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  • In this podcast episode, Barbara Cagnie, a physiotherapist and manual therapist, discusses the topic of dry needling, providing valuable insights into its definition, physiological effects, and clinical applications. Dry needling is described as a technique used by physiotherapists to treat myofascial pain, with the insertion of thin filiform needles into specific trigger points aiming to reduce pain and restore muscle function. Barbara highlights the physiological basis of dry needling, emphasizing its effects on peripheral and central systems, as well as its potential impact on pain and inflammation.

    The discussion delves into the differences between active and latent trigger points, reliability in identifying trigger points, and the mechanism of referred pain. Barbara also addresses the evidence supporting the efficacy of dry needling in various musculoskeletal disorders, particularly in neck pain, highlighting the need for ongoing research to further explore its clinical applications.

    The conversation touches on the contraindications and potential risks of dry needling, emphasizing the importance of proper training and anatomical knowledge to minimize adverse events. The future of dry needling is also considered, with mentions of ultrasound-guided and electrical dry needling techniques.

    Barbara's expertise and comprehensive explanations serve to demystify dry needling and shed light on its clinical relevance. Her insights not only provide valuable information for physiotherapists but also instill curiosity about the potential of this technique in optimizing patient care.

    Chapters

    00:00 Intro 00:46 Defining Dry Needling 01:49 The Physiology 07:26 Difficulty of human studies 08:15 Active vs. Latent Trigger Points 10:05 Reliability Issues of TP Therapy 12:00 Referred pain in Trigger Points 15:40 The local twitch response 17:50 In-situ vs. winding technique 18:36 Research vs. Clinical Practice 20:22 Dry Needling for Tendinopathy? 23:58 Evidence for MSK Complaints 28:01 Contraindications and Risks 30:45 Needles vs. Hands 32:16 Kai's Dry Needling Anecdote 33:06 Are we chasing short-term effects? 35:26 Top 3 Reasons to learn Dry Needling 40:01 Closing thoughts 41:06 Outro

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  • In this episode, Dutch researcher Corinne Visscher discusses temporomandibular disorders (TMD) with a focus on prevalence, risk factors, diagnosis, and treatment. She provides insights on the research she is currently focused on, particularly in understanding the journey of patients with chronic complaints related to TMD. Corinne also emphasizes the importance of screening for TMD, providing counseling and advice on habits, and referring patients to oral facial physical therapists or dentists when necessary. She also highlights the link between TMD and secondary headaches, and offers ways to reach out to her for further information.

    Content

    00:00 Intro

    00:35 What is TMD?

    01:18 TMD Prevalence/Incidence

    02:20 The typical TMD Patient

    03:23 Risk Factors

    06:38 Red Flag Screening

    09:20 The Diagnostic Process

    14:05 Special Tests

    15:25 Questionnaires

    17:47 TMD & Headaches

    19:30 Am I clenching my teeth?

    20:40 Is posture a factor for TMD?

    22:50 The course of TMD

    27:09 A place for Dry Needling?

    28:29 Other Manual Therapies?

    31:50 Current TMD Research

    35:05 Top 3 Takeaways

    40:20 Tension-Type or TMD Headache

    42:28 How to get in touch

    43:08 Outro

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  • In this Physiotutors podcast episode, Canadian researcher Yannick Tousignant-Laflamme introduces the Pain and Disability Drivers Management Model, a groundbreaking approach to understanding and managing chronic musculoskeletal pain, particularly low back pain. This model identifies five key domains across three dimensions, going beyond biomechanics to reveal the root causes of pain and disability. It underscores the significance of interdisciplinary collaboration and effective communication among healthcare professionals.

    By integrating classification systems and prognostic tools, this model optimizes its effectiveness. Classification systems pinpoint patient subgroups, while prognostic tools screen for psychological factors affecting pain outcomes. Clinicians are encouraged to utilize these tools for screening, delving deeper for medium or high-risk patients. The incorporation of questionnaires and patient-reported outcome measures informs evidence-based decision-making. The ultimate aim? Personalized, evidence-based care for musculoskeletal conditions, addressing both physical and psychosocial factors.

    Curious to learn more about this innovative approach? Tune in to the full episode for a comprehensive exploration.

    Guest

    Canadian researcher Yannick Tousignant-Laflamme is a professor at the School of Rehabilitation at the University of Sherbrooke. His research activities target the management of chronic pain associated with musculoskeletal disorders, particularly low back pain.

