Cervicogenic dizziness

“…characterized by the presence of imbalance, unsteadiness, disorientation, neck pain, limited cervical range of motion, and may be accompanied by a headache.”

Dizziness can have multiple factors. The cervical spine, or neck region, can have a role in a person feeling unsteady or dizzy.

“…when all other causes of dizziness are excluded”

Before making a jump to the cervical spine, the professional performing the evaluation/examination should rule out red flags. Some of these include an active stroke, instability of the neck region after a major trauma, a severing or tear in an artery that supplies the brain.

Other causes of dizziness are BPPV (Benign Paroxysmal Positional Vertigo), vestibular hypofunction, Ménière’s disease, issues affecting the inner ear such as a fistula and many other conditions. Click here to learn more about vestibular issues and dizziness.

“… dizziness should be closely related to changes in cervical spine position or cervical joint movement”

In order to state that the dizziness is coming from the neck, movements of the neck should create a change in symptoms.

It seems like common sense, but I’ll never state that common sense is in abundance in healthcare.

It’s like a person comes in complaining of shoulder and arm pain when looking down, which goes away when looking up, but the clinician spends all of the allotted time moving the shoulder and arm 🤦🏻‍♀️

“diagnosis of exclusion”

This is important. In order to get to this as the cause of the patient’s symptoms, the clinician has to rule out red flags (really bad stuff), BPPV (fast changing symptoms), vestibular dysfunctions (slow changing), brain issues (really slow changing) and then finally get to the neck.

The reason this is called a diagnosis of exclusion is this: when a person is thorough all of the possibilities have been ruled out. This is all that’s left.

“…no single test is able to diagnose the condition, and the diagnosis can not be verified by outcomes, imaging, laboratory values, or unique signs and/or symptoms”

This is important. If there are no tests to determine that this is the problem, it truly is a last resort to treat. We are hoping that this is the cause, and it takes a hard sell job to get the patient on board for treatment of this problem.

“…a systematic process is a pragmatic tool for differential diagnosis of CGD…with utilization of a rule out, rule in paradigm”

This is important. The rule in/rule out paradigm is another way of sayin whiteboarding, at least in my head.

This not so short video series speaks to performing differential diagnosing. Although as a PT, I am not allowed to issue a medical diagnosis, we have to be able to perform differentials and I’ll explain why.

When a physician refers a patient to PT for these issues, many times the diagnosis code given is “dizziness and giddiness”, “frequent falls”, or generalized weakness. No offense to any physician, but this doesn’t tell me what’s wrong with the patient.

In defense of the physician, they may not be trained to perform the testing required in order to determine what is the underlying, or root cause, of the dizziness. Also, on average physicians don’t get to spend the allowed time with the patient in order to perform these tests. I surely can’t treat something if I don’t have an idea of what is wrong. There must be some clue telling me where to start, and this is the power of doing a differential in order to classify what is the major problem and what may be the lesser problems causing a person to be dizzy or off balance.

Because there is not just one cause, there can not be just one treatment.

Hope this makes sense.

“CGD should not be considered if the patient does not have neck pain…neck pain can occur at rest, with movement or with palpation”

It only makes sense that if we believe that there is a problem in the neck that is causing a major disruption in that persons ability to function that we should also be able to find a problem in the neck if we try hard enough.

Pain is so elusive that it may not present in a typical manner. I have patients that only have neck pain provoked at their end-range, which is limited. This would fit the category.

“Vertigo as an illusion of movement;a sensation as if the external world were revolving around the individual (objective vertigo), or as if the individual were revolving in space (subjective vertigo). Vertigo is not a symptom arising from cervical spine, but rather is caused by peripheral vestibular disorders or lesions within the vestibular pathways of the central nervous system”

This is where things become fun. It reminds me of taking my daughter to a fun house. First, getting into the house was hilarious. It started as a house of mirrors. I can’t believe how many times she hit her face into the mirror because she thought it was the exit. The first time she hit her face on the mirror, I was a concerned dad and tried to offer help. By the time she hit her face on the mirror the third time I couldn’t constrain myself any longer. Because it was a house of mirrors she saw me laughing…1,000 mirrored reflections laughing.

I digress.

To get out of the fun house, we had to cross a bridge that had a tunnel spinning around it, which gave the illusion that we were moving. If one closed the eyes and walked, it was easy. If one kept the eyes opened it was a scene out of a sinking ship. My daughter was holding onto the rails for dear life…even though nothing she was standing on or touching was moving.

Vertigo is something like that 😂.

“The duration of symptoms for CGD can range from days to months to years”

This is where I start to have some issues.

A classification of dizziness that we can’t prove, have no great testing to show us that it is happening can have a duration of a short period of time to a long period of time.

