surface area of the upper trapezius is significantly less than other muscles of the cervical spine, especially short dorsal musculature of the upper neck.  Therefore, we must take into account the overall influence of the upper trapezius compared to other musculature to optimize patient outcomes and results to improve pain, joint position error and postural stability.

Thus, the theoretical constructs and literature review for the non-articular management of cervicogenic dizziness is unclear and still under scrutiny.   The application of soft tissue management at one location vs another can be determined through a thorough clinical reasoning process and assessment  The type of soft tissue intervention that is most optimal (i.e. dry needling, ischaemic compression, IASTYM, dry cupping, deep massage, etc.) is still under debate, but the authors of this post do feel the location of your intervention can make a difference.

Sign up here for more information on Cervicogenic Dizziness!

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 prices and discounts.

Authors

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Physical Therapist at In Touch Therapy, South Hill, VA

Danielle N. Vaughan, PT, DPT, Vestibular Specialist  

Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

Vestibular Physical Therapist at Drayer Neurological Clinic, Raleigh, NC

 

 

 

In Touch Therapy is hiring!

If my readers (or colleagues of readers) are looking for a fantastic job opportunity (new grads or seasoned), the company I have been with for 9 yrs is hiring.

Working at one location for 9 yrs is unheard of nowadays—and there are many reasons why I am still here! Here are a few highlights:

  •  1:1 time with patients
  • low stressful environment
  • Patient load varies and never same old “post-op rehab!

Please pass on!

Here is our ad:

In Touch Therapy (South Hill, VA) has been making a difference in people’s lives since 2002. We are looking for the right person to join the ITT team. Help us grow our orthopedic/manual Physical Therapy out-patient center. Flexible schedules, monthly production bonuses, health/dental/vision package, matching retirement, and PTO. Our skilled professional team works together to create a learning/teaching environment. We are looking for a positive, driven team member who wants to help people and is eager to learn. Current VA license required. Please email resume, including references, to Marie Walker mariewalkeritt@gmail.com.

Posted in Uncategorized

Re-Sensitization is where it’s at

central sensitization

Unless you’ve been under a rock as a clinician, the term ‘central sensitization’ should be in your vocabulary.  It has gained popularity through the cycle of pain science, especially over the past 5-10 years.  Even though it appears central sensitization is new and sexy, it is not a modern term, and to my knowledge, the seminal paper on it by Dr. Woolfe goes all of the way back to 1983. Much change and marketing has happened in this 33 year span, but even still, the thought process of this term has been around for centuries.

central sensitization

You can find 6 ways to Sunday to explain this phenomenon to your patients, which I do using my “Pain Cartesian Scale (here too).  I encourage you to find the best way to translate this to your patients in the context they need to understand.  My colleague and friend, Dr. Matt Dancigers, explains this better than anyone else I know.  I highly recommend reading his blog.

Nevertheless, I find the explanation of central sensitization to be somewhat limiting to achieving better outcomes for my patients.  Don’t get me wrong, it does help, but not an extraordinary game changer.  What I find works better in clinical practice is the term, “Re-sensitization”.  This is an ad-on to central sensitization and of course has to go alongside it in your education, but seems to be more of a heavy hitter in regards to applicability for the individual—especially after he/she has felt results and gained your trust.

In a nutshell, the way I assimilate Re-sensitization to patients is one they understand—it is an exacerbation of symptoms.  We all know this happens for any condition, but especially chronic pain.  I translate the importance of a healthy diet, stress reduction and general exercise, of ways to reduce re-sensitization—-this is a multi system issue (endocrine, metabolic, cardiovascular, etc) and not just musculoskeletal.  But for the main purpose of my point in this post, I recommend  focusing on a specific HEP based off of what worked for the patient under a course of care.

In some individuals, a general exercise program at a gym may just do it.  But what I find, and I’m sure many of you, is that you need something specific for the area/region that seems to be the one that is picked at the most.  It could be a neural glide, self-mobilization, myofascial ischaemic compression, etc etc—-but your job, and what I get most out of the umbrella term of sensitization, is to find and prescribe what works with the upmost confidence and highest power to desensitize the system to prevent re-sensitization.

It works like this: Peripheral sensitization leads to Central sensitization—-we can ramp down this entire system (and local region) through our interventions—-but then Re-sensitization occurs over a course of Time—this is where intervention is needed again—by either specific HEP and or Therapist Treatment.

resensitization

It is challenging to put more concepts into words and make it applicable to your setting, approach, and patient type.  But, I do hope you are learning more about central sensitization and now the phrase re-sensitization—which has been successful for me in the science of pain.  It also helps me establish a wellness program and principle of coming back to me vs medication/physician/surgeon if exacerbation occur as an overall successful business plan.

As an added bonus for reading my blog,, I am offering a FREE, 30 min, E-mentorship session for anyone who feels they would like more information on re-sensitization, but also mentorship and guidance on complicated cases.  Just email me at harrisonvaughanpt@gmail.com with “re-sensitization” in subject line. You may just find it to be beneficial and would like to go through a mentoring process. Feel free to contact me for more information and read about the Program more on my E-mentorship page.

