Dr. Steve Middleton, PT, DPT, ATC

02/03/2026

Why are physicians still telling patients “I’m sending you to physical therapy but they won’t be able to do anything for you”?

This happens more with patients suffering with chronic conditions and who already think nothing will help. Now that has been confirmed by their doctor.

01/30/2026

Clinician Education: low back pain

The evaluation and treatment of low back pain changed in 1934 when the discs were identified as being pathogenic or able to produce pain (Mixter and Barr, 1934). At this point, the discs were identified as the primary cause of low back pain. The role of the disc in low back pain expanded with technology, primarily magnetic resonance imaging (MRI) that allowed visualization and quantification of disc herniations. However, only 47% of patients with low back pain present with radicular symptoms with 74% having unilateral presentation (Thapa, Lakhey, and Shrestha, 2020). Often, the other 53% of patients are classified as having non-specific low back pain (NSLBP); unfortunately, this ignores a host of other anatomical structures that are known pain generators:
Bone, specifically the surfaces of the facet joints
Entrapped or swollen joint capsules
Ligamentous sprains
Peripheral nerve entrapments
Muscle strains
Fascial compression of cutaneous nerves
Fascial restrictions limiting soft tissue shear

References
Mixter W., Barr, J.S. (1934) Rupture of the intervertebral disc involvement of the spinal canal. New Engl Surg Soc. 2:210-215.

Thapa, P., Lakhey, R. B., & Shrestha, B. L. (2020). Clinical Profile of Patients Presenting with Low Back Pain to Out Patient Department of a Tertiary Level Hospital. Journal of Institute of Medicine, 42(3), 87–91. https://doi-org.wwu.idm.oclc.org/10.3126/jiom.v42i3.37596

01/27/2026

Clinician Education: Fascia

Historically, fascia has been a misunderstood tissue regarding its function in the body. Early anatomists considered it extra tissue and often discarded it. Later, anatomists identified areas of thickening and reclassified fascia as a type of connective tissue to bind the body together. Dr. Henry Gray hypothesized fascia as having two functions in the body: protection and movement (Gray, 2013). Dr. Gray identified areas of thickening where the body lacks bony protection such as the abdominal aponeurosis and thoracolumbar fascia to protect the abdominal organs. Dr. Gray also hypothesized that the fascia covering the muscles, the epimysium, also squeezed the muscles to facilitate contractions. It has been recently proven that fascia does have a slight contractile capacity (Schleip and Klingler, 2019). Additionally, research has identified fascia as having the ability to carry a small electrical charge and may help to coordinate movement patterns (Edelstein, et al, 2016).

Fascia, along with skin and muscle, create tissue layers in the body. Cutaneous nerves are located between the skin and superficial fascia. Lymphatic and blood vessels pass through the deep and superficial fascia. The deep fascia covers the skeletal muscles. Finally, deep to the muscles are the peripheral nerves. Space between these layers of tissue allow normal blood flow and neural function. Additionally, the space allows the tissues to glide across one another as movement occurs.

References
Edelstein, L., Fuxe, K., Levin, M., Popescu, B.O., Smythies, J. (2016). Telocytes in their context with other intercellular communication agents. Seminars in cell & developmental biology. 55:9-13. doi:10.1016/j.semcdb.2016.03.010

Gray, H. (2013). Gray’s Anatomy. Acturus Publishing.

Schleip, R, Klingler, W. (2019). Active contractile properties of fascia. Clinical anatomy. 32(7):891-895. doi:10.1002/ca.23391

01/20/2026

I often joke that as we are becoming Doctors (of Physical Therapy, of Occupational Therapy, of Athletic training), we are becoming more like Doctors (of Medicine) in that many are taking a hands-off approach to patient care. Oddly, some chiropractors are taking a hands-off approach in using adjusting tools such as the Activator Methods International or computerized adjusting equipment from Sigma Instruments. (This is especially ironic since "chiro" is Greek for "of the hands".)

