Our Clinic

We are a clinic dedicated to helping individuals with pain management, performance, and rehabilitation. Our staff has extensive experience addressing neuromusculoskeletal-based issues, rehabilitation, consulting, and individualized treatment plan development. We love helping individuals return to the activities they love!

Our clinic lives in the Shenandoah Valley region of Virginia in the beautiful “Friendly City” of Harrisonburg. We have outfitted our location with everything you could need to improve your fitness. From free weights & weight racks to exercise equipment & a multi-use table – we provide all necessary equipment so you can engage in your treatment plan. We can help!

Weight Rack & Table

Working in the Clinic

Exercise inside Shenandoah Valley Performance Clinic

Last year I released an article on misinformation,

Last year I released an article on misinformation, beliefs, evidence, and EBP. This was in Barbell Medicine monthly research review. We just released this on our website yesterday. Hopefully I was able to do this complex discussion justice and others find it beneficial. Here’s an excerpt:

“In conclusion, we all have beliefs about the world, the question becomes: what level of evidence are we using to substantiate those beliefs? For the context of guiding others’ lives and decision making (a situation we are often involved in clinical practice), we should use the current best research evidence when possible to inform shared decision making. Having a general understanding of scientific methodology and statistical analysis goes a long way towards assessing evidence and relevance to patient cases. Much of this is similar to improving towards goals in the gym – dedication to the process, completing sets and reps, and practice. Said differently, preemptively carving out time daily/weekly to read research relevant to your field can go a long way to improving at assessing evidence. Like most things in life, there’s no magic bullet here. Finally and of relevance in today’s social media world, we should be cautious as champions of EBP with claims of being “evidence-based” somehow elevates us above others. The phrase has almost become an oxymoron at this point. Perhaps, on some level, we should follow Epictetus’s advice, “Don’t explain your philosophy. Embody it.”

Link in bio.

Discussion welcomed.

Recent article sought to explore answers to this q

Recent article sought to explore answers to this question.

We know clinicians have an impactful role collaborating with patients about management but what else factors into management choices.

The authors interviewed individuals experiencing LBP.

Participants were invited to share the approaches they typically use to manage their low back pain and then explain why they used a particular approach.

20 individuals were interviewed (mean age 44).

3 themes emerged:

1. Reducing symptoms in the very short term (hours - day)
2. Effects beyond management of the condition
3. Pleasure or lack of pleasure

Swipe left for quotes.

Theme 1:
In essence, participants reported wanting instant relief from pain (e.g. ‘numbing of sensation’ or ‘distraction from the discomfort’).

Management strategies included: icepacks, soft tissue release, meditation, cannabis, medications, movement, stretches, heat physiotherapy, rest changing positions, back/neck supports, alcohol, watching TV, playing video games, resting/reclining, exercise, their dogs (as hot packs/emotional support).

Theme 2:
These responses included influential factors in management decisions, such as positive or negative ‘side effects’, financial cost, convenience, and social effects.

Theme 3:
Participants may choose strategies which brought about relief and pleasure or were willing to embrace some unpleasantness to have relief (e.g. cold packs).

Collectively this information tells us that decisions for management strategies are individualistic and nuanced. I found it interesting how important the immediate effects of a strategy were to individuals. Admittedly, I have little issue with many of the elected strategies because they were, for the most part, self-guided (i.e. not paying a clinician for a service). Interestingly, it didn’t sound as though participants would be willing to reconsider their preferred management strategies even if evidence contradicted their choice while supporting others. However, I can’t help but wonder if folks knew the rationality behind interventions were lacking and similar outcomes achievable in other ways, would they reconsider.

Recent study assessed beliefs about persistent & r

Recent study assessed beliefs about persistent & recurrent low back pain in a Chinese cohort.

Unsurprising, similar findings to a prior study in Australian cohort.

1. LBP as a biomedical problem = low back pain explained by physical damages, incorrect posture, muscle imbalance, and congenital issues (66.4%).

2. LBP as unbalanced lifestyle = described as a warning symptom or attributable to unbalanced lifestyle (e.g. exercise, sitting, standing g, walking, time or load) (48.7%)

3. LBP is about menstruation and ‘kidney’ status = “In Chinese culture, menstruation is important to women while ‘kidney function’ is vital to men” (9.2%).

4. LBP is about the ‘five elements’ imbalance = Water, Fire, Wood, Metal and Earth. “There is a self-regulating balance within the five elements. For example, Water balances Fire, but Fire produces Earth that balances Water in return. In traditional Chinese medicine it is considered important to encourage this self-regulating balance to maintain good health. Water is considered to be the foundation of the other Elements. These elements are also believed to relate to climate and climate changes related to low back pain.