Holy specific Batman! This is why, as healthcare professionals, we can struggle at time. The research doesn’t give us concrete information that is useful when in front of the patient.

Patient: how long can this last

Doctor: 🤷‍♂️ months to years

Patient: how long do you think it will last for me

Doctor: (silence)

“Ménière’s disease is a chronic vestibular disorder characterized by episodic bouts of aural fullness, vertigo, and hearing loss. Cervicogenic dizziness however, typically does not include aural fullness, tinnitus or hearing loss”

What in the world is aural fullness?

This is a full feeling within the ear. Think of feeling pressure or a buildup of within the ear. In Ménière’s disease, this feeling comes and goes. The sensation may be accompanied by spinning sensations and hearing loss.

If the patient is experiencing hearing loss, then we can state that the cervical spine is not having a role in this symptom and additional testing of the vestibular, or balance gauge, system needs to be checked to ensure that nothing was missed.

As Johnnie Cochran has become famous for saying:

“If it doesn’t fit, you must acquit”

Some reading this may not be old enough to u see stand this phrase, but the meaning is that if part of the evidence presented doesn’t fit the case then there must be a different perspective followed.

This means that if you are experiencing dizziness that stems from the neck, you shouldn’t also experience hearing loss. If your provider is not listening to your symptoms, you may be wasting both time and money by undergoing treatment for the wrong classification.

“BPPV is the most common vestibular pathology… crystals become dislodged from the utricle and migrate into one of the three semicircular canals located within the inner ear.”

Benign (not harmful) Paroxysmal (sudden occurrence or intensification of symptoms) Positional (relating to the position of the body against gravity) Vertigo (illusion of movement when no movement is occurring) (BPPV) is very common to experience in one’s lifetime. About 3 out of every hundred will experience this. Although it doesn’t come close to the statistics for back pain, it is the most likely reason for experiencing vertigo.

The bad news: it really sucks to have this happen because any activity becomes difficult when you are experiencing your world spinning.

The good news: it’s treatable in a high percentage of cases with very few visits.

“if a patient has symptoms of vertigo accompanied by nystagmus in response to changing head position in space, then BPPV is more likely than CGD”

The nystagmus is the quick movement of the eyes. If we see a nystagmus (it is visible to the clinician) when moving patients through different positions, this helps to clarify not only that the patient has a positional dizziness, but also where the problem is located based on the position and the movement of the eyes.

For instance, if the patient has symptoms during a Dix-Hallpike, we can assume posterior canal, we then have to know if it is the left side or right sided canal in order to understand the proper direction of treatment.

If the patient has a positive Roll test, then this would implicate the horizontal canal, but again we would have to understand the side of dysfunction.

“… symptom duration lasting only a few seconds were significantly more common in the BPPV group. Cervical neck movement, fatigue, anxiety, and stress were also found to be more common precipitating factors for exacerbation of symptoms in the CGD group as compared to the BPPV group”

BPPV has short lasting symptoms. Once the crystals settle, then the symptoms subside.

The other symptoms of anxiety and stress do not tend to be causative factors in BPPV.

“…acute, unilateral, peripheral vestibular loss due to labrythitis or vestibular neuronitis…marked vertigo, imbalance…nausea and possibly vomiting…spontaneous horizontal, direction fixed nystagmus in room light”

When we see an acute peripheral vestibular loss it’s pretty cool, at least for me, as the eyes are all over the place. Because the eyes have difficulty focusing, the patient will see objects blurred or moving. This can create an imbalance and the movement seen, paired with the lack of actual movement of the body, can create a nausea feeling.

Although it is fun to work with, it is never fun to be vomited 🤮 on. My first year, I had no clue what I was doing and got a lot of vomit on my shoes.

“Key symptoms frequently present in vestibular migraine, but not CGD, are aura, true vertigo , throbbing headaches, sensitivity to auditory or visual sensory stimulation, and oculomotor changes”

If you’ve ever had a migraine, these can be debilitating. The sensitivity to light and sound are the two symptoms I hear the most, along with nausea. Cervicogenic dizziness should not present with the auditory or visual issues as these are controlled by cranial nerves (think brain nerves) and not neck nerves.

“Cervical arterial dysfunction (CAD) and whiplash associated disorders (WAD) are non-vestibular pathologies that can mimic CGD”

I had one patient with cervical artery dysfunction that presented with a dizziness. The dizziness was produced with neck movements, but not with other testing. It wasn’t until he started to demonstrate a nystagmus with the seated rotation extension test, along with neck pain, that I sent him back to his referring physician. An ultrasound confirmed arterial dissection.

It’s common in my practice to see proprioceptive issues, as tested by the JPET, in patients after a car accident. We use the laser frequently with these patients.