    Content

    00:00 Intro
    00:40 What is the PDDM?
    03:19 The 5 Drivers of Pain & Disability
    07:56 The struggle with interdisciplinary care
    11:15 Lifestyle within the PDDM
    13:28 Why is PDDM more than a classification system?
    17:23 Patient History within the PDDM
    30:57 Why so many PROMs?
    32:45 NSLBP - is it a helpful diagnosis?
    39:37 Can Physiotherapists cover all 5 domains?
    43:18 Is it all talking?
    45:42 What has changed since 2017
    49:28 How can we apply the PDDM? 3 Tips
    51:26 Yannicks closing thoughts
    53:15 Outro

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  • In this podcast, we explore scapular dyskinesis, the abnormal movement of the shoulder blade. We discuss related terms like scapular misalignment and sick scapula, questioning the practicality of assessing it through visual observation. We highlight that identifying it as normal or abnormal may not guide treatment decisions or pinpoint the cause of shoulder pain. We also address its prevalence in athletes and non-athletes and suggest using various tests to assess scapular dyskinesis. Intriguingly, we'll reveal a surprising connection between scapular dyskinesis and an unexpected aspect of training, which might change the way you think about shoulder issues. So, join us for the full episode to uncover this fascinating insight.

    Guest

    Filip Struyf is a sportsphysiotherapist and professor at the Department of Rehabilitation Sciences and Physiotherapy at the University of Antwerp, Belgium. According to Expertscape, he is the #1 shoulder researcher world-wide. He teaches shoulder courses nationally and internationally and has created an online course together with us called “Rotator Cuff Related Shoulder Pain: Separating Facts from Fiction”.

    Content

    00:00 Intro

    01:15 The "correct" definition

    04:05 What is "normal"

    12:05 Prevalence

    14:21 Is it a functional adaptation?

    16:46 Scapula Dyskinesia as a risk factor?

    26:09 How do we assess it?

    28:51 How reliable or valid is assessment?

    32:39 Can we improve scapula movement?

    39:09 What's up with focussing on the lower trapezius?

    42:26 What about Rhomboid Pain?

    46:21 Is there a place for scapula mobilization techniques?

    49:42 Filip's closing thoughts

    52:15 Outro

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  • In this podcast episode, sports physiotherapist and lifestyle expert Jaap Wonders discusses the several aspects of successful lifestyle interventions as part of the treatment plans in physiotherapy practice. He outlines the guidelines on proper sleep hygiene, diet and other important factors to take into account when prescribing a healthy lifestyle. We discuss the challenges of adopting healthy habits and what we can do about this.

    Content
    00:00 intro
    00:45 Why the interest in Lifestyle?
    02:50 How to deal with unhealthy lifestyles
    05:52 Failing to meet movement goals
    10:43 Movement snacks
    12:28 10K Steps a Day. What's the deal?
    17:55 Recommendations on Nutrition
    20:55 Healthy vs unhealthy Protein
    24:55 The importance of sleep
    31:16 How we address stress
    36:09 Positive Stress
    38:15 Mindfullness
    39:05 Cold Showers
    42:10 What doesn't kill you makes you stronger?
    47:22 Lifestyle interventions in chronic conditions
    58:00 3 steps to a healthier lifestyle
    01:03:20 Closing thoughts
    01:05:08 Outro

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  • In this podcast episode, physiotherapist Sarah Michiels discusses somatic tinnitus, a type of tinnitus that is often caused by dysfunctions in the upper cervical spine and jaw. She highlights the prevalence of somatic tinnitus and the importance of a comprehensive diagnosis to rule out other causes. The talk provides insights into her evaluation and treatment approach, emphasizes the role of physiotherapy in improving muscle function and coordination to manage this debilitating condition.

