An “Anecdote” on Dry Needling by Dr. Justin Dunaway, DPT

Want to do something that you’ll feel good about forever?? Then donate RIGHT NOW to Justin’s fantastic Kickstarter project@StandHaiti is very close to meeting their goal, and you can make it happen.

Physio Twitter is getting it’s panties in a bunch over Dry Needling. Take a chill-pill & soak in this much-needed Point Of View by Dr. Justin Dunaway. In case you aren’t already familiar with him (who isn’t??), then check out my interview with Justin here & here.

Enjoy!


 

An “Anecdote” on Dry Needling

With all this talk about RTCs, efficacy and effectiveness, and the necessity or futility of clinical experience… I’d like to share an experience, one that I feel matters more than the research, more than opinions or my clinical experience: a patient experience.  While I am very well read on the needling literature, have a strong foundation in physiology and a deep understanding of placebos, nocebos, and non-specific effects, as well as very strong opinions on all of these things…I’m going to leave them out of this discussion. I feel as we delve deeper and deeper into this rabbit hole of which research is better, who has a stronger understanding of its nuances, and the over reaching value of the research, we are forgetting about why we do it all. Each year of schooling, the piles of research, and the endless debates… aren’t about the stats or publications, and certainly are not about the paycheck. It was, is, and always should be about the patient first.  I want to share this single anecdote, keeping in mind the current debate between Dunning et al and Ridgeway/Venere et al in regards to the effectiveness and efficacy of dry needling.

This is the story of Sandy. Sandy is a person, not a statistic or a subject in a well powered RTC that wound up in a systematic review with a metanalysis showing strong evidence in support of my treatment choice, but a human in a very debilitating amount of chronic pain.  A human with loads of bias, confounding variables, and expectations.

Sandy (who is now 70 years old) was in a car accident 20 years ago, leaving her with chronic neck pain and headaches. Like many patients, she received radiographs, medical interventions, medications, shots, and legitimately good PT. As all these interventions failed and her condition worsened, she became depressed, decreased her activity due to pain, took increasing amounts of pain meds, and her condition ultimately deteriorated. She ended up having a cervical fusion (which was unsuccessful) that launched her into an even more pain and deeper depression and was prescribed methadone 3x/day. At this point, she was spending 90% of her time crying in bed, her medical team had given up on her and she on herself. Sadly, we’ve all known these patients.

When I first met Sandy, I just let her talk. A quick objective revealed neck joints and musculature that had clearly not moved in over a decade and a human feeling hopeless about her situation, just as you’d expect. After talking about treatment, she agreed to give dry needling a shot. I placed 10-15 needles in her neck, upper traps, back of her head, and a few points in her hands and applied electric to the needles for 20 min.

The next day she called to tell me that she had had her first good night’s sleep in longer than she could remember. I saw her twice a week for a few weeks and primarily performed DN. Within a month, she was going to the store, having family dinners, and playing cards with friends. Within two months, she was hiking the grand canyon with her new boyfriend pain free.  All from an intervention with no therapeutic value.

I realize this is anecdotal, Level 5 evidence, clinical experience, or whatever you want to call it. I understand that it is full of bias, confounding variables, “placebo”, “non-specific effects”, and other terms we use to discredit the things we don’t understand. But really, this is a human, a person who lost her life and then got it back through physical therapy. Sandy has regained her life because of an intervention. The choice of this specifically was guided by clinical experience, which may or may not be backed solidly in the literature. No RCTs have been written about the Sandys or the countless others with similar stories and certainly, if I practiced “Evidence Blinding Medicine,” Sandy would still be in bed, lonely and miserable.

I am not writing this to stoke the fires of the current debate on needling, what it means to be evidence based, or where clinical experience falls into the mix. I write this as a reminder that we treat humans, not statistics, and we should not forget that. We cannot be so focused on the PDF on our laptop that we forget about the human on our table.  Let the evidence guide you, but not blind you. Clinical experience, while full of bias and confounding variables, is absolutely paramount in treating the Sandys of the world. As promised, I will not cite any literature, nor will I reference any gurus or experts in the field. But I will leave you with this quote, one that we continue to get further and further from as we “advance” our knowledge, education, and research skills…one that speaks to the human element of what we do and the need for clinical experience and expertise.