5. LBP is about energy status = related to TCM concept of Qi. “‘Qi’, understood as a ‘matter-energy’ or ‘vital force’, connects physical and mental energies in individuals. A low (disturbed) energy status can be caused by, or causes, ‘Qi’ stagnation, resulting in muscle pain.”

Belief origins:
1. Healthcare professionals (59.2%).
2. Internet (24.3%)
3. Family’ (23.0%)
4. Friends (16.4%))

The overarching theme of a biomedical lens is an obvious undertone in both Australian and Chinese population beliefs. However, the other 4 emerging discourses appear uniquely related to TCM and the idea of balance. Understanding sociocultural differences and beliefs is an important aspect in helping those experiencing low back pain. Interestingly Confucianism also influenced the lower healthcare professional source of information and higher sources for family and friends.

More evidence simply inquiring about why someone thinks their low back pain is occurring is a solid starting point for addressing beliefs.

Meet Barley He is a Bernese Mountain Dog, and wa

Meet Barley

He is a Bernese Mountain Dog, and was born on June 1st. He currently weighs 14#s.

Welcome to the family little dude!

@ladyray87

Youtube Videos are predominately providing incorre

Youtube Videos are predominately providing incorrect information regarding low back pain.

This study did a great job assessing information validity on YouTube regarding low back pain. The authors searched for 200 most popular videos on YouTube about low back pain and assessed if they were delivery guideline based information.

Details: 200 most viewed LBP videos considered  Most labeled as “program or interview”  Median upload date: 2016 Median duration: 10 minutes and 18 seconds  Source: unable to be determined for half of videos. Almost half were business related.   Median views: 2,018,167  Median likes: 537 Median dislikes: 283 Median comments: 404  Most common speaker: physical therapists (40%)   Most common intention category was ‘‘inform about intervention’’ (100%).

Overall: only about 1/3 of the videos gave a SINGLE guideline recommendation on diagnosis and about 1/2 gave a SINGLE guideline recommendation on treatment/management.

“Some examples of nonevidence-based treatments found in the videos were: passive interventions (treatments based only on manual therapy such as osteopathy or massage),traction table,and natural remedies.”

Swipe left for some of the top videos listed (zoom in) and more quotes from the authors.

One of my favorites:

“With regard to the greater number of videos about interventions we can surmise that there is a focus on ‘’solving’ LBP instead of explaining or informing about the condition, even though there is evidence to support interventions such as health education for individuals with LBP.”

Thoughts? Comment below for a discussion. Tag someone who needs to see this.

It’s rare I reshare a post like this, but I thin

It’s rare I reshare a post like this, but I think @the_rehab_chiro nailed the messaging I was attempting to relay in the latest @thelevelupinitiative podcast.

My only addition would be, as clinicians we are the guides in this process, providing a map with quests to overcome the trap guarding the chest.

Check out the post!

#Repost @the_rehab_chiro
・・・
This was a monstrous concept to cover that is incredibly complex so hopefully I did it justice.

Here I attempt to provide a visual aid for @michael_barbellmedicine ‘s video game analogy for affordances and how they relate to an enactive approach and pain.

I would highly recommend you read @peter.stilwell and Katherine Harman’s paper on the subject. It’s fantastic.

On the latest podcast of @thelevelupinitiative , the aforementioned authors go into great detail about their thoughts on enactivism. Be sure to give it a listen.

………..

@barbell_medicine Podcast Episode #149 - Education

@barbell_medicine Podcast Episode #149 - Education & Learning in the rehab field

This is part 2 of our discussion around education and changes we’ve gone through in the rehab field. Be sure to check out part one, episode 143.

In this episode we discusses our similarities and differences in education, where we think education should head in the future, and field questions curated from social media.

We hope you enjoy this podcast!

A recent qualitative analysis interviewed 70 patie

A recent qualitative analysis interviewed 70 patients dealing with persistent low back pain. The authors set out to assess how diagnostic labels affected participants pain, beliefs, and daily life activities.

Most common diagnosis - lumbar spondylosis, intervertebral disc injuries (e.g. dehydration, bulging disc, disc protrusion).

13 patients received one diagnosis, 25 received two diagnosis, and 31 received three or more diagnoses since the first episode of low back pain.

