CEU Review: DN-1 & DN-2

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I recently attended DN-1 & DN-2 by the Spinal Manipulation. The courses were fantastic experiences and have provided me with new means of addressing a variety of conditions in the clinic. Both courses surprised me on two fronts:

1. The Research. I wasn’t expecting so much time spent on discussing the research and how it guided their approach. The amount of research presented simply blew me away. Research is research regardless of which geographical region of the world it was done and in which professional journal it was published. And so, they pulled research from all over the planet and thought a decent variety of disciplines. This was strangely refreshing. The lectures were quite heavy on the current relevant research; and, it was presented fairly in that both positive and negatives were mentioned. I don’t know about the nuances & specifics of these studies, but the fact that they exist and haven’t been explored in other courses is very interesting.

2. Pain Science Lectures. Yes, I know what you’re thinking…it’s a dry needling course and they’re presenting lectures on pain science? Oh, yes they did. The phenomenal lectures on pain science as it relates to Dry Needling also caught me completely off-guard….in a very good way! I gotta admit: pain science talks in both courses were in-depth on biochemical and mechanical levels as related to dry needling. It was fantastic and convincingly presented. Very convincing. Tommy presented a very detailed & balanced lecture, and Ray bled passion during his lecture.

Now onto specific critiques on the courses themselves, as well as recommendations for future attendees.

The Negatives.

About 40% of the manual was summaries of research reports. While this provides a nice foundation of research on which to base Dry Needling treatments, it could easily be converted into a PDF to be emailed and downloadable to course attendees. Another issue with the current manual (DN-1 2016) is that it didn’t always correlate with the material presented. In other words, material was presented that wasn’t in our course notes, and there was no way to obtain an updated manual. Why? Apparently the new manual wasn’t yet approved for publishing. It would be fantastic to make this information accessible to 2016 course attendees (with a reduced price) when it is available. Maybe you could save paper and simply email/download it in PDF form; printed manual could be an extra charge.

The manual had a couple more short-comings. 1) There was very limited space to take notes. 2) The semi-standard protocols weren’t to be found; however, there is ample instruction on palpation, needle placement, and needle technique. It would’ve been nice to have drawings/pictures of the protocols alongside written instructions for future reference within the manual itself.

When it came to lab time, there was often ran into extremes of either excessive or short practice periods. This was the first Dry Needling course for a number of attendees, and spending a little longer on basic needling practice would’ve been more beneficial. Then again, maybe I was just too slow to get comfortable before moving on to labs 2 or 3. DN-2 did a much better job of managing lab time.

Finally, there should’ve been more time spent on the technicals of employing Dry Needling in the clinic – things like how to bill insurance for it, how it’s incorporated into a cash practice, orchestration of Dry Needling into the Plan of Care to address questions of stretch after/before or skip exercising entirely. All these items should be addressed up front and as clearly as possible. I had these questions addressed in DN-2 by asking the instructor during lab time. Be sure to ask this question to multiple folks – instructors & other DN practitioners.

Some Tips & Recommendations.

Take lots of pics from a variety of angles – at least 2 different angles. This will allow you to get a better appreciation of needle placement when you’re practicing it on your friends, family, and coworkers after the course.

If you’re a visual learner like me, then it might be a smart idea to sketch out the lab demo with all the insertion markings. It might also be useful to re-create this on your own after the course is over. This way you feel more confident about inserting the needles, and know exactly what you’re doing before you start poking your friends, coworkers, and/or family members.

Let’s stick with the lab demo for a bit longer. As I mentioned earlier, the course manual provides very little room to take adequate notes. So, it’s a really good idea to jot down instructions/sketches during the lab demo into either a separate notebook or sheets of paper. Using a clipboard with unruled sheets of paper works best for me. This allows freedom to sketch and jot down info as it suits my visuals without the constraints of ruled pages.