“I would rather know the person who has the disease than the disease the person has.” 

–Hippocrates 460 BCE – 375 BCE

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Why Physical Therapists Need Physical Therapy

I wrote a guest post for Dr. Erson Religioso, DPT on Why Physical Therapists Need Physical Therapy. Here’s a preview:

Until recently, I didn’t consider seeing a fellow Physio for any other reason than necessity – pain, injury, etc. However, curiosity got the best of me, and I signed up for a few PT sessions and learned more than I expected. Here are my Top 5 Lessons so far.

Prima – every physio should know what it’s like to be a patient. Let’s drop the fact that you are a physio and might quietly (or not!) critique your care. View it purely from the perspective of a patient looking to return to full function: running, walking, sex, lifting, etc.

Here’s how Jill Baugh put it: “Only way to know if we get good care is to know if we get good care.

[Continue reading….]

5 Lessons Physical Therapists can Learn from Bruce Lee

I wrote a guest post for Strive Labs. Check it out:

“Bruce Lee is one of my personal heroes. While there are many reasons I admire him, I find his philosophical approach to everything the most salient and magnetic feature of admiration. We can learn numerous lessons from his life. Here are 5 lessons that apply to Physical Therapists as individuals, and Physical Therapy as a profession.”

Continue reading…

What Would MacGyver Do?

I wrote a guest post for Strive Labs titled “What Would MacGyver Do?” about some lessons we can learn from this 1980’s icon.


 MacGyver has been an icon of resourcefulness ever since he first hit TV decades ago. While we may not be able to cobble together lifesaving devices using toothpicks and chewing gum, there are some worthwhile lessons to be learned from Angus (can you believe MacGyver’s first name is Angus?? Me neither…). Let’s look at 2 filters of MacGyver wisdom; the first one is from a company that makes soap: Method.

Method grew from “a very dirty San Francisco flat” into a very successful brand and company. Their mascot was, and still is, MacGyver. “What Would MacGyver Do?” is one of their core values. Here’s how they described it: [read more]…

What kind of runner are you built to be?

Recently the question came up about minimalist shoes and if I was an advocate of them. In general I don’t think they’re a good idea and here’s why: The primary focus of the shoe is to attenuate ground reaction forces of landing. Barefoot or minimalist footwear fails in this prerequisite.

Now maybe you are scratching your head because many people have transitioned to minimalist footwear and have found joy by getting off of their heels?! So why did the shoes work for select percentage of the population and why do we have others that are non-responders and end up with stress fractures?

The key comes back to our anatomy and myokinematics (our own unique activation patterns). The dispersion of ground force reactions to a large extent is managed by how the tibia transitions over the ankle. Some people are blessed with wonderful enhancements to the tibialis anterior muscle. These folks are naturally able to heel strike and allow the tibialis anterior to eccentricly control the foot to the ground. Others are more dominant in their calves & when they attempt to land on their heel, transmit far too much force to their knees. A better way for them to manage the impact is to land in a relative plantar flexed position and eccentricly disperse the load through their calves.

So if you give someone a pair of unpadded shoes and they are not built to manage the forces through their calves (said another way-get off their heels), even with all the transitioning time in the world they will never adopt a pattern that will protect them from injury. Eventually one of two things happens: the energy requirements for that gait style are too excessive or generalized fatigue of the activity brings on a neurologic malaise and the runner breaks down.

Conversely, if you give someone who was always meant to be dominant with their calves permission to do such, it’s a religious experience!

Hopefully in the not-too-distant future, we’ll talk about the softness of the shoes and optimizing your strides.

There is some good data out there that for every ounce you take off your feet, your efficiency increases by 1%. If you want to incorporate some speed training into your regimes-go to a reputable running store and buy a pair of 5K shoes instead of minimalist footwear.

* just don’t go try and run a marathon in your new 5K kicks.

@alpineathlete

LeeAnne K-G: Top 5 Life lessons Learned So Far

I recently asked LeeAnne Ketchen-Gullett, ATC, MS about her “Top 5 Life Lessons So Far” and she was generous to respond with this fantastic guest blog. It is a worthwhile read that I will definitely re-visit periodically. In case you haven’t already met LeeAnne, you can find her on twitter @LKetchen14ATC (not only is she a Certified Athletic Trainer, but she’s also a Full-time Volunteer!). Enjoy the read and I hope you get as much out of it as I do.