“…as CAD related dizziness presents with only one symptom in less than 1% of the cases. Other symptoms of CAD include severe headache, diplopia, nystagmus, numbness around the lips or mouth, dysphagia, dysarthria, and upper motor neuron signs”

The patients that present with a suspicion of cervical artery dysfunction or dissection should be referred back to the physician immediately, as this is a risk factor for major complications like stroke.

“Common symptoms of WAD are cervical neck pain and hypersensitivity, decreased cervical ROM, dizziness, tinnitus, and headache”

I see the hypersensitivity frequently in the clinic, along with reduced movement in the neck and a fear avoidance mentality. We don’t expect to see hypersensitivity in those with cervical based dizziness.

“Positive results on cervical instability testing or CAD testing indicate a need for immediate medical attention and imaging”

Again, this was stated above, but I will leave the quote as it is very important to get these patients medical attention immediately.

“A neurological screen should include an assessment of radicular symptoms, myotomes, dermatomes, deep tendon reflexes, upper motor neuron signs and cranial nerve function”

This is a basic evaluation.

Has your PT ever checked your lower reflexes or

“…the vestibular examination should be next”

This type of evaluation is looking at the health of the vestibular nerve and possibly the cochlear nerve through special tests.

The semicircular canals are also tested through positional testing, described later in the post.

Some of the testing performed in the clinic are as follows:

Head Impulse Test or Head Thrust

Head shaking test

The DVAT is described below.

“A thorough evaluation of the cervical spine is best performed in step 4 because first ruling out vestibular dysfunction increases the probability that the cervical spine is the cause of the dizziness”

This goes back to the classification of exclusion. If we’ve cleared the brain of signs of stroke, cleared the canals for signs of BPPV, cleared the nerve of signs of hypofunction and looked at other possibilities such as fistula, then we are left with the neck.

Treating the neck can be helpful for many, but it shouldn’t be the first line of treatment for a patient walking off of the street with complaints of dizziness.

The JPET is one way to test the cervical spine for deficits in spatial awareness.

The Head neck differentiation test is another way of assessing the neck region for dizziness.

“…oculomotor evaluation should include evaluation of nystagmus, skew, smooth pursuit, saccades, Dix-Halpike test, static and dynamic visual acuity, and the vestibule-ocular reflex (VOR) including VOR cancellation and the head thrust test”

Another video showing a nystagmus

The Test of skew is a part of the HINTs exam, which could indicate an active stroke.

Smooth pursuit is another test to measure brain involvement in dizziness.

Saccadic testing is easy to perform in the clinic.

The Dix-Hallpike maneuver is classic for testing of the posterior semi-circular canal, which is typically implicated in BPPV.

The DVAT is used to classify BVH and UVH. (I am choosing to use a student page for this one to help support student programs).

“A horizontal, direction, fixed nystagmus, is consistent with unilateral peripheral vestibular hypofunction.”

These are hard to imagine without context. This video is perfect to demonstrate a quick horizontal beat towards the stronger side.

The eyes will slowly drift in one direction and rapidly correct towards the other direction. This is an indication that one vestibular nerve is “stronger” than the opposite nerve.

This can be treated successfully through rehab.


Reflections on “The Alchemist” Part X

“Now, I’m beginning what I could have started 10 years ago. But I’m happy at least that I didn’t wait 20 years.”

It’s the adage: “the best time to plant a tree was 20 years ago. The second best time is now.”

This is very fitting in my life. I seem to have a 3-8 year itch regarding my profession.

It’s hard to believe that after 38+ years, the longest job I held was Sam’s Club 8298. That job was perfect for me. I get bored relatively quickly and try to do more or challenge myself in a different fashion. I could bounce from one section to another without ever having to quit.

In the PT world, it rarely works that way. I may be able to switch locations, but it’s essentially the same job. There’s rarely additional challenge.

I can honestly say that every job, but one, which is a different story for a different day, I left to do better, be better or work harder.

If there is a dream that you have and the opportunity presents itself, what’s stopping you?!

Don’t regret the decision you didn’t make!

Always think of the worst case scenario. How would that worst case scenario affect you and your family?

If it’s not a death blow, why not make the jump? Sink or swim, but do your due diligence before making the jump.

Research what you have to do to be successful. Spend some time that you would’ve slept to figure out how to stick the landing on the jump and not fall flat on your face.

I landed flat on my face and you know what?…

It wasn’t a death blow. We lived to fight again.

Reflections on “The Alchemist” Part XII

“Once you get into the desert, there’s no going back. And when you can’t go back, you have to worry only about the best way of moving forward.”

In 2017, I made the decision to leave a good paying job, with good benefits and it was only an 15 minute commute.

I walked away to take a chance on a better position. It started at less pay, worse benefits, and a 45-60 minute commute each way.

