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Modern Pain Sciences Course in Pittsburgh, PA


I just wanted to take the time to let everyone know about a great course being taught in the Pittsburgh, Pennsylvania area by NXT Gen Institute of physical Therapy. I have already registered and am looking forward to learning more about pain science and how I can integrate this approach into my clinical practice. Additionally, by using the promo code Snyder10, you can save 10% on the registration fee!


Course Title: Modern Pain Sciences: Manual Therapy’s Keys to Motivation, Input and Plan

Date: December 7th, 2014

Location: Pittsburgh, PA

Faculty: Joseph Brence, PT, DPT, COMT, FAAOMPT, DAC & Francois Prizinski, PT, DPT, OCS, COMT, FAAOMPT, DAC

Seminar Description: This course is designed to provide a biopsychosocial insight into the emerging neuro-scientific revolution of pain science, particularly as it relates to plasticity of the brain and the dynamics of the nervous system. Modern concepts of pain neurophysiology will be taught which are vital in the care of every one of our patients’ “painful” conditions. This course will assist the modern manual therapist on how to examine, evaluate and treat the physical health of the nervous system. It is geared toward practicing clinicians who want to learn how to effectively discern when pain is likely due to nociception, peripheral neuropathy or central sensitivity and how to approach with treatment. Additional intervention emphasis is placed on neurodynamics, engaging social forces to communicate with patients and imagery to reduce their painful experience. This is an intermediate level course.

Duration: 8 contact hours

Cost: $300.00, use promo code Snyder10 to save 10%!


For a sneak peek of the concepts and philosophy behind this approach, watch the following clip from the 2013 AAOMPT Annual Conference…


Differential Diagnosis: Superior Labral Anterior-Posterior (SLAP) Lesions


The following is another article written for the online, video-based physical therapy continuing education company MedBridge

Amongst overhead throwing athletes, there are several injuries that typically come to mind, and at the top of that list is the Superior Labral Anterior to Posterior (SLAP) Lesion. While this is not an overly common injury for the general population, with an overall incidence of 26% (Kim et al, 2003), diagnosis and subsequent surgical intervention does seem to be on the rise. Onyekwelu et al reported that the incidence of SLAP repairs in New York State rose by a factor of 5.5 between 2002 and 2010. Similarly, Weber et al analyzed 4,975 cases of SLAP repairs collected from the American Board of Orthopaedic Surgery (ABOS) and found that ABOS candidates were performing SLAP repairs at a rate 3 times higher than expected. With the growing incidence of this pathology, clinicians must understand which mechanism of injury and patient presentation is indicative of a SLAP lesion. [CONTINUE READING]


What to Read: July 2014

Cathedral of Learning

Blog Posts

We Need to Educate and Interact – With Ourselves and Our Patients“, by Joseph Brence, PT, DPT, FAAOMPT, COMT, DAC

Utility of the Head Thrust Test to Investigate Vestibular Function: A Clinical Pearl“, by Jeff Walter, PT, DPT, NCS

Repeated Motions Exam and Treatment: Why You Should Be Using It“, by Chris Fox PT, DPT

Return to Play After ACL Reconstruction in Preadolescent Athletes“, by Brian Schiff, PT, OCS, CSCS

The Language of Pain“, by John Barbis, MPT, cert. MDT

How can resistance-training programs best improve power?“, by Chris Beardsley, PhD


1. Butler RJ, Myers HS, Black D, et al. BILATERAL DIFFERENCES IN THE UPPER QUARTER FUNCTION OF HIGH SCHOOL AGED BASEBALL AND SOFTBALL PLAYERS. International Journal of Sports Physical Therapy. 2014;9(4):518–524.


3. Cook G, Burton L, Hoogenboom BJ, Voight M. FUNCTIONAL MOVEMENT SCREENING: THE USE OF FUNDAMENTAL MOVEMENTS AS AN ASSESSMENT OF FUNCTION – PART 2. International Journal of Sports Physical Therapy. 2014;9(4):549–563.