44 patients received some advice from a healthcare professional. Among these, 41 received movement avoidance advice

Participants were asked a series of questions related to:
Pain
Disability
Physical therapy treatment outcomes
Damage perception of spine

4 themes emerged (swipe left for participant quotes):
1. Pain has a multifactorial explanation in physical dimension
2. Improvement expectation is extremely low for chronic non-specific low back pain
3. The number of clinical diagnosis influences pain and activities of daily living
4. Clinical diagnosis is extremely valued by patients.

Authors takeaway:
“Our findings indicate that clinical diagnosis can inﬂuence the perception about pain, treatment beliefs, and daily life activities of patients with chronic NSLBP. The themes identiﬁed in this study suggest that there is a perception of a strong relationship between structural changes (i.e. ﬁndings on imaging exams), pain, and daily life activities, suggesting that patients rely on the biomedical model to explain their condition.”

These sorts of qualitative analyses are depressing. We apply labels in an effort to give an explanation and rationalize interventions. However, often in these scenarios our labels and their framing are having more of a negative affect on the individual and not meaningfully impacting treatment selection or outcomes. We need to continue to push for change regarding our preferred clinical lens and model while accepting our explanations and narratives have power to influence human beliefs and behaviors. I’m sure I’ll continue to rant on this matter for quite some time. #wordsmatter

Thoughts? Tag someone who needs to see this.

This is an interesting study. The authors examined

This is an interesting study. The authors examined kinematics and kinetics of a repeated lifting task for those with LBP vs w/out.

41 participants were included. They completed 100 lifts from various positions and weights. The weight is of low magnitude (highest was 10% of participants BWT). However, these loads & repetition mimic many manual laborers daily activity & work demands.

Key points:
✏️Biomechanics initially differed between groups (with vs w/out LBP). Specifically the LBP group adopted a more squat style lifting position while those without LBP lifted in a more stopped position (straighter knees / more horizontal torso).
✏️By the end of the 100 repetitions, the groups biomechanics transitioned to more homogeneous presentation, that is they mimicked one another more by the end. The LBP group began adopting a more stooped posture.
✏️Despite biomechanics becoming similar throughout the repeated lift task, the LBP group did report on average a 2 point increase in pain experience & greater fatigue level.

What does this all mean?

Pain is an individual multifactorial experience. Our behaviors in response to such experiences is underpinned by our societal and individual level beliefs.

Excerpt:
“There are strong beliefs in both occupational health and clinical settings regarding the importance of squat lifting and minimising lumbar flexion, both for the prevention and management of LBP. This is commonly taught in the workplace and advocated in clinical and rehabilitation settings. However, there is currently no in-vivo evidence to support this view. In contrast, there is growing evidence that people with LBP demonstrate a lifting technique that they perceive to be ‘protective’ compared to people without LBP. That is, people with LBP tend to lift with a deeper knee bend, more vertically inclined thorax and less intra-lumbar flexion (squat lift) and slower. Ironically, survivors in our study (those who have been employed in manual work for greater than 5 years without LBP) tended to lift in a manner that is considered to increase their risk for the development of LBP (more stoop-like with greater lumbar flexion and faster).”

@thelevelupinitiative podcast: Beyond the BPS Mode

@thelevelupinitiative podcast: Beyond the BPS Model of Pain: An Enactive Approach to Pain & Rehab

@zakgabor.dpt and I did two podcasts on models a few years ago. We wanted to do an update of sorts on models regarding clinical practice and specifically pain.

Grateful for the opportunity to sit down with Zak, @coninxsabrina , and @peter.stilwell to discuss this important topic.

I often hear folks say,
“Why should I care about philosophy?”
“How does this change practice?”
“I’m tired of philosophical discussions.”

On one hand I get it. Sitting down and thinking about why we have particular beliefs, where did they come from, what evidence do we have to support them, maybe we are wrong, maybe we can do differently - these are not easy moments for anyone but are necessary if we want to improve healthcare.

Ultimately we all have a philosophy of pain, either implicit or explicit. Our beliefs around the human experience, meaning, and how to respond or help are scaffolded on this philosophy.

I hope folks find this chat beneficial. It’s obviously a personal passion of mine. If you have questions, comments, or concerns, let us know in the comment section.

Link in bio to the podcast.

Thanks to Zak, Sabrina, and Peter for both their continuous hard work in the pain and rehab space as well as for having this discussion. 👊

A thread on interventions in the MSK space sparked

A thread on interventions in the MSK space sparked by Demonization of MT article.