I never looked back. I poured 100% of my efforts into this new position because…there was no going back. I made the decision to better myself and my family’s lot in life. This means that I am working way more than I ever had in the previous job, but it has a much higher upside than the last job would’ve been able to afford my family. There were some growing pains, as now I get paid when we make money and if there is no money being paid, I don’t make as much. It’s the life of an employee vs an employer.

Never take for granted the position of employee. It comes with perks, such as low cost of entry (for the most part just sitting through interviews and hoping to get paid), it comes with a salary (unless you are commission based), it gives benefits such as vacation and sick time.

The role of employer is not as predictable. It has a higher cost of entry. The employer has to purchase equipment , pay employee taxes, doesn’t come with a standard salary (employees get paid first) and it’s is much harder to take a day off when there is no one else that will give the business the same care that the employer does.

This quote applies to any decision in life. Gary Vaynerchuk is famous for saying “don’t do anything half pregnant”. In other words, go all in.

When you have a family depending on you, this is much easier. When you’re younger, you have the ability to taste a bunch of different aspects of life to determine what direction you want to go all in.

But once you make your decision, you go all In and don’t look back!

Medicare for all

Are you paying attention?

Medicare for all would not be a great option, since we can barely sustain Medicare for some.

Government has to get more and more creative in order to make the 💰 last longer.

Part of that creativity is to reduce output.

Another part of that will be to increase revenue to this system.

Reducing output is easy. They are simply paying less for services and taking less risk than previous years.

For instance, ACO (hospitals and other entities) are seeing less reimbursement than previous years for the same procedure.

Less income means that the hospitals have to find other ways to generate income or to become “leaner” in their operations. This may mean less one-one time for PTs.

What do you think the solution should be?

See some of the comments to understand why we are running into problems.

Functional movement screening: the use

“The rehabilitation professional must realize that in order to prepare individuals for a wide variety of activities, screening of fundamental movements is imperative.”

I agree with this statement. I disagree that we yet have a tool that can screen all individuals from all sports. This screening tool has yet to prove its worthiness of use on athletes.

I recently was certified by USAW as a weightlifting coach. I really like what they use to screen participants before allowing them to train the weightlifting lifts of the clean and jerk and snatch. They use the basic movement patterns, without load or speed, that are needed in order to perform the entire lift safely.

This makes logical sense, but I don’t think a study has been performed to see if this is a good/bad thing to do prior to allow safe lifting.

The FMS is proposed to be a screening tool for athletes and tactical workers. I’m not sure this one tool can encompass all of the movements required in life.

It’s still a good thing to learn about, not for use as a screen, but instead to better understand how the body as a system can move through the spectrum of very stiff and weak through very mobile and supportive.

“Many individuals train around a pre-existing problem or simply do not train their weaknesses during strength and conditioning (fitness) programs.”

If a person is unaware of a problem, this is also a problem. I would be all for a low cost screening tool, which everyone is required to have tested on a yearly/decade basis.

For instance, someone that lacks ankle mobility may not know that they are unable to squat without something under their heels. They may not know that this leads to increased use of the anterior chain, which increases knee stresses. They may not utilize their hips and may round their back when performing their repetitive squatting activities.

There are so many possibilities for a person to lose mobility, that this should be screened. The problem is that we have yet to know an effective screening tool.

“The perception of many past researchers is that no set standards exist for determining who is physically prepared to participate in activities”

If there are no standards, then everyone can participate in a physical training program. This is only partially true. There are some standards, but not many.

1. The person must be breathing

2. The person must not be at a major risk of death if participating in an exercise program

3. Start exercising!

“…the main goals in performing pre-participation, performance, or return to sport screening are to decrease the potential for injury, prevent re-injury, enhance performance, and ultimately improve quality of life”

This is what makes a universal screening tool so hard to find. I don’t even think we have a tool for different positions of the SAME sport because the requirements are so diverse. I keep bringing up the USAW screening tool, but that’s because the athlete, in the end only needs to be safe enough to perform TWO movements. The screening tool has more movements than needs to be performed. If this were to hold true for any other sport, the screening tool would be too long to be useful.

“…intended purpose of movement screening (1) identify individuals at risk, who are attempting to maintain or increase activity level (2) assisting in program design by systematically using corrective exercise to normalize or improve fundamental movement patterns (3) providing a systematic tool to monitor progress and movement pattern development…(4) creating a functional movement baseline”

I can agree with all of the above stated. Im not sure if research supports these statements, but they sound pretty good.

I do like the idea of creating a movement baseline, but that baseline measurement will need to be extensive enough to capture relevant information to that patient.

“The FMS (TM) is comprised of seven fundamental movement patterns (tests) that require a balance of mobility and stability (including neuromuscular/motor control)”

This is true. The seven movement patterns tested are adequate tests for ADL’s but I don’t know if it goes far enough to test anything other than a persons baseline movement.