Consider reviewing the relevant anatomical regions prior to taking the course. Here’s how I would’ve done it: cover the insertions of major/important muscles and their innervation, trace major nerves (for DN-1 think brachial plexus), and, finally, roughly familiarize yourself with the “spaces” (for example, the quadrangular space) that are created by the framing muscles and/or other structures – no need to be very meticulous about this, just consider the obvious ones.

Finally, bring some cash. They tend to supply needles like your grandmother would supply dinner items: better too much than too little. This allows you the opportunity to purchase some needles right after the course and start practicing right away. $50 worth of needles should be a nice start.

The Positives.

Their conceptual application of combining spinal manipulation and dry needling certainly peaked my interest. It made me want to explore these “segmental effects” deeper on my own prior to taking a spinal manipulation course. I really appreciate the work behind creating these protocols (much of which was lifted directly from research articles).

Both instructors were knowledgeable, presented the material well, AND presented it fairly. They pointed out studies that showed both sides of the argument. Their perspectives on utilization of the literature was refreshing and made me open my eyes a bit more toward how some (many?) folks view the literature through tainted lenses while wearing blinders. 

This course provided me with incorporable content and manual intervention options that can dove-tail nicely with my current clinical framework. While I don’t think wearing the “osteopractor” label is in my future, the concepts were intriguing and definitely warrant more of my curiosity.

Final Take.

I came away from this course with much more appreciation of an intervention that I had ignored just 4 years earlier. Dry Needling seems to have the potential to address multiple fronts at once: save my hands, access structures that are difficult to reach/treat with manual palpation, provide another route to address chronic pains, and provide me with another differentiator with which to market my services for the benefit of my future clients. Good content. Engaging instructors. Worth the time.

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Mea Culpa

2016 exploded onto the scene, and there’s no looking back. A couple milestones await for me in the next few months. One of them is a Physical Therapy Class Reunion. No, I’m not going to mention how many years have passed, but let it suffice to know that I’m more excited about our profession now than ever.

Emotion and Experience were vital components to my growth as a Physical Therapist thus far, and they will likely continue to play their vital role for the foreseeable future. Emotion and Experience are also vital components of our growth as human beings. Perhaps the Environment we grew though, and will continue to grow in/through, is an equally (or more) significant determinant in our Emotional and Experiential growth.

Either way, here are some thoughts that are crossing my mind in this period of critical change. I hope you find them as useful as I do.


Don’t shy away from asking yourself “What the fuck am I doing with myself?” Don’t shy away because there’s no wrong answer to this question. The reality is a very small percentage of you (no, it’s probably not you) are following a life-plan penciled perfectly in high school. Asking yourself this question is more about self-correcting than proselytizing. It’s a series of continual adjustments based on your long term vision.

Entertain yourself. It’s more fun than you can imagine.

Don’t shy away from intentionally disappointing someone if you know that there’s a high probability that the bread is about to fall jelly-side down. This doesn’t mean you have to be memorably offensive. Saying “no” effectively without crushing relationships is a skill worth developing.

Don’t worry about what people think of you. This simple life-hack will free your mind more than almost anything. Also, it clears your lens on life by allowing you to see how clever or transparent people truly are. You’ll be tempted to gain and keep the recognition of those smart people you think you identify with. The reality is you’re probably fooling yourself into building a self-image that is ultimately painfully unsustainable.

If you aren’t any closer to your desired lifestyle this year than the last year, then hop on that horse and make it happen. It’s incredible how 1 year turns into 3, and before you know it you’ve been treading water…at best. This simple fact will continue to boggle your mind in real-time and in retrospect. Some smart guy once said: “The best way to predict the future is to invent it.” He might be right.

Health is wealth. Yup, the oldies were right. Health truly is wealth.

Consider the impact of all the non-renewable resources in your life. “Time” deserves to be very high on that list.

One of the few constants other than Time is Change. Don’t be afraid to change. It’s going to happen anyway, so why not take the wheel rather than handing it off to people you don’t really know – employers and their management teams, especially their management teams. Don’t be afraid to take the wheel and change lanes.