My biases:

1) I don't think we are doing a great job in MSK care (I include myself here)

2) I'm consistently worried about ruining the potential of natural history or incurring negative secondary effects (nocebo) w/ misinformation leading to less than ideal coping mechanisms

3) I think our interventions at hand based on scope of practice for rehab professionals for the most part have very similar outcomes when hinged to quantitative pain outcomes.

4) I'm not aware of our available interventions having standalone disease etiology direct influence. What I mean, our interventions are not silver bullets (it's ok, many healthcare interventions are like this - example insulin usage for type 1 diabetes).

5) The argument is not interventions lack effects rather the question is how do these effects come about. Given point 4, I'm comfortable in saying in many scenarios w/ quantitative pain outcomes as the concern, these effects are secondary (contextual, placebo, meaning) effects.

6) If I think about risk vs benefit & my options are invasive procedures, medications, or manual therapy then yes, highly probably I'd pick manual therapy but these are not our options & the available options we have can reach similar outcomes (see above).

The argument I want to see is why should I pick manual therapy? Before someone says patient preferences, let's reflect on where those preferences came about (I am not solely looking at clinicians here).

7) What narratives are being supplied to patients to validate interventions in the MSK space (this doesn't just apply to MT but yes exercise too). How are we rationalizing our interventions?

8) We talk about quantifiable adverse events w/ interventions but sometimes measuring all potential adverse events isn't so straightforward. Our qualitative analyses are showing what I would label as AEs via narratives/beliefs/conditioned behaviors.

I wish we could focus on different discussions but what we "do" to patients seems to permanently be the discussion without accepting sometimes doing nothing, or as little as possible, is the right move as well.

Neck “Rehab” Exercises I recently finished th

Neck “Rehab” Exercises

I recently finished the neck series, and in part 4 various exercise progressions and programming are provided.

Here are two videos we put together for guidance. Full videos are linked in part 4.

A few caveats:
⭕️I don’t think these exercises are magical but for some folks, going through a structured plan of movements helps dose in tolerable activity over time while building back to their activity goals.
⭕️These two videos are general outlines and exercise prescription would need to be adjusted based on individual goals.
⭕️When dealing with neck pain, typically there is not an underlying concerning variable necessitating investigation and specific intervention. However, if you are dealing with neck pain, are concerned, or do not know how to manage - please go see a trusted clinician. We’d also be happy to consult remotely @barbell_medicine

Expectations:

To aid with coping through the process, our usual recommendation is that pain symptoms shouldn’t increase to the point of significantly reduced function or remain exacerbated for several days after a bout of physical activity or exercise. If pain symptoms are regularly increasing during or after activity, modifications to the activity should be made — for example changing the intensity, duration/volume, frequency, or type of activity. Attention should also be paid to the other variables that may be associated with increases in pain intensity such as marked increases in life stress, poor sleep, or other disturbances in mood or emotional states. Fluctuations in these other variables may necessitate alterations in the exercise programming.

Check out part 4 (linked in bio) for general exercise programming recommendations.

Comment below if this is helpful. Tag someone who needs to see it. Let us know if you like this type of content for the future.

Becoming An Elite Athlete A few years ago I star

Becoming An Elite Athlete

A few years ago I started reading Macnamara’s counter claims to Ericsson’s popular deliberate practice ideas (further sensationalized by Gladwell’s book, Outlier, as the 10,000 hour rule).

To familiarize - there’s been a longstanding idea that deliberately practicing one’s sport/musical instrument/etc is a highly impactful direct correlate to elitism. This has often been coupled with the idea of early sport specialization, i.e. start as young as possible, incorporate deliberate practice as soon as possible, and consistency wins.

But there’s a big hole here….many folks can dedicate a significant portion of their lives to an endeavor and not become “great” (whatever the context we are validating great in, e.g. sports = Olympics).

Sport endeavors lends itself to these sorts of investigations given often universal rules/regulations throughout a sport from lowest to highest level of participation.

Macnamara recently conducted a meta-analysis to build on their 2016 article (I have a post on this if you scroll back a few years) to see is the early specialization model or the development model of sport specialization (delayed specialization with multi sport practice) more related to elitism (world class athletes). Admittedly, this has to be one of the most thorough analyses I’ve read on this topic.

✏️6,096 athletes from 15 countries.
✏️Represented sports: all sports of Olympic Games, individual sports (e.g. artistic gymnastics, swimming, tennis, track & field, or wrestling) and team sports (e.g., baseball, basketball, cricket, soccer, or volleyball).