“The term ‘regional interdependence’ is used to describe the relationship between regions of the body and how dysfunction in one region may contribute to dysfunction in another region”

I speak with many PTs throughout the week that know this term and can recall this term, but don’t apply this term on a daily basis when working with people. For example, a significant loss of dorsiflexion (ankle flexibility) will keep the knee from bending and shifting towards your toes. This will in turn cause you to learn more forward with your hips.

A loss of movement at your shoulder can make you move your back more when reaching overhead.

This is the term regional interdependence at play.

“Programmed altered movement patterns have the potential to lead to further mobility and stability imbalances, which have previously been identified as risk factors for injury”

This is where I start to deviate a little from the article. There are way too many logical jumps being made without proof that a screening tool is predictive of injury.

“…an important factor in prevention of injuries and improving performance is to quickly identify deficits in symmetry, mobility, and stability because of their influences on creating altered motor programs throughout the kinetic chain”

I don’t agree with this.

Everything here forward is my opinion and I don’t have any proof that it’s true: we live in an asymmetrical world. We start off as one handed or one footed. We play sports that drive this asymmetry. It’s hard to say that moving towards a more symmetrical society will improve performance in asymmetrical sports or activities.

I personally don’t think it happens.

There are many saying that at a young age that kids shouldn’t specialize, and I would agree with that, but at what age does specialization become more appropriate. I remember hearing stories about Ken Griffey Jr (one of the greatest baseball players of all time with baseball being a very asymmetrical sport) playing basketball in order to improve mobility and hand eye coordination.

It’s a theory that working towards symmetry improves performance, in just not at that point yet.

“Scores serve to tell the professional when a person needs more investigation or assessment”

The score on the movement screen does not predict injury. It just states that the person doesn’t move like the ideal.

For instance, my shoulder mobility for the internal/external rotation test is not ideal. That’s expected for me because I have shorter arms and am overweight. The investigation of this test is that I have to lose weight in order to see if that has an effect on my testing. The same “problem” of being overweight can affect the rotary test in quadruped as the belly can get in the way of the test. “Problem” solved. It may not be a muscle/joint problem at all.

Read the article to see the testing and what the authors propose that the test is measuring.

Link to article

Reflections on “The Alchemist” Part IX

“There is only one way to learn, it’s through action. Everything you need to know you have learned through your journey.”

Some people are frozen when having to make a decision. Whether it be what type of beer to drink at a brewery or what major to choose in college. I make decisions mischief easier now than when I was younger.

There is only one asset that has a limit and that is time. All other assets are potentially limitless.

I recently went to a brewery with friends. They had a ton of beers on tap. I could’ve spent my time deciding what beer to try while standing at the bar and my friends were at the table discussing life. Why bother?!

Time is more important than a few dollars at that point in the weekend. The amount of time that I would’ve been away from friends that I only get to see but a couple times per year wasn’t worth it for me to be standing at the bar.

I spent a few dollars more and bought a flight of beers. It cost only $3 more than buying one of the 50 beers that they serve. The $3 was a risk I was willing to lose. I only drank one of the 4, but at least tried them all for one sip. I was very satisfied with that decision even though I left 3 beers on the table (mind you I don’t really enjoy drinking to begin with so I would’ve had to ask a lot of questions just to order one beer).

I was able to enjoy conversing with old friends and make memories. That was worth the $3.

I think many people struggle to make decisions because they don’t look at what is lost in the time to make decisions. I recently started learning about decision fatigue and try to make fewer and fewer choices throughout the day. Essentially, my day is very structured (it’s both good and bad, but it’s a trade off). It saves me a lot of time and prevents any sort of stress in decision making by keeping a routine.

This same strategy of weighing cost to benefit works for me in all decisions. I discuss this with all students going into college and professional school. Is the decision to go to college worth it?

The student should have a pretty good stronghold on what they want out of college before signing up for school. Otherwise, that person is spending tens to hundreds of thousands of dollars on an education that they may not use or enjoy the benefits/wages.

There are plenty of trades that one can join at a low cost of entry. If a person is unsure of their life’s purpose, they should do something with a low cost of entry because there is little to keep one from walking away when the time comes. A high cost of entry, not paid for in cash on hand, causes a person to make different decisions and to feel stuck in a position because they will have to pay off the debt that accumulated prior to jumping into a different profession.

I wish this stuff was talked about in college preparatory courses. Unfortunately, many learn the lesson the hard way through decisions that they would not have made if they were 20-30 years older.

Reflections on “The Alchemist” Part VIII

“The secret is here in the present. If you pay attention to the present, you can improve upon it. And, if you improve on the present, what comes later will also be better.”

This was hard for me for so long, until Natalia was born. She really put life into perspective. I loved life for big goals. I would be so focused on the future, that the present was just something that I had to get through in order to reach my goals.