    Content

    00:00 Intro
    00:46 Definition of Somatic Tinnitus
    01:35 Tinnitus and the Cervical Spine
    04:47 Prevalence of Tinnitus
    06:22 Epidemiology of Tinnitus
    08:15 Physiotherapy Diagnosis Possible?
    10:30 ENT Diagnosis of Somatosensory Tinnitus
    14:27 Special Testing for Tinnitus
    16:00 Cervical Spine Assessments
    17:35 Tinnitus and the Jaw
    18:51 Red Flags
    20:53 Physiotherapy Effectiveness for Somatosensory Tinnitus
    22:00 Typical Treatment Course
    23:20 What causes Improvements in Symptoms?
    25:18 Tinnitus Relapse
    27:10 Prognostic Factors
    29:30 Sarah's Treatment Approach
    31:48 Why Patients get worse
    34:15 How to learn more about Tinnitus
    35:10 Is MT knowledge required?
    36:20 Sarah's Closing Thoughts
    37:30 Could Van Gogh have been saved?
    38:10 Outro

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  • Welcome to Physiotutors podcast episode 56 with Thomas Mitchell. Thomas is a wrist and hand specialist physiotherapist, and working toward his PhD at Sheffield Hallam. He is a physiotherapist of 25 years standing in primary care, private practice and sports. He is a First-contact Practitioner clinical supervisor and member of the British Association of Hand Therapists. He is also a Member of the Mulligan Concept Teachers Association, so the perfect person to talk to about the Mobilizations with Movement abbreviated as MWM.

    He is also an instructor for our online courses and has developed the complete upper limb focus together with Andrew Cuff.

    Content

    00:00 Introduction
    00:48 Definition of mobilizations with movement
    02:42 Discussion on Mulligan's positional fault concept
    04:14 Importance of symptom modification
    06:39 Principles of mobilizations with movement
    08:20 The concept of "Pill" in mobilizations with movement
    10:36 The "Crocks" principle in mobilizations with movement
    12:17 Empowering patients through functional positions
    13:41 Personal adjustments in practice based on Mulligan's concept
    15:33 Importance of Self-Treatment and Patient Expectations
    17:03 Discussion on Plausible Fallacies and Patient Beliefs
    18:40 Understanding Mulligan Concept and Pragmatic Approach
    19:24 Explaining Treatment to Patients
    20:40 Thomas Online Course
    21:18 Differentiating MWM from Other Manual Therapy Techniques
    23:16 Patient Control and Bottom-Up Approach in MWM
    27:51 Evidence and Systematic Reviews on MWM
    33:23 Importance of self-treatment and clinical expertise
    35:57 Application of MWMS in chronic pain patients
    37:40 Challenges with musculoskeletal rehab in the UK
    40:13 Effectiveness of MWMS for lateral epicondylalgia and De Quervain's disease
    44:34 Benefits of mobilizations with movement
    47:36 Learning resources for Mulligan concept and MWMs
    49:17 Thomas closing thoughts
    51:08 Outro

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  • This episode of the Physiotutors podcast features Julia Treleaven, a researcher and physiotherapist, who discusses cervicogenic dizziness and its diagnosis. We delve into the condition's pathophysiology and prevalence in patients with chronic neck pain. We also discuss red flags to watch for during patient history taking and differentiating cervicogenic dizziness from other forms of dizziness. The episode covers functional tests used to assess balance and motor control and treatment options, including sensory-motor exercises, manual therapy, and posture correction. The discussion emphasizes the importance of focusing on the neck's role in such cases rather than just diagnosing the condition.

    Content

    00:00 Introduction

    01:20 Definition

    06:36 Characteristics of Cervicogenic Dizziness

    12:08 Physical and Orthopedic Tests for Cervicogenic Dizziness

    15:03 Functional Assessment for Cervicogenic Dizziness

    18:25 Treatment for Cervicogenic Dizziness

    26:10 Progressing Sensory Motor Control Exercises for Cervicogenic Dizziness

    29:46 Role of the neck in dizziness

    32:08 Research endeavors in neck-related dizziness

    34:58 Determining the role of the neck in dizziness and the controversy of cervicogenic dizziness

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  • Nicol van Dyk is a physiotherapist and clinical researcher currently occupying the role of Injury Surveillance and Medical Research Officer with the Irish Rugby Football Union in Dublin, Ireland. In 2018 Nicol completed his PhD in Health Sciences at Ghent University, Belgium titled “Risk factors for hamstring injuries in professional football players.” During this time Nicol was a physiotherapist at the Aspetar Orthopaedic and Sports Medicine Hospital.

    In this episode we are joined by Nicol van Dyk. We discuss injury prediction and screening tests, individual risk factors for athletes at risk of injury, the importance of clinical reasoning and individualized approaches as well as why it rains so much in the Netherlands....

    This was a great episode to record and we hope you enjoy it.