Sleep. Sleep because feeling well-rested is a glorious feeling.

Don’t “grow up”. I’m still not sure what that term means, but avoid it as much as possible. The “grown-ups” tell me it’s overrated.

Be nice. The world is getting smaller every year…which means Karmic paybacks happen quicker and/or with greater intensity today than yesterday.

Simplicity is priceless. If you can’t explain what you’re doing to a 12 year old, then you’re carrying around unnecessary baggage. Lighten the load, and clear your plate down to the bare essentials. At the very least, simplicity makes it easier to smile.

You can’t outrun your fork.

And, if you’re riddled with indecision, then apply the Regret Minimization Framework.

As many of you are well aware, I enjoy reading books. Early March 2016 saw the first edition of my Quarterly Readings Newsletter. It is an update on some of the more interesting reads of the 3 months preceding publication of the email Newsletter. Email me with “I love to read!” in the subject line, and I will add you to the email list. 

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…

“The Front of the Back”

https://twitter.com/Cinema_Air/status/535089100374556672

He walked with a very rigid trunk, no trunk reciprocation, and a compensatory forward R trunk lean with initiation of R LE swing. He seemed to have difficulty loading his R LE. His general complaint was pain and major stiffness throughout his R hip, low back, and neck.

We worked on mobility and motor control to improve R LE loading for better & pain-free gait, but nothing major changed. I decided to have him on the table and check passive pelvic mobility; that’s when it got interesting. R pelvic anterior elevation seemed “boggy” and posterior/anterior depression was incredibly limited. And, it seemed like something anterior/superior to his R pelvis was preventing him from moving.

“Mind taking off your shirt? I feel like something along the front is preventing you from moving better and I’d like to take a look.”

“Sure.”

“WHAT HAPPENED HERE?”

“Oh yeah, I had major abdominal surgery in my late teens after a stabbing incident.”

During the Initial Evaluation (last visit) I observed him from anterior, posterior, and lateral angles. I asked him to take off his shirt; so he got down to the tank-top he was wearing underneath. When viewing from posterior, I rolled up his tank-top to get a better view of his low back. I asked him to turn around so I could view him from the front. He rolled down his tank and turned around. Then we did lateral views.

In case you didn’t catch it, my error was in NOT asking him to take off his tank-top as well so I could have a clear view of his trunk. While most men don’t wear more than 2 layers on top, this guy sported 3-4 layers of clothes. I should have cued him to go completely topless instead of making due with the remaining 1 layer of clothing on his trunk.

This error revealed itself in grand form on his next visit (as you read at the beginning of this post).

Lesson Learned: Always get prior medical history related to the abdominal and ribcage areas, and never forget to assess “the front of the back”.

Erica was right; I’ll never forget it.

@Cinema_Air

My Morning Routine

This is something that has interested me for at least the last year. How can I optimize my day so that I feel productive by the end of the day?

Morning rituals have been a popular topic in the last year or so, and it was my first exploration. I’ve found my preferred waking time lies around 2 hours before I have to leave the house. What I choose to do with these 2 hours is, essentially, my morning routine. The following is a list of my attempts to fill these 2 hours in order to optimize my day starting from when I first wake up.

1. Block off the internet. This was my first attempt at altering my morning routine. At face value it is seems very simple, but in practice it can get a bit tricky. Here’s the rule: no social media, email, or internet before 10AM.

2. Read or Write. The first 30-45min might just be the best time to work on that book you wanted to start (or finish). You could also spend this time exercising your idea muscle by trying to come up with 10 new ideas every morning. This, just like everything, else is hardest at first, but after a few days or a couple weeks you’ll be surprised at the connections you can make. If 10 new ideas are too much, then do not settle for less than 5.