 

 

 

 

What angle are you addressing your patients?

There is an old saying in the orthopedic manual world that goes to the tune of:”You can teach a monkey how to manipulate, but not why and when to manipulate”

Any clinician who has been around the realm of manipulation in clinical practice can relate to this statement. However, I think it can apply to other aspects of our care too. Let me give you an example.
During one of my recent e-mentorship sessions, my mentee was providing me a story of a patient who is seeking his care after failure to improve following 4 weeks at another facility. This individual is diagnosed with achilles tendinosis.
What comes to mind when treating this diagnosis?
I guarantee a large percentage of you, including myself, jolt with excitement and say, “eccentric training!”

We say it without much thought as it is what the research says works. The highest of the evidence pyramid glows with excitement.  

But in this case…it didn’t work. The patient wasn’t satisfied…the outcomes were not positive. The patient decided to seek out a cash based service.  

Fast forward a few treatments — patient recovered and returned to soccer.

So what was the difference?

I can’t take the credit as my mentee did a full examination and came up with a plan of care. He did it all and came from a different thinking process.  I can say that the treatment was based on concepts and principles. These concepts and principles that have been around for decades and do not fail.  

So what’s the moral of the story?
“You can teach a monkey to read the research, but not why and when to use the research”
Literary articles are intended to be another layer to your treatment to justify it even further based on your assessment using concepts and principles. In this case, the research was the first layer versus secondary or tertiary layer.  In this age of evidence , I continue to urge the importance but at a different layer.  
If you find yourself doing the following:

Give my e-mentorship program a shot. I personally believe you are attacking the problem from the wrong angle. 

Let’s work together to get your patients better— quicker — give them that experience we all look forward and spread the good news.  
Next time you want to spend $100 on a local continuing education course for a day, give me time once/week for a month.  I guarantee it’ll change your thinking process and up your game.  Contact me so we can work together personally to make you a better clinician and get the outcomes your patients deserve. 

Don’t Chicken Out! Prescribe “Clucking” to Your TMD Patients

I recently nerded it up from home and on the go while learning about TMJ disorders and treatment approaches from the Manual Therapist himself, Dr. Erson Religioso.  The following is my analysis from Dr. Religioso’s Eclectic Approach to TMJ Disorders. 

If you would like access to 600 accredited courses and growing from the comfort of your home, as well as patient education models, and HEP software—and you like my stuff….be sure to use my affiliate link, inTOUCH, in order to save $100 off A YEAR for the low price of $200 for access to continuing education through MedBridge.  Not a bad deal at all!

The following blog post originally appeared on MedBridge Education’s blog on July 6, 2016.  Click the previous link for access to a 2 minute clip on tongue resting position.

From my experience teaching interns in the clinic, they are normally nervous about treating temporomandibular joint disorder (TMD) as it is typically not covered at physical therapy school. In the video segment below, Dr. Erson Religioso III takes a simple, yet productive approach to explaining the problematic TMD condition.

Dr. Religioso’s course is a great introduction for new graduates and a detailed refresher for experienced clinicians. His knowledge of the TMJ and its relationship with the upper cervical spine is simplified in a digestible manner that allows the learner to step away from the screen and perform effective treatments immediately.

A Diversified Approach

The course focuses on treating the patient by decreasing threat and tone through an eclectic orthopedic manual therapy methodology. You will learn the relationship of posture to TMJ, education through “clucking”, and several other effective approaches to patient care. Moreover, because Dr. Religioso’s work incorporates interdisciplinary techniques, he is able to answer numerous clinical questions:

  • Why should the movement screening come before the repeated movement exam?
  • Why does he try to relieve pain rather than produce pain?
  • Why does he place his hand over the maxilla vs mandibular (not just due to pain over the TMJ)? Hint: The biomechanical component!
  • Why can loading the joint with repeated movements assist in re-setting the central nervous system better than unloading the joint? Hint: It’s opposite of what most clinicians do!
  • Why using a tool can inhibit tone better than hands/fingers?
  • Why certain soft tissue patterns are effective in individuals with high tone vs low tone?
  • Why does he use soft tissue work first in the treatment sequence?
  • Why is working on soft tissue on ipsilateral side vs contralateral side (where we normally would stretch as “tight” tissues) a better approach?
  • Why does regional interdependence play a huge role in treating TMD and in soft tissue mobilization techniques to multiple patterns of the upper quarter?

Besides the answers to all of these questions, Dr. Religioso also focuses on patient education of posture, neck position, and the cause/effect for patients to keep improvements.

If you have read his blog, you will hear echoes of Dr. Religioso’s writings in his voice as he describes what worked for him in treating TMD over many years. His advanced training by Dr. Racabado, one of the pioneers of TMD in the states, is evident in his course.

Clear & Confident Treatment Strategies

As physical therapists, we know that manual therapy, exercise, and education are key components to overall patient care. The treatment of TMD is no exception. Home exercise programs fuel the patient’s retention from short-term manual relief. This course reinforces that essential message for therapists. “Clucking” is a fundamental aspect of the HEP that I took away. What will be yours?

Thanks everyone for reading! Continue to aim high and finish strong.