    Content

    00:00:00 Introduction

    00:01:00 Screening tests and injury prediction

    00:05:10 Importance of screening tests in injury prevention and building athlete trust

    00:13:14 Importance of Previous Injuries

    00:17:47 Role of Technology and Social Support in Rehab

    00:21:35 The Significance of Sleep in Injury Prevention

    00:26:41 Understanding individual athlete risk factors

    00:30:10 Importance of clinical reasoning and individualized treatment

    00:38:08 Using mixed methods approach for injury prediction

    00:41:09 Injury prediction vs risk estimation

    00:44:32 Focus on performance and robustness

    00:46:24 Importance of communication and empathy in physiotherapy

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  • Welcome to episode 53!

    In this episode we are joined by Adam Dobson who is working as a specialist triage & treat spinal physiotherapist for South Tees Hospitals NHS Foundation Trust. He is the author of "Lumbar Radicular Syndromes - At a Glance" and actively shares his knowledge around radicular syndromes on his Twitter (@adamdobson123) and as guest on various podcasts. We are very happy to have him on the microphone for this episode. Enjoy!

    Content

    00:00 Intro
    00:40 Definition of Lumbar Radicular Syndrome
    02:57 Signs & Symptoms of Sciatica
    06:12 Red Flags
    14:14 Cauda Equina Pathway
    19:20 Facet Joint Stenosis Differentiation
    21:54 K.I.S.S.
    22:30 Motor Control Exercises
    24:45 Opinion on Piriformis Syndrome
    30:20 Minor Neurogenic Dysfunctions
    35:17 Treatment for LRS
    38:55 Advice. Anything Else?
    44:16 Clinical Decisionmaking
    45:52 Adam's closing thoughts
    50:47 Encore - Stenosis
    53:05 Outro

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  • Andrew is a consultant physiotherapist from the UK with a special interest in the upper limb and particularly the shoulder, which is also the reason he has created a course on the stiff shoulder, the elbow and wrist for Physiotutors together with Thomas Mitchell. He is in the process of finishing his PhD this year on imaging for musculoskeletal conditions in primary care at Keele University, so he’s the perfect person to talk to about imaging!

    Content

    00:00 Intro
    01:25 How far are we from ideal?
    05:56 Scale of MSK Imaging
    09:40 Why don't we stick to guidelines?
    15:50 When imaging makes sense
    21:35 Do Patients Expect Imaging?
    23:49 Sponsor
    24:59 The goal of Imaging
    27:52 Risks of Imaging
    30:27 Imaging Techniques 101
    35:10 Should Physios use Ultrasound
    37:56 Scan interpretation as a skill?
    43:10 How to explain imaging findings
    48:15 Andrew's closing thoughts
    49:49 Outro

    Sponsor

    This episode is sponsored by the CSP student conference 2023. For more information and to sign up visit: https://www.csp.org.uk/studentconference23

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  • Hi and welcome to Physiotutors podcast episode 51 with Henrik Riel.

    Henrik is a physiotherapist from Denmark and has obtained his PhD in the management of plantar heel pain. He is doing a post-doc fellowship at the university of Aalborg and he is an assistant professor at the physio department of the university of northern Denmark.

    In this episode we will talk about plantar heel pain etiology, the risk factors associated with it, Henrik's approach to examination, imaging, and treatment. We will answer the question if there are prognostic factors for the condition, what mode of strength training is recommended and discuss the efficacy of adjunct treatment modalities for plantar fasciopathy. So make sure to listen to the entire episode.

    Content

    00:00 Intro
    00:45 Plantar fasciitis, Plantar Fasciotpathy or Plantar heel pain?
    02:41 Is it a tendinopathy?
    03:33 The typical patient
    04:40 Risk factors
    07:13 Signs & Symptoms
    09:05 Differential Diagnoses
    10:10 Examination/Imaging & Testing
    13:00 What about Heel spurs?
    14:10 Prognosis
    19:28 Isometrics for Plantar Heel Pain
    22:04 Treatment Options
    26:35 Load Management
    28:15 Plyometrics/SSC Exercises
    30:54 Henrik's Closing Thoughts
    32:00 Outro

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  • In this episode we will talk about all things shoulder instability. You will learn more about the Stanmore classification and structural damage after dislocations. We will discuss the typical patient with shoulder instability and how an examination process looks like. We will touch on muscle activation patterns, surgery and how physiotherapeutic management of a patient with shoulder instability could possibly look like.
    So make sure to listen to the whole episode!