There is Value to Each Individual You Meet

Meeting new people is one of my favorite things whether it is on a plane, conference, sports event,  work related or standing in a line. I take it as an opportunity to understand people and myself. I am not saying I “like” or have great experiences with every person I meet but I do take something away from each individual and interaction and carry it with me. During good or bad interaction I learn how to listen, engage in intellectual conversation, know when not to speak, and use of body language.  I’ll admit, often I have learned communicating the hard way but its valuable the next time a similar situation presents itself. I have met amazing people in unique circumstances and they have made an impact on me forever and may or may not even realize it. The world is big and full of incredible people. I would like to meet as many people as possible for the experience and to take a little bit of them with me. I find great importance to live in the moment and take the opportunity for person interaction because everyone has their own story and we can all learn from one another. That being said- even the smallest interactions can play a role, never underestimate the impact you can have on someone else’s life.

The world owes you nothing

Just because bad things happen doesn’t mean something good will happen to make up for it. Just because you work your tail off may not mean you get the job you want or put you necessarily where you want to be. I have learned to not “expect” much in return for what I do or accomplish. It is about changing your mindset and attitude. I work and am there for people because I love to do it and the reward is it makes me feel good. It is about being a good person and waking up with a positive attitude. I find that if I can do that then it will trump many things. It is important to focus on what we do have control over and the goals we set for our self. It is not okay to expect rewards for all things we do because we feel that we “deserve” it. It doesn’t always workout that way and we must carry on, work hard, and move forward. In life nothing is ever guaranteed, so everyday create your own luck and opportunity.

You cant wait for the perfect opportunity- Take a chance and step out of your comfort zone

Looking back I feel like I missed out on some opportunities because I was waiting for the perfect “moment” or “timing” where everything would fall together nicely and work out perfectly. What I’ve learned: rarely does this happen. I discovered that I wasn’t good at having a plan. I just ruined plans. However, I was better at planning and found it to be more efficient in accomplishments. If you take a chance and go with a positive attitude, it WILL work out and you will find success. I used to be scared that something bad would happen and it would mean a big set back in my life. I was wrong. It was in the moments where I didn’t have a plan, that potential opportunities opened up, when I dove in fully. I had no idea how things were going to turn out or where it was going to lead me, but it is in those moments I learned the most. Being in uncomfortable situations uncovered feelings I didn’t know I had and didn’t know I could handle. It’s about discovering parts of yourself you didn’t know existed and using them for future situations. This has happened to me on more than one occasion and I couldn’t be more grateful for chances that I have taken on a whim. It has lead me down a strong path of meeting amazing people and being put in tough situations that has built me as a person and professional.

Show that you care, be present

I believe that we are all connected somehow and this kind of goes hand in hand with my lesson number one.  I have found that building trust, being passionate, being considerate and caring can be the most rewarding thing one can do.  I didn’t understand this until I started getting e-mails and cards from people expressing gratitude about how important it was to them that I gave them time, listened to them, and show that I care. I truly value each person I work and interact with. It has to do with being a good person, doing the right thing, and being there for someone because you want to be genuine, to be their listening ear, and show concern. When I get feedback (cards and emails), I realize how much their feedback affects me, and I then understand the impact I may have on others. That is what feels amazing.  I think it is so important to not only show that your care, but when given the opportunity, let others know that you appreciate them. Even if it is as simple as a solid “thank you”, I know in my industry it can go a long way.

“I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.” ― Maya Angelou

Intuition and instinct can go a long way.

I think it is important to be in tune with our instinctive nature and follow the path it leads us down. Intuition and instinct isn’t measurable, it’s a feeling and belief based around experiences and facts that have been in our life. These experiences turn into our ability to problem solve and respond to situations for success. I suppose I can take the top four life lessons already mentioned and say intuition and instinct play a huge role in all of them. I would like to think growing up I have had a solid foundation built around strong morals and beliefs. As I get older and go through new experiences and challenges, I find self-talk and reflection to be one of the most beneficial parts to my day. Trusting my intuitive nature and making quick decisions has led me down an amazing journey.