Major Takeaways:

✏️Multisport participation major factor separating adult wordclass athletes from national level athletes
- Slide 2
✏️Predictors for junior-level performance were opposite to those for senior-level performance.
- Slide 3
✏️Neither model fully explains the findings. Be sure to check out the authors’ hypotheses at the end of the article.
✏️Authors’ Conclusions
- Slide 4

Finally, although this MA focused on sports, we have similar data in science and academia.

Thoughts?
Go read this paper - RPE (rate of perceived education) 10/10

@barbell_medicine Guide to Neck Pain Part 4: A Fun

@barbell_medicine Guide to Neck Pain Part 4: A Functional Approach to Management

This is the final part of our guide to neck pain. Part 4 provides insight into practical management when dealing with neck pain. We set expectations for the rehab process and provide general exercise prescription that can be adapted to your goals.

Brief excerpt:

“Once ‘red flags’ — situations where there is an ominous underlying cause of pain needing specific intervention — have been ruled out, we shift away from unnecessarily worrying about the meaning of symptoms, and instead address the unique goals of the person. Many clinicians choose passive approaches to care, where things are done ‘to’ a patient to supposedly treat a specific impairment in the neck. These include things like joint manipulations, massage, TENS therapy, or ultrasound, among others. However, these claims remain largely unsupported. We prefer a more active approach to care, involving the patient in the treatment to aid with symptom reduction, building confidence, and progressing towards desired activities.”

We hope this guide has been helpful.
Shoutout to @austin_barbellmedicine & @derek_barbellmedicine for their input and recommendations on part 4 and the neck series overall.

Link in bio.

Comment below for a discussion. Tag someone who needs to see this.

Recent umbrella review examined effectiveness of 1

Recent umbrella review examined effectiveness of 10 most popular elective ortho surgeries against no treatment, placebo, or non-op care.

✏️ACLr - no difference in pt reported outcomes between surgical vs non-surgical management

✏️Meniscal repair - superior to meniscectomy for pt reported outcomes, better activity levels, and lower failure rates. 1 RCT compared surgical procedures vs non-op. Non-op was unsatisfactory.

✏️Arthroscopic partial meniscectomy of knee for degenerative tears - not better than conservative mgmt for function & pain.

✏️Arthroscopic rotator cuff repair for acute rotator cuff tears - No RCTs comparing repair vs no treatment/placebo. Cochrane review “…no clinically important benefits of arthroscopic rotator cuff repair over non-operative care.”

✏️Arthroscopic subacromial decompression for impingement syndrome - did not provide important improvement in pain, function, or quality of life compared w/ other treatments.

✏️Carpal tunnel decompression for CTS - No RCTs comparing decompression w/ placebo/no treatment. Open vs endoscopic similar in effectiveness. Surgery vs non-op showed surgery superior but w/ more complications.

✏️Lumbar spine decompression for spinal canal stenosis - No RCTs compared lumbar spinal decompression w/ no treatment/placebo. Surgical techniques similar in outcomes.

✏️Lumbar spine fusion for DDD - No RCTs compared lumbar spine fusion w/ no treatment, placebo, or sham surgery. Lumbar spine fusion vs non-op management demonstrated no difference in disability but lumbar spine fusion w/ surgical complications.

✏️Total hip replacement for end stage OA - No reviews of RCTs comparing total hip replacement w/ no treatment, placebo, or sham surgery. No RCTs comparing hip replacement vs non-op treatment.

✏️Total knee replacement for end stage OA - No reviews of RCTs comparing knee replacement vs no treatment, placebo, or sham surgery. 1 RCT compared knee replacement + non-op treatment vs non-op alone in folks w/ mod-severe. TKA + non-op had better outcomes. TKA w/ higher serious adverse events.

Swipe left. Theme, we need more RCTs to make more informed decisions but surgery isn’t living up to expectations.

“On the road again Just can't wait to get on th

“On the road again
Just can't wait to get on the road again”

@derek_barbellmedicine will likely appreciate the Willie Nelson reference here.

He and I will be heading to Florida in October to kickstart our in-person seminars again.

We don’t have fancy or magical interventions to talk about but what we can promise is a jam packed weekend with nuanced discussions around pain, injury, rehab, and training.

Topics Include:
- Evidence Based Practice
- Pain Education
- Hip Pain
- Shoulder Pain
- Low Back Pain
- Youth Resistance Training, and
- ACL Rehab

In addition to our lectures, we will have active break out sessions to go over case examples and exercise prescription (regressions and progressions). Bring your workout attire.

Approved for Chiro and Physical Therapy CEUs.

I am really looking forward to doing seminars again. Hope to see you there.

Cheers!

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