5. Butler R, Arms J, Reiman M, et al. Sex Differences in Dynamic Closed Kinetic Chain Upper Quarter Function in Collegiate Swimmers. Journal of Athletic Training. 2014;49(3). doi:10.4085/1062-6050-49.3.17.

6. Beynnon BD, Vacek PM, Newell MK, et al. The Effects of Level of Competition, Sport, and Sex on the Incidence of First-Time Noncontact Anterior Cruciate Ligament Injury. Am J Sports Med. 2014;42(8):1806–1812. doi:10.1177/0363546514540862.

7. Haik MN, Alburquerque-Sendín F. Scapular Kinematics Pre– and Post–Thoracic Thrust Manipulation in Individuals With and Without Shoulder Impingement Symptoms: A Randomized Controlled Study. Journal of Orthopaedic & Sports Physical Therapy. 2014;44(7):475–487. doi:10.2519/jospt.2014.4850.

8. Ryan J, DeBurca N, Mc Creesh K. Risk factors for groin/hip injuries in field-based sports: a systematic review. British Journal of Sports Medicine. 2014;48(14):1089–1096. doi:10.1136/bjsports-2013-092263.

9. Kamath GV. Anterior Cruciate Ligament Injury, Return to Play, and Reinjury in the Elite Collegiate Athlete: Analysis of an NCAA Division I Cohort. Am J Sports Med. 2014;42(7):1638–1643. doi:10.1177/0363546514530866.

10. Paterno MV, Rauh MJ, Schmitt LC, Ford KR, Hewett TE. Incidence of Second ACL Injuries 2 Years After Primary ACL Reconstruction and Return to Sport. Am J Sports Med. 2014;42(7):1567–1573. doi:10.1177/0363546514530088.


CEU Review: MedBridge Education’s Patient Care HEP

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Patient education and the instruction of a home exercise program (HEP) is of utmost importance to clinicians in order to obtain positive patient outcomes and to improve compliance. Recently, MedBridge Education rolled out their Patient Care Portal, which includes a HEP and Patient Education materials. I have had the opportunity to use this software for the past month or so and have broken my review into the following areas…


With 1,500 exercises (and growing) this HEP is almost all you will ever need with regards to prescribing a patient’s home program. These are not just simple stick figures or awkwardly drawn models either. Each exercise includes simple, modifiable instruction of technique, exercise parameters, and an in-depth video demonstration. Each exercise program can also have a detailed description and 3D video demonstration of the injury and/or disorder that your patient is being treated for. Additionally, if you cannot find the exercise or disorder that you need, both can be easily uploaded to the system. After you finished creating your patient’s program it can then be printed out, e-mailed, or the patient can visit their ‘Patient Portal’ to view their HEP and associated videos.

Ease of Use

MedBridge’s Patient Portal is one of the most user friendly HEPs that I have come across. Finding the correct exercise is simple with the ability to search based on body region, exercise type, or by searching for the specific exercise’s name. We all know that there can be countless names for the same exercise and this can cause significant issues when attempting to find your exercise in most HEPs. MedBridge’s program actually gives you the ability to modify the exercise’s name so that you can keep things straight in your head and so searching for the exercise in the future can be more efficient. Finally, to create a more efficient process, you can create templates for the more common disorders/injuries that you see on a day to day basis.

Patient Feedback

In my limited use of this program, I have heard nothing but positive feedback. Most patients are used to receiving crude drawing with poorly described exercise techniques and once they get home, all memory of how to perform their exercises is gone. I have noticed improved patient compliance and recall of exercise technique since implementing MedBridge’s HEP. The only negative comment I have received from a few patients/clients is that the pictures on the printouts are rather small and when printing in black & white, they can be difficult to see. Obviously, they could go to the website to watch the associated videos, but many patients don’t want to take that extra step.