Lenna is our oldest, but it was different. Anita, my wife, is amazing at what she does. She can juggle so many balls in the air at the same time and still manage and take care of Lenna. I never had to worry about that one.

Natalia was different, and not just because she has Down Syndrome. It’s a radical change going from one child to two. Ania needed more help. I spent a lot more time with Natalia, when she was a baby, than with Lenna. It’s the same with our third now, Adam. I spend maybe more time with Adam than Natalia when she was a baby.

That’s only because Ania usually takes care of the other two and I only have to take care of one at a time!

Having Natalia made me slow down a little. I appreciate the cartoons, coloring with Lenna, helping Lenna with her “sight words” (if you don’t have young kids then this is a foreign concept), and working on homework with her. It’s because of the youngest two that I spend more time with the oldest.

Enjoying the present makes me realize the WHY for the future.

PT and tendons: where are we at?

“Complicating matters further is the mismatch between reported pain (and disability) and imaging (and pathology), as well as evidence of widespread sensory nervous system sensitization in some tendonopathies.”

A little background. Pain is not always viewable. This is a large debate even among the highest level of pain organizations. The IASP (Thanks to Colin Windhu for catching a mistake) is looking to change the definition of pain to include tissue based problems, or at least perceived problems.

Not all pain has a tissue based component, as some have a cognitive and emotional based component. For instance, I treated a person that was so afraid of performing activities that this person developed a pain from the thought of movement. After establishing that movement was safe, this person more than 10X increased the ability on a functional test…in less than 6 weeks.

This person, and others that I’ve worked with, have a “stinking thinking” type of pain. This may not be the fault of the patient, but instead it may be the fault of the faulty medical system. One that drives fear.

How many people have heard a physician say

“This is the worst spine I have seen”

“You shouldn’t squat/run because it’s bad for your knees”

“You shouldn’t work with heavy weights because it’s bad for your back”

“Your knees/hips are bone on bone and you will need a new knee/hip in the future”

Your pain is because you have a rotator cuff tear/disc herniation/arthritis etc”

These types of interactions do more to hurt the patient than help the patient and can start the cycle of inactivity out of fear of breaking oneself.

Don’t buy into the hype. A little stat, when a physician diagnoses your back pain as a herniated disc, arthritis, muscle strain, stenosis, etc do you know that the diagnosis is only right about 10% of the time?!

People are hanging their health habits in a guess that has a worse chance of being right than flipping a coin. You would have better odds of getting 4 of a kind in Texas Holdem.

Let’s start by not placing too much weight into the diagnosis because it’s a best guess at best.

Here’s what we think may happen. Some pain can cause more pain. Nerves can communicate with each other.

It’s similar to an infection. Any nerve that comes in contact with the nerve that is irritated can then become infected (irritated). Hmm?

I’ve seen many patients that experience widespread pain even though “everything is healthy”.

Yet another reason not to hang your hat on one specific tissue problem.

“… A diagnosis of tendinopathy is reasonably easy to make clinically, on the basis localized pain over the tendon that is associated with loading of the tendon.”

If you hurt your biceps and you ask your biceps to work, it makes sense that it may not like that.

If you hurt/injured your biceps and it hurts when you make your ankle muscles work, we wouldn’t expect that to create a problem in the biceps if the problem is localized to the biceps.

Make sense?

In other words, when a tendon is injured, we expect specific behaviors like

1. Pain with contraction under load that may increase with increasing loads

2. Pain with compression of that area

3. Pain with stretching that specific area

4. No issues when that area is not moving.

If the symptoms operate outside of this narrow set of parameters, it may not be only a tendon issue. This is not to say there isn’t a tendon issue, but instead is meant to say that the tendon may only be a part of the problem and we have no idea how much of a part it is until more assessment is done.

“…management of tendinopathy should optimally involve addressing loading of the tendon”

A tendon connects a muscle to a bone. It doesn’t have a ton of blood flow and can be slow to heal.

It needs to work in order to get back to its normal function.

This is what it means to load the tendon. Make it work, but don’t irritate/create harm. As long as the tendon/pain is not worse following an activity…awesomesauce…no harm done.

“Management of load…usually commenced with complete removal of offending activities and the introduction of appropriate and graduated loading activities”

If you break your leg, you will expect to be on crutches. This is to allow the bone time to heal. This stage lasts anywhere from 4-6 weeks. Loading before then one is ready to accept load can result in worsening the injury. You would know this because the pain worsened or you would break it further.

Loading a tendon before it is ready to be loaded OR more than it is ready to accept will lead to increased pain in that area, pain that is lasting and worsening function over time.

These are the clues a patient needs to give their attention towards.