    Our guest is Anju Jaggi. She is a physio consultant shoulder specialist at the royal national orthopedic hospital in stanmore, UK. She’s a past president of the European Society of Shoulder & Elbow Rehabilitation (EUSSER) and a published researcher with a particular interest in shoulder instability.

    Content

    0:00:00 - 0:01:08 Introduction
    0:01:08 - 0:02:32 What is Shoulder Instability?
    0:02:32 - 0:05:50 What causes the shoulder pain?
    0:05:50 - 0:13:44 TUBS/AMBRI/Neuromuscular
    0:13:45 - 0:18:13 What gets damaged in the shoulder?
    0:18:13 - 0:22:22 The typical patient fenotype
    0:22:22 - 0:28:55 Examination Process
    0:28:55 - 0:30:05 Special testing
    0:30:55 - 0:34:29 How to test the cuff
    0:34:29 - 0:37:16 When is the cuff weak?
    0:37:16 - 0:40:05 Muscle activation patterns
    0:40:05 - 0:43:30 Risk factors
    0:43:30 - 0:46:14 Risk of Developing OA
    0:46:14 - 0:47:58 Relocating a shoulder as physio
    0:47:58 - 0:55:02 Shoulder Instability Rehab
    0:55:02 - 1:00:21 Surgery vs. Physio
    1:00:21 - 1:01:38 Anju's closing thoughts
    1:01:38 - 1:03:10 Outro

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  • Welcome to episode 49!

    Today's guest is Mike Reiman who is a physiotherapist, active clinical researcher, educator and mentor with a special interest in the hip. He is also an associate professor at Duke University and an adjunct professor at Wichita State University.

    In this episode we will talk about femoroacetabular impingement abbreviated as FAI. You will learn more about FAI morphology and the development of FAI. Mike will elaborate on the epidemiolgy of FAI, what can trigger symptoms and the prognosis in regards to the development of hip osteoarthritis. Of course we will talk about diagnosis and physiotherapeutic treatment and finish of with a discussion about surgery for FAI.
    So make sure to listen to the whole episode! Enjoy!

    Content

    0:00:00 - 0:01:04 Introduction
    0:01:00 - 0:02:50 What is FAI?
    0:02:50 - 0:04:35 How FAI develops
    0:04:35 - 0:08:10 Epidemiology of FAI
    0:08:10 - 0:09:52 Asymptomatic FAI
    0:09:52 - 0:13:13 Triggers for symptomatic FAI
    0:13:13 - 0:18:13 Prognosis: Do patients develop hip OA?
    0:18:13 - 0:21:34 Screening
    0:21:34 - 0:25:35 History & Examination
    0:25:35 - 0:28:13 Confirming the Diagnosis
    0:28:13 - 0:29:45 Imaging necessary?
    0:29:45 - 0:31:54 Muscle Strength Testing
    0:31:54 - 0:45:10 FAI Rehab Start to Finish
    0:45:10 - 0:48:45 How good is Physio for FAI?
    0:48:45 - 0:53:40 How good is Surgery for FAI?
    0:53:40 - 0:58:30 How to choose: Surgery or FAI
    0:58:30 - 0:59:50 Mike's Closing Thoughts
    0:59:50 - 1:00:29 Outro

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  • In this episode we will talk about different rheumatological conditions that can mask as musculoskeletal pain and how to recognize them. Our guest is Jack March, a physiotherapist specialising in rheumatology who provides CPD courses on the recognition, investigation and management of rheumatological conditions. We will shine a light on imaging and medical tests for different conditions and cover differences between genders. At last, we will discuss how patients with rheumatism are best treated, talk about precautions during exercise and how to positively influence their prognosis. So make sure to listen to the whole episode! Enjoy!