Honestly, I have very few negative things to say about this software. It is intuitive, detailed, and a game-changer with regards to home exercise and patient education. The only negative I see is having to log into the online program in order to make a program, but this is a very minimal hassle for such a beneficial component to my patient’s care. After using basic and (mostly) frustrating HEPs in the past, my switch to MedBridge’s Patient Portal has been seamless with a very minimal learning curve. After 15-20 minutes of playing around with the program, I felt comfortable creating, editing, and sending programs to my clients. What’s the best part of this program? The cost. Currently, the Patient Portal is included with MedBridge’s online continuing education product, so for all those therapists already using this great resource, it is absolutely FREE.

For those of you who have not yet subscribed, you can purchase a one-year subscription to the continuing education, patient portal, and reference tools (Orthopedic Exam Videos, Manual Therapy Technique Videos, and 3D Models) for only $200, which is a savings of $225! For the Discounted rate, CLICK HERE or feel free to check out the MedBridge website and use promo code orthomanualPT when you’re ready to buy. This sale is good until 11:59 PM EST on Sunday, August 10th, so don’t wait too long!


What Are We Missing? The Influence of Fatigue.


The following is another article written for the online, video-based physical therapy continuing education company MedBridge

Recently, a lot of attention has been paid to re-injury and return to sport following anterior cruciate ligament reconstruction (ACLR) and the results continue to be less than exceptional. A recent case series of elite collegiate athletes who suffered ACL injuries prior to and during their college careers continually found difficulty returning to sports participation (Kamath et al., 2014). Of the 35 athletes who had undergone ACLR prior to enrollment in college, the rate of re-operation on the involved limb was 51.4%, the rate of re-rupture of the ACL graft was 17.4%, and contralateral ACL rupture was 20.0% within this population of athletes. Similarly, those who underwent ACLR during college had a 20.4% re-operation rate, 1.9% suffered re-rupture of the ACL graft, and 11.1% of these athletes underwent ACLR on the contralateral limb. In agreement with these findings, a prospective cohort study of 456 collegiate athletes conducted by Rugg and colleagues found that athletes entering college with a history of ACLR had a 892.9-fold increase in knee surgery compared to those who entered college without undergoing surgery. Unfortunately, these findings are not isolated to collegiate athletes as professional (Busfield et al., 2009) and high school athletes (McCullough et al., 2012) alike have similar statistics. Considering these numbers, it points to inadequate or premature return to athletic participation, which may be because we are overlooking a very important aspect of athletic competition… [Continue Reading]



What to Read: April to June 2014

Cathedral of Learning

Blog Posts

What is the Lateral Shift & Why Does It Matter?“, by Trent Nessler, PT, DPT

Kinesio Taping looks so cool, but is it effective?“, by Leo Costa, PT, PhD

Assess, Don’t Assume“, by Mike Reinold, PT, DPT, SCS, ATC, CSCS

Is hip strength a risk factor for patellofemoral pain?“, by Christian Barton, PT, PhD

How do rest periods affect strength gains?“, by Chris Beardsley, PhD

Assessing VBI before cervical manipulation: Should we test for it?“, by Chris Fox, PT, DPT

There is no skill in manual therapy…?“, by Adam Meakins

Unstable Surface Training: The Good, Bad, and Ugly“, by Eric Cressey, MS, CSCS

Iliotibial Band Syndrome, Running, and Gender – What you should know“, by Christopher Johnson, PT, MCMT, ITCA

Common Misconceptions of the Functional Movement Screen“, by Phil Plisky, PT, DSc, OCS, ATC, CSCS

Screening for Movement Dysfunction: Are We Missing Anything?“, by Greg Lehman, BKin, MSc, DC, MScPT


Kooiker L, Van De Port IGL, Weir A, Moen MH. Effects of Physical Therapist–Guided Quadriceps-Strengthening Exercises for the Treatment of Patellofemoral Pain Syndrome: A Systematic Review. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(6): 391–B1.

Enseki K, Harris-Hayes M, White DM, et al. Nonarthritic Hip Joint Pain. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(6): A1–A32.

Cools AM, Borms D, Cottens S, Himpe M, Meersdom S, Cagnie B. Rehabilitation Exercises for Athletes With Biceps Disorders and SLAP Lesions: A Continuum of Exercises With Increasing Loads on the Biceps. American Journal of Sports Medicine. 2014; 42(6): 1315–1322.