3. Liquids. There’s something about rituals that provide a sense of structure and framework to think (about anything). This isn’t new to you; in fact, you probably do this already. What do you do when you’re stressed? Exercise? Sleep? Watch TV? Grab that pint of ice cream? These are routines that you’ve created for yourself without intentionally fostering an end result. So why not create a routine intentionally? A morning routine of making tea or coffee, or simply making breakfast fits the bill.

4. Shower. Not everyone prefers morning showers, but if you are, then consider the James Bond shower. This just involves taking your usual warm/hot shower, followed by a minute or two of cold shower. How cold? As cold as you can tolerate. Ease into it. You’ll be more awake than you thought you could be at this hour of the day.

5. Clothes. Will-power is limited. Minimize decision-making in the morning by doing one of two things: 1. wear the same clothes every day (like a uniform), or 2. decide what you’re going to wear before you go to bed. This step should not involve having to decide which shirt, socks, shoes, etc. to put on in the morning.

Mea Culpa: I haven’t stuck to this 5 step routine as consistently as I hoped I would, but I can say that having some routine puts your day on the right track from the start. You might include other activities in your routine; maybe running, exercise, yoga, meditation. Whatever you chose, it should probably be something that you want to do in order to become the person you’ve always wanted to become.

What’s your morning routine?

@Cinema_Air

Competitive Advantages in Physical Therapy

[The following is pure speculative garble. My thinking could be deeply flawed on various levels. I’m sure there are things related to this topic that I haven’t mentioned, thought about, or even considered. If so, then please enlighten me.]

The Affordable Care Act is forcing healthcare changes at a very noticeable rate. Patients now incur greater out-of-pocket expenses in the form of higher deductibles and copays. Localizing this patient expense to the world of physical therapy (at least here in the US) creates new and interesting dynamics. The patient has morphed into an active medical consumer voting for their provider of choice with their money. This is where familiar circles overlap yet again.

Physical therapists now compete with more than the local chiropractors, massage therapists, and athletic trainers. The rub is now within the profession itself. If you, dear PT, haven’t felt it yet, you soon will. The question you will soon have to confront will take the form of “what would make my clinic the patients’ first choice?”

An old guy who goes by the name of Warren Buffet once said, “In business, I look for economic castles protected by unbreachable moats.”

Everyone wants a castle, but what protects their cherished castles? What keeps the competition at bay? What’s your competitive advantage?

According to Pat Dorsey (from The Five Rules for Successful Stock Investing) there are five ways a company can build a sustainable competitive advantage:

1. Real Product Differentiation – via superior technology or features

In PT terms, this would translate into techniques/modalities of treatment and specialty certifications. While this would provide a unique product, the advantage is a race against time. It’s only a matter of time before the latest treatment zeitgeist saturates the neighborhood. The virality of this differentiation will be modulated by provider and patient perception, difficulty in achieving specialized certification, etc. This temporal arbitrage could provide a nice cushion for brand-building.

2. Perceived Product Differentiation – via brand or reputation

Real Product Differentiation provides the first mover with tremendous initial potential. Given the temporal nature of such an advantage, building a brand or reputation to stack the bricks of future progress in a timely fashion is of incredible importance. Given the power of perception in terms of patient outcomes, having a strong brand or reputation will be a formidable moat.

3. Driving costs down – Walmart comes to mind.

This is always a real, but weak threat in the PT business. Retaining or increasing margins via increased volumes will likely decrease job satisfaction, increase stress levels, and result in questionable decision-making resulting in negative outcomes such as burnouts or fraud.

4. Locking in customers – via high switching costs

This was a legitimate moat until a few years ago. PT clinics basked in the bright sunshine of “in-network” status with insurance companies in hopes of greater volume of patients walking in the door. This advantage is quickly (if not already) evaporating as a result of higher and higher out-of-pocket expenses. Now it’s up to the clinic to win over the healthcare consumer. It ain’t what it used to be.

Referrals from MDs/DOs was a major driver of patients into PT clinics. However, this is already changing, and the change will likely accelerate as Direct Access provides healthcare consumers with greater perception of provider choice.