Accept no ones definition of yourself because no one knows you better than you do. Society, parents, teachers may have an image about how you need to be and how to live your life in order to be successful. Fact of the matter is that everyone reacts and responds to situations differently. Life is here for us to create and define our self as a person, how we want to be and what path we choose. It is important to spend life on your own terms and what you believe in.  This is created by the choices we make and not the choices people think we should make. Be you, listen to yourself, and create yourself based on your intuition and instinct. I look forward to each morning, excited to create new opportunity and another day to build a better version of myself.

Connect with LeeAnne Ketchen-Gullett, ATC, MS on Twitter.

And find me @Cinema_Air

Austin Sheldon – Top 5 Residency Lessons

Dr. Bradley Grohovsky, DPT did a guest post on his Top 5 Residency Lessons So Far. If you haven’t read it, then I encourage to do so. Here we have a guest post by Dr. Austin, Sheldon, DPT on the same topic. 

“Austin Sheldon PT, DPT is currently a staff physical therapist working at Box Butte General Hospital in Alliance, Nebraska. While maintaining a busy outpatient orthopedic caseload, he also assists with the Sports Medicine outreach program by providing pro-bono care for high school athletes, provides in-patient coverage, and occasionally helps with skilled nursing facility coverage. Austin is a 2008 graduate of Regis University’s DPT program. In December of 2013, Austin officially graduated from the Andrews University/NAIOMT orthopedic manual physical therapy residency program’s initial cohort. Currently, Austin is enrolled in Andrews University DScPT program and closing in on the dissertation phase of the program and also is a NAIOMT OMPT fellow-in-training. Clinical areas of interest include patient education, the cervical spine, hip/pelvic girdle, conservative management of pars defects, conservative management of avulsion fractures, pain management, and education. He enjoys the rural western Nebraska life and outdoor opportunities with his wife, son, and two Labrador retrievers.”

Enjoy the read!


Perhaps how I arrived at doing a post-graduate physical therapy residency will resonate with some readers: Put yourself in the shoes of a new graduate. You are ready to take on the world, ready to become a vital member of the healthcare force, and let’s be honest, ready to start making some money. You graduated from a great PT program, learned from leaders in the field, and made some great friends along the way. BUT, along the way, while you spent three years working hard to keep your head above water, your other non-PT school friends were already earning money, traveling the world, paying off undergraduate debt.  You, a newly minted DPT, with student loans from undergraduate AND graduate school, are faced with the reality that the grace period for loans is looming like an un-escapable thundercloud, the closer it gets the bigger it appears…

The situation above is what I was faced with and in talking to students and new graduates, the situation above is all too common. Faced with growing debt and diploma, I applied for and accepted the highest paying job I could get: a SNF. I worked in a sub-acute/LTAC/SNF for the next 2.5 years, earning good money. Don’t’ get me wrong, I enjoyed the patients I worked with, each with medical complexities that needed to be acknowledged, respected, and addressed. My heart warmed when the patients succeeded and left the facility for home; however, I felt a deep professional emptiness. I was burnt out with the bureaucracy of RUGS, of constantly being asked to “look for opportunities for more minutes,” of having my clinical opinions and recommendations trounced, lack of professional growth, and absence of any one to talk to about clinical questions.

Long story shortened: I quit feeling sorry for myself and changed jobs. I became proactive rather than reactive. I moved on to an opportunity where I felt I could flourish personally and professionally. After having accepted the position, I looked into residency options that allowed me to keep my current job and ultimately applied to the Andrews University/NAIOMT program. After a series of interviews, I was accepted and began a nearly two-year long residency program that was formative, both personally and professionally. Without further ado, here is my “Top 5 Things I Learned from Residency:”

1) Don’t Forget How to Read

My residency instructor, mentor, and friend told me this the night we first met face-to-face. I was in Seattle, WA for the first class of the NAIOMT component of the residency program. Brett Windsor PT, PhD(c), MPA, OCS, FAAOMPT looked directly at me and said, “If you want to be the best you can be, read. Read everything. And read it for understanding.” It’s through reading pertinent and relevant literature to the clinical questions you are faced with that foundational differential diagnosis skills and clinical patterns are developed. Too many clinicians use the professional journals they receive from their professional associations as coasters for their morning coffee, collecting dust and stain rings. Open those journals if you get them and aim to read at least one article of interest per week that is applicable to a current clinical case you are managing. Don’t forget that, though your library access to journals from graduate school may have lapsed, PubMed is free to everyone!