Drew BT, Smith TO, Littlewood C, Sturrock B. Do structural changes (eg, collagen/matrix) explain the response to therapeutic exercises in tendinopathy: a systematic review. British Journal of Sports Medicine. 2014; 48(12): 966–972.

Kiesel KB, Butler RJ, Plisky PJ. Prediction of Injury by Limited and Asymmetrical Fundamental Movement Patterns in American Football Players. Journal of Sport Rehabilitation. 2014; 23(2): 88–94.

Powers CM, Ho K-Y, CHEN Y-J, Souza RB, Farrokhi S. Patellofemoral Joint Stress During Weight-Bearing and Non—Weight-Bearing Quadriceps Exercises. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(5): 320–327.

Nilstad A, Andersen TE, Kristianslund E, et al. Physiotherapists Can Identify Female Football Players With High Knee Valgus Angles During Vertical Drop Jumps Using Real-Time Observational Screening. Journal of Orthopaedic & Sports Physical Therapy. 2014; 44(5): 358–365.

Otsuki R. EFFECT OF INJURY PREVENTION TRAINING ON KNEE MECHANICS IN FEMALE ADOLESCENTS DURING PUBERTY. International Journal of Sports Physical Therapy. 2014; 9(2): 149–156.

Glaws KR. INTRA- AND INTER-RATER RELIABILITY OF THE SELECTIVE FUNCTIONAL MOVEMENT ASSESSMENT (SFMA). International Journal of Sports Physical Therapy. 2014;9(2):195–207.

Rust DA, Giveans MR, Stone RM, Samuelson KM, Larson CM. Functional Outcomes and Return to Sports After Acute Repair, Chronic Repair, and Allograft Reconstruction for Proximal Hamstring Ruptures. American Journal of Sports Medicine. 2014; 42(6): 1377–1383.


When Can I Play Again? Return to Sports Testing for the Upper Extremity.


The following is another article written for the online, video-based physical therapy continuing education company MedBridge

A lot has been written and researched with regards to return to sport criteria and testing for injuries of the lower extremity, and more specifically following anterior cruciate ligament reconstruction (ACL-R), however little attention has been given to injuries of the upper extremity. As with ACL-R, return to sport following surgical intervention in the upper extremity is less than stellar. Harris et al conducted a systematic review that found amongst elite pitchers undergoing shoulder surgery (rotator cuff, biceps/labrum, instability, internal impingement, ect.), only 68% returned to play 12 months following surgery. Additionally, they found that 22% of major league baseball pitchers included in their review never returned to sport. In agreement with these findings, Cohen et al evaluated the return to sport of professional baseball players following shoulder and/or elbow surgery and found only 48%  of participants returned to the same or higher level of professional baseball following surgery. Why are these numbers so low and what can we do as rehabilitation specialists to improve the rate of return to sport following surgery?

Sometimes, it simply takes correctly identifying those who are at risk of re-injury or those simply not ready to rerun to their chosen sport. When devising an appropriate return to sport test, Phil Plisky, PT, DSc, OCS, ATC, CSCS says in his course, “Return to Sport and Discharge Testing“, that each test should be reliable, predictive of injury, have discriminate validity, and the test must be modifiable with training/rehabilitation. With regards to the upper extremity, there is a significant gap in knowledge/research in comparison to the lower extremity. That being said, the Y-Balance Test has recently been adapted to help fill this gap. Gorman et al investigated to reliability of the Upper Quarter Y Balance Test (UQ-YBT) and found that the test-retest reliability (0.80-0.99) and inter-rater reliability (1.00) ranged from good to excellent. Along with this information, normative data was determined amongst active adults with males generally performing the test superiorly to females and a minimally detectable difference of 8.1 cm in the medial direction, 6.4 cm in the superolateral direction, and 6.1 cm in the inferolateral direction. In addition to these findings, Westrick et al found that there was no significant difference between the dominant and non-dominant limb when young females or males perform the UQ-YBT. This shows that, generally speaking, any significantly asymmetrical findings should be investigated further prior to returning the athlete to his/her sport. While, currently, there are no studies investigating this test’s capacity to predict injury or its ability to be modified with training, the excellent reliability and discriminate validity make this a solid return to sport test.

