What a Holistic Multi-Factorial Physical Therapy Approach Looks Like.

Preface. This article is a summary of one of the podcasts that we host called “Awakening the Physio”, where Dr. Ngo elaborates on how he brings a holistic approach to a singular field of Orthopedics and Sports Medicine. You can listen to the podcast as linked below. As part of Dr. James Taylor’s mentorship, he graciously took on this task as part of his mentorship experiences at ReVITALize Rehab Club.  

Before we start with Dr. Taylor’s summary, we would like to emphasize that there is ONE focus when it comes to how we bring care to you. Your goal is our goal. Many come to us with the desire to move better and enhance their mobility, strength, alignment, and/or posture. The holistic perspective is good and dandy, but unfortunately, the consumer gets the short end of the stick when a holistic practitioner is not focused on one particular path during your plan of care. Holistic is broad and the experience can be all over the place. This is the reason why we decided this is an important article to help you to know how we blend many systems with the FOCUS on better movement.  

Everything trickles down to movement. We evaluate holistically to learn how we can help you to move better. Every question we ask is targeted in the direction of learning why you have trouble moving. The targeted treatment and therapeutic exercises are geared towards getting you to be closer to enhanced movement. More energy. More confidence. As you read this whole article, you will understand why 90 minutes is the right amount of time for a practitioner to understand your problem at another and deeper level. This is how you will get better.  

Enjoy! The article starts below and is geared to teach other Physical Therapist aspiring to adopt the Holistic and Functional Medicine model.

One of the biggest keys is to build good habits and make it a system. Part of these good habits is to keep the system always adapting, as this is what drives good outcomes. There are many systems in movement science (Maitland, Frank, Sahrmann, Greg Johnson, Mulligan), and these systems produce good results. However, one issue that arises is that clinicians have to immerse themselves in these systems, and many tend to become rigid and don’t tend to deviate as much from these systems. The purpose of this discussion is to examine Dr. Ngo’s system.  

One model that research is proposing is the biopsychosocial system as well as the work of Chad Cook and Yannick Tousignant-Laflamme, the developers of the “five domains of pain and disability driver’s model”, which blends an ortho-sports model with holistic and functional medicine.

In addition to the sensory system, we also must consider the socioeconomic status of the patient as well as their spiritual and/or religious beliefs as these will place a huge impact on whether they will follow through with the advice that you are giving them. Paul Chek developed a totem pole hierarchy which states that one’s sense of self is at the top. From the primal/ancestral perspective, the general thought is that your body will protect you at all costs, however in some cases, feeling important and having a sense of purpose is more important than having a sense of existence. This is why people who feel deficient in this area tend to commit suicide because they feel (rather, unfortunately) that they have stopped to matter. 

All of this is why Dr. Ngo spends at least 5 minutes of every evaluation discussing what motivates the patient, what gets them going in the morning so that he can evaluate to what extent they have a sense of purpose. If this is not included or considered, it would mean more work and more time that needs to be dedicated to helping them feel better.  

Dr. Danh Ngo will elaborate more about the biopsychosocial model later as there is a key concept that will help bridge the two systems of managing the person and managing the body’s ability to move. One of the key principles of this model is that the source of an individual’s dysfunction comes from one of the following three areas: input, processing, and output.  Constantly, the body receives info through the peripheral sensory system that is delivered to and is processed by cortical/spinal structures. These then initiate an output based on how the brain interprets what it is receiving from the periphery. Any patient coming into a PT clinic typically complains of an output problem manifested by pain, tightness, or decreased ROM. This means that the body’s ability to produce output is dysfunctional. This output problem is what school generally teaches to focus on, but we must look at the inputs that are creating this output problem. 

An important concept to keep in mind is the fact that the sensory drives motor, whether that be from the auditory system through the startle reflex exhibited when you hear a loud “boom”, the visual system that causes you to shorten your stride when in a dark room, and any of the olfactory, vestibular, or proprioceptive systems.

The end goal of treating any patient is to get them to move well and without compensation.

To reinforce that brain/body connection, we want the output to be very predictable so that the patient can predictably produce a good movement pattern or motor response. For example, if you have your client performing a knee extension, they may feel it more through the inner thigh or hamstring area. This level of unpredictability messes up the equation. 

Anything that interferes with the input and the ability to bring better “ease of pain, better movement” output can be looked at as “white noise”. There is an error in processing, as demonstrated in the example above. Another way to think about processing errors is with the metaphor of mind-body connection. Healthy movement leads to a harmony of muscles working like an orchestra to work with the joints, ligaments, and other passive structures. Movements are dictated by the brain. You cannot move if you are brain dead. Right?  

The mind-body connection can be looked at the same as a router-wireless connection. The number of blocks or walls that prevent the router (brain) from transmitting a clear signal to the body (WiFi) is what we need to determine and address it. We need to help the brain to process the sensory and motor input for healthier movements. 

The end goal of functional medicine is to help eliminate this “white noise” by looking at the internal health of the patient, utilizing movement (external health) as a reference point. Movement, in and of itself, never “lies” as it is a product of the response of the CNS to an input. Any factor that impacts this internal health and well being of the individual, not just the musculoskeletal system, will be reflected in the quality of their movement. 