2) Don’t Stop Listening

This is applicable to both the patients/clients you interact with as well as the instructors in your residency. When interacting with the patient, take the time to listen to the story he or she is telling you. Don’t interrupt. Part of the therapeutic process is allowing the person in front of you to tell you why he or she is seeking physical therapy to began with. Don’t look at the clock or the phone (that shouldn’t be in your pocket anyway, right Dr.?) or talk through the curtain to a colleague about last night’s “Mad Men” episode.

Part of participating in a post-graduate residency program is to better yourself as a clinician. Again, in the words of my mentor Brett Windsor, “to become a better clinician, you have to learn from someone better than you.” Listen to your mentor and consider what he or she is telling you. Be open to constructive criticism and leave the ego at home.

3) Don’t Discount Mentorship and Relationship-Building

You don’t need to complete a residency or fellowship program to find an invaluable mentor or to build positive relationships with colleagues; however, I am of the opinion that mentorship and relationship-building skills are integral parts of a residency program that will only better your professional development and satisfaction. One of the precipitating factors that lead to my dissatisfaction early in my PT career was the lack formal mentorship. I did not have a senior colleague to bounce problems, ideas, successes, and failures off of.  My mentor and residency instructor made himself available to me via phone, text, email, and in person throughout the program. He selflessly gave of himself at the expense of his time and resources to mentor me. Find a mentor that will challenge you rather than stroke your ego and coddle you.

Social and inter-personal skills are important to become a successful clinician and businessperson too. As part of the residency program’s requirement, I interacted with orthopedic surgeons, interventional radiologists, MSK radiologists, physiatrists, physician assistants, and nurse practitioners.  Understanding other healthcare professionals’ perspective and being able to communicate effectively and positively can only lead to improved inter-disciplinary care.

4) Don’t Become a Technician and Don’t Pigeon-Hole Your Learning

Realize that the primary reason to participate in a residency program (in my opinion) is to improve clinical reasoning and critical thinking, first and foremost.  Upon returning from the AAOMPT conference in Cincinnati last year, I was sitting on a bus at Denver International Airport on the way to long-term parking when I noticed the conference program sticking out of a fellow bus rider’s gigantic purse. I then asked the fellow attendee what she thought of the AAOMPT conference. She looked at me aghast and asked me how I knew she was there; I just pointed at the program hanging out of her purse. Turns out this colleague was Kristin Carpenter, a fellow-in-training through EIM. We had a great conversation and compared our experiences with EIM and NAIOMT as well as our experiences and take-aways from the conference.  The biggest take-away from our conversation was the agreement that clinical reasoning and critical thinking are more important than the psychomotor skills of mobilization, manipulation, dry-needling, etc. that may be learned in a residency program. If you critically think and reason through clinical problems, then the psychomotor skills/techniques you arrive at (if you choose to do anything at all) will develop. Don’t carry out a particular technique and then retrospectively ask yourself why said interaction succeeded or failed; think about what you are doing before, during, and after the interaction.

I think the mark of a good residency program is the realization and openness of the faculty that, while the instructors and mentors may have some answers, insights, and techniques for most clinical situations most of the time, NOBODY knows what do all with every situation 100% of the time. So, as a resident, I was encouraged to participate in other learning opportunities with other programs, institutions, and continuing education providers. In this way, I wasn’t pigeon-holed into uni-lateral group think. Be open to other approaches. Use what you like and what seems to work and forget the rest.

5) Add Value (for the patient/client) to Your Clinical Encounters

Quite simply: What do you add to the patient/client’s well-being that they have not already received? Listen, engage, interact, and connect with the patient. Patient education and activity modification, in my opinion, are two of the most valuable interventions a physical therapist can provide. By educating the patient/client about what is going on (and perhaps more importantly, what IS NOT going on), you are providing re-assurance that improvement is most likely going to occur and providing a “green light” to the patient to explore the world in a safe and pain-free manner. Aside from patient education and activity modification, you also may be the first person to touch the patient and provide a comprehensive examination. Providing hands-on care that facilitates pain-free movement that can then be reinforced through active and independent exercise is also key to adding value to the clinical encounter. The patient/client has “bought in” to physical therapy.