Similarly, the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST) offers an additional way to assess upper extremity dynamic stability, albeit in a singular plane. Once again, this test demonstrates excellent reliability with a Test-Retest Reliability of 0.92 (Goldbeck et al), an intersession reliability ranging between 0.87 to 0.96 (Tucci et al), and an intrasession reliability ranging between 0.86 and o.97. Furthermore, Tucci et al also found the CKCUEST to have discriminate validity as those performing the test with diagnosed subacromial impingement performed significantly inferiorly in comparison to asymptomatic participants. Along with this excellent reliability and obvious display of closed kinetic chain dynamic stability, the CKCUEST also has recently been shown to have the capacity to predict injury. Pontillo et al performed a prospective cohort study attempting to identify potentially factors that would be predictive of upper extremity injury in collegiate football players. The only significant factor in predicting future injury in this population of athletes was a CKCUEST in which the athlete completed < 21 touches (Sn= 79%, Sp= 83%, + LR= 4.74, – LR= 0.25, Odds Ratio= 18.75). This is a significant finding and shows the benefit for utilizing this test not only for return to sport, but also in pre-season testing to identify individuals who are at risk for injury.

For a more demanding task, similar to the single-leg hop testing utilized for patients following ACL reconstruction, the One-Arm Hop Test was created to test the athlete’s plyometric, power, and dynamic closed kinetic chain stability. Unfortunately, to this date, there has only been one study investigating this specific return to sport test. Falsone et al found the test to have good Test-Retest Reliability (0.78-0.81) and also found only a 4.4% difference between non-dominant and dominant limbs when performing the test. This once again shows the ability to assess post-operative function based upon the symmetry between limbs. While this may not be a perfect solution, it allows the ability to utilize the test with evidence-based backing until further research is conducted investigating its ability to predict injury and/or be modified with training.

Returning an athlete to sport is a multi-factorial decision that must incorporate that athlete’s psychological readiness to return to play, strength, range of motion, pain level, and ultimately the ability to perform the movement patterns consistent with their sport and/or position. The aforementioned return to sport tests provides a hierarchical (i.e. increasingly demanding) system for testing the individual’s capacity to withstand the rigors of their chosen activity. This allows clinicians something outside of subjective reports, range of motion, and strength measures to assess your patient’s ability to perform dynamic upper extremity tasks prior to returning to sport and in doing so, we may be able to identify some of the deficits our athletes are hiding that are preventing them from ultimately returning to their sport.


Things are not always as they seem… The Basis for a Regional Interdependence Model


The following is another article written for the online, video-based physical therapy continuing education company MedBridge Education

Think for a minute about what you would do if the following patient walked into your clinic…

A 24-year-old female patient presents with left anterior knee pain, which was exacerbated after beginning a rigorous marathon training program. No other complaints other than pain during her runs and for 4-6 hours thereafter, but no other functional limitations when performing her ADLs. 

So, based on this scenario, where would you focus your evaluation? My guess is that the majority of clinicians would focus on the knee and more specifically, the patellofemoral joint. Active and passive range of motion would be taken, gross lower extremity strength would be screened, and special tests would be performed. But, what if the patellofemoral joint was not the issue?