    Content

    00:00 - 00:58 Introduction
    00:58 - 02:18 What is Rheumatism?
    02:18 - 03:47 Rheumatological diseases to know
    03:47 - 05:28 When to think it's Rheumatic
    05:28 - 08:16 Screening for Rheumatoid Disorders
    08:16 - 11:46 How Rheumatoid Inflammation is different
    11:46 - 15:32 What are the Signs & Symptoms
    15:32 - 17:04 How helpful is Imaging?
    17:04 - 18:55 Difference in males vs. females
    18:55 - 22:10 Testing for Rheumatoid Disorders
    22:10 - 27:11 Referral to Specialist Management
    27:11 - 35:45 What Physios can do in RD
    35:45 - 37:55 Jack's Closing Thoughts
    37:55 - 38:54 Outro

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  • In this episode we will talk about the demonization of and the future of manual therapy with Chad Cook. Chad is physiotherapist, a professor at Duke University and a clinical researcher who has published over 330 peer-reviewed papers. One of the latest papers he has published is called “The Demonization of manual therapy” where he evaluated common critique on manual therapy based on the current literature.

    News: We do have an announcement to make: You might be wondering why you’re listening to a podcast host with a German accent. Our former podcast host Sunny Sandhu has left us to work in the clinic again full-time after hosting our podcast for 46 episodes.

    We wish him all the best and his British accent will be dearly missed.

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    Content:

    00:00:00 - 00:01:46 : Introduction

    00:01:46 - 00:02:48 : Chad's definition of MT

    00:02:53 - 00:04:54 : The Pendulum has swung too far

    00:04:55 - 00:07:20 : How is MT different from other modalities?

    00:07:25 - 00:09:04 : Does hypomobility assessment still have a place?

    00:09:05 - 00:10:26 : Do we need to be specific with MT?

    00:10:28 - 00:13:44 : How to know when to use MT in a patient

    00:13:48 - 00:16:37 : Is the cost of current MT education justified?

    00:16:40 - 00:21:31 : Time to embrace the placebo effect?

    00:21:34 - 00:24:42 : The biggest critique on MT

    00:24:44 - 00:26:11 : Are we sending the wrong message to patients?

    00:26:14 - 00:32:10 : The value of Costs vs. Patient Satisfaction

    00:32:16 - 00:36:05 : How MT education needs to change

    00:36:06 - 00:39:24 : The future of MT

    00:39:25 - 00:40:34 : Outro

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  • Research and evidence based practise are the cornerstone of the modern clinician - ensuring that we use the best, up to date methods to support our clients and patients. With that said however, there's so much out there, how can you be sure what you're reading is worthwhile, is relevant or of any half decent quality. We have to understand the limitations of the research we're reading to understand the implications and potential application of that research too. It's unfortunate, but when working with people - whatever your discipline - there's no one size fits all approach and there's always nuance. With that said, myself and James spoke about why we need to dig further than *just* the abstract before we make up our minds on a research paper, to fully gage whether it is of clinical or statistical significance! We discuss what are some of the things you should look out for when reading and discerning research as well as some of the wider elements of research to better understand that world.

  • I speak with the amazing Dr Melissa Farmer, Clinical Psychologist, Neuroscientist, researcher, CCO & co founder of Aivo Health! Melissa and I talk about chronic pain and the influence that has on both the brain & body as well as what we can do in clinic to both utilise these changes as well as how we can manage our patients with chronic pain with our approach to help them both feel seen and heard. We discuss her approach as to how she applies her research in clinic and what the importance is of getting research into clinics quicker rather than how it now trickles down! We touch on a lot of different topics throughout the hour, tune in and find out!

  • We've returning guest the always fantastic Enda King with us this month to discuss ACL Biomechanics & movement strategies post op - an area where Enda had done his PhD in! We look at how you can objectively help your patients even if you don't have a fancy biomechanics lab, where the idea of a 10% difference for RTP comes from and how that translates into reality as well as how you can coach your patients without coaching through movement constraints! Tune in to find out more!

  • This months guest is Curtis Anderson, a severe traumatic brain injury (TBI) survivor for a new area we’re looking to dive deeper into on the podcast – the patient’s perspective. We talk to Curtis about his 20 year journey and how he defied what was initially thought possible for the full extent of his rehab. After 3 weeks in a medically induced coma he spent a year in a rehabilitation center and he has since gone on a journey to be a motivational speaker helping other get through their own journeys as the prime example of what can happen when you don’t give up, even after 20 years, when you are determined to treat every day as an opportunity to do better, be better and perform better. In his own words, it took him 8 years to learn to drive again, 8 years to use a staircase with the railing on the left side, 10 years to be able to pick up change from the counter top & 16 years to pick it up off of the ground! He's an inspiration and the personification of never giving up and I hope you enjoy hearing about his journey as much as I have!