There are 8 categories of dysfunction that can create this “white noise.

  •  gut dysfunction
  • Hypothalamus-Pituitary axis (HPA) dysfunction
  • chronic infection
  • cellular dysfunction
  • nutrient imbalances
  • immune dysregulation
  • hormone imbalance
  • toxic overload. 

All of these categories can affect the threshold of a patient’s pain, so we must examine areas such as the cardiovascular system and the patient’s history of chronic disease or autoimmune disorders. 

Anyone who has an emotional breakdown or who lacks sufficient self-confidence cannot be expected to perform at peak efficiency. The same holds of those who train endlessly to participate in high-level spots but who also neglect to get sufficient sleep as this significantly impacts the brain’s ability to provide clear and precise signals to the desiredmotor output. Unlike the zombies of the Walking Dead show, we do not move as coordinated and reflexively when we are sleep deprived zombies. 

Another important area to screen for is that of the level of stress or “allostatic load” on the individual, a concept developed by Bruce S. McEwen.

According to Dr. McEwen, there are four types of stress.

  • Perceived (Anxiety/depression related to neurotransmitter imbalance)
  • Circadian disruption (sleep impacted by caffeine/sleep apnea and an irregular work shift),
  • Inflammation (inflammatory signals (interleukin/TNF/high glycemic index)
  • Glycemic dysregulation. 

An easier way to screen for stressors in the PT clinic would be to examine the pneumonic NUTS. By this device, we ask if the stressor is Novel (something new), Unpredictability (no way of knowing if/when that stressor can occur), Threat (any perceived threat), and Sense of Loss of Control (feeling you have no control in a situation). 

Our current situation with the onset of COVID-19 reflects as it impacts all four of these areas, and hence creates white noise so that the brain has to work harder to connect to the musculoskeletal system. 

From an osteopathic perspective, mechanical stress on any bodily tissue can also create white noise that affects the connection to the musculoskeletal system. Dr. Ngo’s training reflects this perspective, as he has been trained in visceral, cranial, and vascular manipulation that he utilizes in his clinical practice regularly. 

In summary, it is important that, in addition to being pain-free, your patients can feel how they are supposed to move. For this, Dr. Ngo created a screen containing the common stabilizers for each joint and tests these to make sure that the patient is feeling the muscle work in the correct position (i.e. making sure the patient feels the longus colli and rectus capitis muscles work anteriorly in a deep neck flexor endurance test and not more laterally).

Healthy movement is a big subject of debate within PT as the pendulum is swinging from a strict biomechanical perspective to a model more accepting of movement variability. From Dr. Ngo’s perspective, 80-90% of the time, people go through a predictable sequence of activity in their day (get up, brush teeth, go to work, etc.), and our expectation of movement should reflect this. Novelty and variability within the movement are great, however, we need predictability for what the body region in question is supposed to deliver. 

This can first involve tapping the sensory system through the vestibular and ocular systems and improving this area first so that the body-brain map is less smudged. Once we provide a predictable response that the CNS can react to positively, then we can add in layers to build upon this (for example, progressing from left/right discrimination to explicit motor imagery). 

From there, we can start to focus on breaking down the components of complex motor tasks that are meaningful to the patient. Has the client acquired the skills of moving well with factors that we can influence include endurance, flexibility, power, and speed? This applies whether we are training a normally, sedentary individual or training a high-level athlete. If we do not take the time to instill a predictable pattern of what movement should feel like, the patient might feel better for 3 minutes before they revert to their older patterns (most likely utilizing common global movement patterns).

Treating patients requires looking at the rehabilitative process from a multi-faceted perspective. Yannick Tousignant-LaFlamme and Chad Cook are among the chief proponents of this model. Yannick and Cook’s theory describes a pentagon with each side of the pentagon representing a different driver that can increase the level of pain/disability that the individual is experiencing.

Yannick Tousignant-LaFlamme’s model and list below. 

  • Nociceptive pain drivers
  • Nervous system dysfunction drivers
  • Comorbidity drivers
  • Cognitive-emotional drivers
  • Contextual drivers. 

Looking from this perspective involves looking at that patient’s history for MVA’s (recent trauma), sports participation, and/or physical abuse. Other models integrated in Dr. Ngo’s practice include those models of understanding pain offered by Butler and Moseley. As PT’s help bring higher level of understanding of the brain and individual’s expression of pain, we forget that the nervous system can greatly be enhanced with direct mechanical interventions. Dr. Ngo utilizes the hands to address mechanical tension in the brain/spine/dura. He provides dietary considerations to get nutrients more in balance. As the brain and body have the fuel resources to comprehend the task at hand, it can help.  

Ultimately, it is the responsibility of us as clinicians to listen with an open heart to the patient and be emphatic to the patient’s situation as if it were your own. Science/evidence has a purpose to protect our clients and to give us as clinicians a framework from which to do no harm and to allow us to see the client as a whole person.

For further questions with the topic discussed, feel free to email us at info@revitalizerehab.com.

We like to express gratitude for Dr. James Taylor for his contribution.