While these tests and measures are often indicated, with regards to musculoskeletal injuries, a joint or muscle group proximal or distal to the involved site can actually be the cause of the patient’s complaints. This concept is known as Regional Interdependence. This can be seen with a variety of orthopedic complaints as hip involvement has been associated with low back pain (Cibulka et al) and knee osteoarthritis (Cliborne et al), and thoracic/rib involvement in neck pain (Cleland et al) and subacromial impingement (Bergman et al). Specifically speaking of patellofemoral pain syndrome (PFPS) and our marathon running patient, proximal and distal impairments have also been shown to be very common in this patient population. A recent study conducted by Khayambashi et al found that following 8 weeks of hip abductor and external rotator strengthening, reduced pain and improved function was reported in women with PFPS in comparison to a control group. Furthermore, Khayambashi et al later conducted a randomized controlled trial comparing quadriceps strengthening to posterolateral hip strengthening in patients with PFPS. This study once again favored the hip-strengthening group with improvements in VAS and WOMAC scores in the posterolateral hip exercise group being superior to those in the quadriceps exercise group post-intervention and at 6-month follow-up. Going along with these findings, a systematic review investigating the utility of proximal stability training in patients with PFPS, which included 8 RCTs and found a consistent reduction of pain and improved function in the treatment of patellofemoral pain (Peters et al). Additionally, looking distally from the knee at the foot/ankle joint, according to a case-control study performed by Barton et al, individuals who present with PFPS, possess a more pronated foot posture and increased foot mobility compared to controls.

So, as the research shows, there is a fairly significant amount of evidence supporting the premise of Regional Interdependence, but how do we evaluate how and where to address the potential proximal or distal impairments? While there are several systems available to therapists to identify and address impairments based on the regional interdependence model, one of the most well-known and widely accepted systems is that of the Selective Functional Movement Assessment (SFMA). This system consists of a series of 7 full-body movement tests designed to assess fundamental patterns of movement, such as bending and squatting, in those with known musculoskeletal pain. From this assessment, interventions can then be applied to the identified impairments. While in comparison to its brother system, the Functional Movement Screen (FMS), which was developed for movement assessment in individuals without a painful condition, the SFMA has significantly less research available. That being said, a reliability study was recently conducted by Glaws et al in the International Journal of Sports Physical Therapy. This study found intra-rater reliability that ranged from Good to Poor and inter-rater reliability ranging from slight to substantial agreement. Those raters with increased experience utilizing the system demonstrated superior performance compared to those who were less experienced. This study provides preliminary evidence with regards to the reliability of the system, but there has yet to be a study conducted to validate the system’s effectiveness. In lieu of this evidence, the system itself still provides a reliable way to assess your patient’s movement impairments and allows the clinician to apply interventions, whether manual therapy techniques or therapeutic exercise, that will improve the patient’s quality of movement. For further information regarding the SFMA and its utility, take the time to understand the intricacies of the system by taking “Movement Dysfunction: An Evidence-Based Overview” by Kyle Kiesel, PT, PhD, ATC. The research indicates that movement relies on a coordinated interaction of multiple joints, muscles, and biological systems (cardiovascular, musculoskeletal, neurological, ect.). Because of these multiple influences, the therapist must look at potential factors that may be predisposing the patient to their painful condition and many times this will take us away from the effected joint.


2014 Therapydia Blog Awards: Best Student Blog!


Orthopedic Manual Physical Therapy was officially named ‘Best Student Blog’ in Therapydia’s PT Blog Awards for the second consecutive year! Thank you so much for the continued support and taking time out of your day to to vote for OMPT! I was honored just to be nominated along with The AAOMPT sSIG, Pitt Physical Therapy, The Student Physical Therapist, and A Cup A Day.

OMPT also came in 3rd place for ‘Best Research Blog’ and it was honestly great just to be named in the same breath as Body in Mind and Forward Thinking PT. Congratulations to Joseph Brence, DPT, FAAOMPT and all those that contribute to Forward Thinking PT!

Thanks again for all of your continued support,

John Snyder, DPT, CSCS


2014 Therapydia PT Blog Awards!

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Thanks to all your continued support, was nominated for both ‘Best PT Student Blog’ and ‘Best PT Research Blog’ in Therapydia’s 2014 PT Blog Awards. It’s an honor to be named in the same group as all of the nominees in both categories!

Please continue to support and CAST YOUR VOTE (voting ends in ~ 2 weeks)!


John Snyder, SPT, CSCS


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