Geography plays a major role here. If travelling to another location requires greater effort, then the path of least resistance will likely be followed. Patient outcomes and experience can erode this advantage.

5. Locking out competition – via high barriers to entry or high barriers to success

I do not believe Physical Therapy clinics have high barriers to entry. This might be supported by evidence of low entry costs, increasing number of new clinics even after the recent recession, and abundance of future PTs looking to start their own practices.

Barriers to success will likely depend on network effects and brand consciousness. Geography and demographics will (and already have) provide a barbelled advantage – cities or rural areas will have inherent benefits. The middle ground (suburbs) will likely turn Darwinian, with the fittest surviving. Cities, while holding high fixed costs, will also have an relatively price-insensitive population pool. Rural regions will likely continue with first-mover advantages as a limited population cannot support many new entrants.

Of course, outsized returns will attract new players into your pond. The question is how will you maintain your competitive advantage? How will you bolster your moat?

[Again, what you just read was pure speculative garble. My thinking could be deeply flawed on various levels. I’m sure there are things related to this topic that I haven’t mentioned, thought about, or even considered. If so, then please enlighten me.]

Find me on Twitter @Cinema_Air

How to Fail Miserably

Charles T. Munger’s 1986 Harvard School commencement speech was inspired by a prior commencement speech given by Johnny Carson. Carson’s sarcastic speech provided a blueprint for guaranteed misery in life. Carson’s prescription included:

  1. Ingesting chemicals in an effort to alter mood or prescription
  2. Envy, and
  3. Resentment

Munger commented on Carson’s recommendations, and then added four more prescriptions:

  1. Be unreliable
  2. Learn everything you possibly can from your own personal experience, minimizing what you learn vicariously
  3. Go down and stay down when you get your first, second, or third severe reverse in the battle of life
  4. Ignore the advice of a rustic who said: “I wish I knew where I was going to die, and the I’d never go there.”

Following suit, let’s consider some prerequisites for guaranteed failure and professional burnout. I will skew this towards the Physical Therapist, but can be applied to any profession.

First, resist change. Graduated with a DPT, you are now equipped with enough moxy to delegate patient care. Still drenched in research and free from the wisdom of an evaluated experience, begin entertaining the thought that you are now the international filter of ideal patient care and physical therapy treatment. Continuing education courses are merely confirmation of what you already know; a checkmark to maintain your licensure. This applies to you too; yes you, the seasoned physical therapist. Don’t risk professional evolution by assimilating new and relevant research, or by learning from the very individual you are attempting to treat. A surefire recipe for failure is holding onto the past; hold fast.

Second, fly solo. If history is any guide, then you must not risk attaining a rewarding career by collaborating with those around you. Do not, by any means, aid or abet the very organization that represents and preserves your profession. Also, related to change avoidance (see above), beware social collaboration. It would serve you well to abstain from the wisdom distilled from the following quote by Stephen Landauer:

In Plato’s Republic, guards were taught by poets. Views contrary to your own are always helpful, as sometimes you will see truth in them and effect change, and, if not, you will be stress-testing and ultimately strengthening your own convictions.

Your desire for failure may hit a roadblock as closely held ideas and perspectives could be challenged, and errors exposed. Remain steadfast in your resilience for professional atrophy; stay inside.

And, finally, stop focusing on solutions. Given the dedication to failure, one must avoid solutions; instead, spin the wheel of status quo by repeatedly underlining problems without suggesting creative alternatives. Maintain a purely subjective point of view, avoid objectivity. In fact, it might be easier to simply beat the drums of your favorite dogma. Becoming an agent of change could put you at risk of developing a meaningful and impactful career. Embrace cognitive ossification; stop exploring.

Ladies and Gentlemen, Boys and Girls, keep staring at your feet.

Find me on Twitter @Cinema_Air

Sources:                                                                                                                      “Seeking Wisdom: From Darwin to Munger” by Peter Bevelin                                                “Maximize Your Potential” edited by Jocelyn K Glei