Sometimes you need to remove all load from a tendon to allow it to rest and others you can perform your normals daily activities, but any more would result in increased pain that lingers.

When the pain no longer lingers after an activity, it is time to do more activities and create a new norm.

It doesn’t have to be any more complicated than this. Some research shows that 1200 repetitions of calf raises should be performed weekly, but it doesn’t have to be this structured.

“…requires patient buy-in…involves the clinician educating the patient about the nature of the tendinopathy, its relationship to loading, and a likely recovery trajectory.”

This is by far and away the most important detail.

If the patient is not educated on how the body should respond AFTER performing the activity, then the patient may be reluctant to continue anything that creates transient (short-lived) pain.

This is one of those issues that only gets better with direct loading. It doesn’t “fix” with time because it needs to be strong enough to handle the loads that you would throw at it on a daily basis.

“This exercise program should be adequately supervised, reviewed, and progressed to ensure adherence and resolution of the tendinopathy.”


“(a) symptom-guides management, (b) symptom-modification management (c) compressive versus tensile load (d) stages of loading through the rehabilitation process (isometric and isotonic strengthening, energy storage and release, return to play), and (e) what I will refer to as movement competency…in a way that does not provoke pain.”

This doesn’t need to be summarized and is great advice for most soft tissue disorders.

“In the lower limb (Achilles tendon, patellar tendon), it appears that pain up to 5/10 on a numeric pain rating scale during and after training is not harmful and may be desirable”

This is a little more aggressive than I go initially, but the patient’s response gets to dictate how hard we push.

If there is a 3 point change and the patient is no worse after repeatedly creating a 3-point change, the. They have earned the right to go to a 4-point change. At some point, we would predict that too much of an increase would lead to an inflammatory effect, but we just don’t know what that number is for that specific patient.

The only way we will ever know is to test it.

“The fad of giving all patients with tendinopathy an eccentric exercise program from the onset has largely abated; however, after adequate strength of the muscle has been achieved, it is necessary to use eccentric exercises to reinstitute the energy storage/return capacity of the musculotendinous complex”

Not sure if this is any different than just load the tissue. The tissue needs to be able to contract under load and stretch under load. That’s normal mechanics for a muscle.

“Movement competency…is mainly about the form and shape (posture and alignment) with which physical activity is performed.”

This is consistent with what Dr. Kelly Starrett has been preaching for years through his books, videos and interviews.

A squat should look like a certain shape and many things look similar, such as a lunge (squat with one leg), clean start position, deadlift start position, standing up from the toilet etc.

Of course I know there are nuances between the squat and deadlift regarding hip height and back angle, the clean and lunge regarding shin angle etc, but in the end the basic shape still applies (knee bent and hip bent with shoulders forward and back fairly flat with head looking straight ahead). The similarities are where most people need to function and the nuances are what make the exceptional athletes different.

Link to article

Reflections on “The Alchemist” Part VII

“My heart is a traitor… It doesn’t want me to go on.

Naturally it’s afraid that in pursuing your dream, you might lose everything you’ve won.

Well then, why should I listen to my heart?

Because you will never again be able to keep it quiet.”

I have a couple of big picture drivers in my life.

1. Have no regrets

2. Don’t do anything that would bring shame to my dad.

In 2008, my brother died. He died from an overdose of Benedryl…(I hear it all the time, I didn’t know it was possible…me neither).

He had his demons…we all do. He was a great guy, but again, he had his problems. He had been imprisoned for DUI and just got out. He started joining me at the gym and he was making great progress in the gym. He couldn’t squat more than me, but that bastard deadlifted 405 on his first attempt. (I say that out of love because it took me years to lift 405).

Anyway, we would have conversations about serious things every once in a while (we shared a room growing up. I worked overnights and was going to school and at the time he wasn’t working, so the bed was his at night and mine during the day).

Aside: those that know me, know that I am like a tornado. Wherever I go, I organize things so that they make sense to me. This usually means a bunch of separate piles with very clear distinctions between the piles. (It works for me!) Mike, on the other hand, was just a slob! He loved candy. It wasn’t uncommon for me to come home after working overnights and going to school in the morning, only to find a ton of wrappers in the bed and a full cup of coke on the floor. It was like living with a big kid at times (usually that’s one of the ways I get described, but Mike took it to an extreme). I used to think that if I just pushed it all on the floor that he would clean it up…Nope. Just a new pile of wrappers the next day! I miss my brother. He was a good person and was very good to me growing up. I’m going to keep reminiscing a little because…why not?