So, those are my “Top 5 Things I’ve Learned from My Residency.” I hope that some of the insight, experiences, and opinions I’ve provided resonate with some of the readers. I’d encourage anybody that strives to become a better physical therapist to explore residency options. Structured learning is important to a point; however, the mentorship, clinical reasoning, and critical thinking that residencies provide are priceless and set the stage for life-long fulfillment in the physical therapy profession.

Find Dr. Sheldon on Twitter: @ASheldDPT


I am @Cinema_Air

Brad Grohovsky: Top 5 Lessons from the Residency Trenches

I am a big proponent of doing a Residency program upon graduation from Physical Therapy school. Not only does it contextualize what you learned in PT School, but it also gives you valuable mentorship that fast-tracks you on your journey to become a better clinician (and more!).

Dr. Bradley Grohovsky, DPT serves on the APTA Private Practice Section Government Affairs Committee and is currently a Resident studying with the Institute of Physical Art at Encompass Physical Therapy in Annapolis, MD – specializing in Functional Manual Therapy™. Brad received his Bachelor’s degree from Western Kentucky in his home state prior to moving to Boston, MA for physical therapy school. While attending Simmons College he also served on the APTA Student Assembly Board of Directors prior to graduating with his Doctorate of Physical Therapy in 2011.”

You can read more of his thoughts here. I recently asked him about the top five lessons he learned from his Residency so far. He responded with this generous guest post. Enjoy!


“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. The practice of evidence-based medicine is a process of life-long, self-directed learning…” (Sackett)

​Physical Therapy is a rapidly evolving profession that is experiencing some revolutionary transitions both in our position in the healthcare system, but more importantly in our clinical skills and approach to patient care. Our profession currently stands at a great pinnacle with an opportunity to integrate into a vital (and missing) medical role in our society as both movement and lifestyle experts. Residency education is a catapult towards clinical expertise – if our profession is truly going to step into this role then we must step up to the plate as clinicians. If you are a student who is about to graduate (or just passed the NPTE..congrats!), a new professional, or a burnt-out experienced veteran I encourage you to check out a Residency in a specialty that interests you!

Here are the top five most valuable lessons of my Residency:

1. There is nothing more valuable than a mentor you respect and who challenges you to be your best.

-Because if you are not being challenged to be a better clinician everyday, then really what’s the point? Having an experienced mentor that challenges you to be your best improves both your skills as a clinician and your patient’s outcomes.

2. Attempt to prove yourself wrong with EVERY patient.

-Develop a hypothesis and use objective pre/post tests to validate your treatment and direct your plan of care. This allows you to develop and test your hypothesis every visit – if your theory isn’t correct, then change your treatment next visit (don’t wait until the next re-eval)! Every treatment becomes evidence-based and the objective information can provide immediate positive feedback for the patient!

3. Use your eyes, but trust your hands.

-More often than not, we are the first clinician to actually touch a patient’s pain. Learn to trust what your hands are telling you – they are your most valuable tool. In the book Outliers, author Malcolm Gladwell claims that 10,000 hours is the amount of time it takes to master a craft and achieve “greatness”. You can’t be Yoda – a Jedi Grand Master PT without mastering the force – and you can’t understand the force without putting in your time in the Jedi Academy.

4. Make every patient understand that this is a team effort.

-This reinforces compliance and accountability, which will encourage long term success. We are the mechanic who can repair broken parts, provide a tune up and clarify sections in the owner’s manual, but it is up to the patient to maintain the condition of their vehicle to the best of his/her ability.

5. Be an intelligent teacher, but an excellent pupil.

-Evidence continues to mount in support of the neuromatrix components of chronic pain involving neural, psychological and social components in addition to the physical presentation (Butler, Moseley, Wardlaw). Patients often teach us how to best treat them, whether intentionally or unintentionally. During treatments, be an active listener – both treat and educate each patient based on his/her individual learning style!

For further Residency reading please check out my recent post on PTHaven.com – To a Residency and Beyond!

Follow me on twitter @DrG_PT

Resources:

1. Sackett: Evidence Based Medicine: What it is and what it isn’t, BMJ 1996;312:71

2. Butler, D: Explain Pain

3. Wardlaw C: Taming Pain

4. Moseley: A Pain Neuromatrix Approach to Patients with Chronic Pain, Manual Therapy 2003


I am @Cinema_Air