I used to love to sing Karaoke and was actually a DJ for a while. It paid good money, but I’m glad I stayed in school because: who goes out to sing Karaoke anymore? Mike had a problem with alcohol. I’m not saying anything bad about him, it was just true. It didn’t make him a bad person, but like I said, he had demons. We went out to the bar (mind you, I didn’t drink at the time), after working out (the bar was right next door to the gym). I sang some songs, bought him a Long Island iced tea (I had no clue what this drink was prior to that night) and he listened to me sing a couple of songs. The car ride home (I’m the little brother, obviously not by size). He said, bro I’m proud of you. You grew up in the same house we all did. You can go out to the bar and drink orange juice and have a good time. You work full time and go to school. You’re going to be great at anything you do. (This memory always brings tears).

I was a new grad physical therapist. Not even practicing for a year when my mom called me in the middle of the night to scream through the phone that “I lost my baby!” Those words and that conversation is burned in my brain. That whole night at the hospital was like a haze. Hard to believe.

What’s harder to deal with is that 10+ plus years have passed and how much he’s missed out on. He was great with kids. He would’ve loved my kids. I think of all that he could’ve done and seen. He always wanted to go to Alaska. I made a copy of one of his pictures and carried it with me while we honeymooned in Alaska. I miss my brother.

I learned one thing…life is very short and don’t have any regrets.

The second big picture ideology that I try to live by is to not bring shame to my dad.

You’ll hear me say it frequently that my dad is my Superman. He knows that, which was very important for me to make sure that he knows I’m proud of him and the life he lived and continues to live.

He served as a medic for the 101st Airborne, the Screaming Eagles, in Vietnam. He stated in Vietnam longer than he had to in order to ensure that his younger brother didn’t have to go to Nam. He came home and worked in the family business (construction) for 30+ years. He divorced my birth mom (whom I have no contact with, which is why I say birth mom) and took care of all the kids as best he could. He and Aida worked hard to move us to a quieter area with less shootings. They made the decision to send me to Providence. Essentially, all of the good things I have came from that man.

I disappointed my dad one time. I was 13 and was a shoplifter. I would steal anything just to see if I could.

I got caught at the old Cub Foods on Larkin Ave. I was stealing magazines and baseball cards. I was with my cousin at the time (and I still believe that he got caught, but water under a bridge). I was fined $2,000 and was out in handcuffs, but wasn’t arrested.

I got home that night (understand that my dad typically would wake up at 3 AM to prepare for work) and it was about 11 PM. My mom told him what happened. I was never really punished (aside from paying back $2000, which at the age of 13 wasn’t easy to make…thanks to Norm Fanning for getting me a job shoveling manure). He said that “I’m disappointed in you son”.

I worked my tail off to pay back the fine by the end of summer.

It’s been 25 years and I’d like to believe that I haven’t done anything since that day to bring shame to my dad.

The moral of this story is twofold.

1. Have no regrets.

2. Have a role model in which to look up to and live up to.

Thanks for reading.

I got to go see a man about a horse.

Reflections on “The Alchemist” Part VI

“Tell your heart that the fear of suffering is worse than the suffering itself. And that no heart has ever suffered when it goes in search of its dreams, because every second of the search is a second encounter with God and with eternity.”

This rings true in my life. I thank my wife for supporting me in my decision to do more as a PT.

I had fear of jumping out of the position I had and jumping into a new position in a different city with a new company.

We played out worst case scenarios and you know what?…

Worst case scenario played out.

The clinic loses due to issues outside of my control and I was without a job.

The work that I put into trying to make the first clinic a success is what landed me the second job. The second job came with a substantial raise, but no time off of work. Those that know me, also know that this is not an issue. I enjoy my profession so much that I give back to the profession free of charge most nights. Working more hours is not an issue, at this point in time.

When I speak to students or those looking for their life’s meaning, I typically spend some time playing Devil’s advocate. I will use my best logic and knowledge to dissuade someone from following their dream. If I can convince someone that they should not do something within a 30 minute conversation, the reason FOR doing that something was not very strong.

Usually, the argument that dissuades people FROM making a decision is MONEY! I’ve found that when money is the driver, it’s easy to help that person discover what they really want.

1. Why does salary matter?

Because I want to make enough to support myself

2. What experience have you had that led you to believe that life is harder without money?

Xyz from childhood

3. Could you live on $60K/year?

Usually the answer is yes.

4. How many professions pay at least $30/hr?

They do a little research and then things start to open up a little more regarding what they would like to do or other options.

When money is the driver, it clouds our judgement.

If you believe that money buys happiness, I’m sure you’ve made decisions based on finances.

Sometimes it’s as simple as living on a few dollars less than you make. That becomes a lot easier to manage.

I’m reminded of stories from the Dave Ramsey Millionaire hour. Many people making less than $75k per year go on to have millions because they followed that one simple concept: spend a little less than you make.

Follow your passion! Follow your purpose!

Money is easy to get, but happiness and satisfaction in life…not so much. Too many other aspects cloud our judgement.

Love your life or change it!

No regrets!