While physical touch can have many positive influences from a rehabilitative stand point, it can also improve psychological and emotional well-being:

Manual therapies have been shown to decrease anxiety, tension and depression in active populations(Weinberg, Jackson, and Kolodny, 1988). The results have actually shown a greater reduction in psychological complaints than running. Improving psychological well-being may influence physical pain by decreasing central sensitivity or how the brain interprets peripheral input.

Massage may also create multi-system releases in tension. Interventions have been shown to decrease pulse rate which is under autonomic control(Field, Grizzle, Scafidi, and Schanberg, 1996). These individuals also reported decreased anxiety while demonstrating decreased output of cortisol in their urine and saliva (decreased adrenal activity).

Eating disorders such as bulimia are also psychological in nature. Manual therapy has been shown to be an effective intervention in decreasing anxiety and depression associated with disordered eating which can also help control the disorder eating itself(Field, Schanberg, and Kuhn, 1998).

On the opposite end of the spectrum are aggression issues. These may be hormonally or psychologically induced issues. Manual therapy has also been shown to decrease anxiety and aggression in adolescents via positive affects on mood(Diego, et al, 2002).

Often, these results are thought to be associated with traditional massage therapy practice of 60 to 90-minute sessions. However, results can be seen with as little as 10-minutes(Frazier and Kerr, 1993). Elderly patients noted a psychological state of relaxation after the interventions of kneading from the occiput to the sacrum.

Even if manual therapy is not a strong suit, touch can be incorporated into treatment in several ways. Stabilizing touch during therapeutic exercises may have the same affect. Facilitating touch on the muscle that should be contracting is another approach.

REFERENCES
Diego, M.A., Field, T., Hernandez-Reif, M., et al. (2002). Aggressive adolescents benefit from massage therapy. Adolescence. 37:597-607.
Field, T., Grizzle, N., Scafidi, F., Schanberg, S. (1996). Massage and relaxation therapies’ effects on depressed adolescent mothers. Adolescence. 31:903-911
Field, T., Schanberg, S., Kuhn, C. (1998). Bulimic adolescents benefit from massage therapy. Adolescence. 33:555-563.
Frazier, J., Kerr, J. (1993). Psychophysiological effect of back massage on elderly institutionalized patients, Journal of Advanced Nursing. 18:238-245
Weinberg, R., Jackson, A., Kolodny, K. (1998). The relationship of massage and exercise to mood enhancement. Sports Psychologist. 2:202-211.

01/13/2026

Clinical Education: effects of fascial densification

Fascia, along with skin and muscle, create tissue layers in the body. Cutaneous nerves are located between the skin and superficial fascia. Lymphatic and blood vessels pass through the deep and superficial fascia. The deep fascia covers the skeletal muscles. Finally, deep to the muscles are the peripheral nerves. Space between these layers of tissue allow normal blood flow and neural function. Additionally, the space allows the tissues to glide across one another as movement occurs.

Through injury and overuse, an increase in collagen crosslinks produces a densification of the tissue by filling in the spaces between the existing fibers (Ingber, 2008; Loghmani, et al, 2016), This creates a pseudo-dense irregular connective tissue that is highly resistant to change(Schleip, et al, 2012). This pseudo-dense tissue can compress cutaneous nerves which hypersensitive them; movement overstimulates the cutaneous nerves which the brain may interpret as pain

01/08/2026

“If you can't explain it to a six-year-old, you don't understand it yourself," often attributed to Albert Einstein

Clinical Suggestions: patient education

Health care professionals have their own secret language based in the dead language of Latin. While this allows for clear and concise communication between clinicians, it can lead to confusion with patients (Sand-Kecklin, 2007). Research has consistently shown that most Americans read at approximately the fifth grade level (Wilson & McLemore, 1997). When describing medical conditions, it is generally better to communicate in lay language to ensure understanding. This can help with patient compliance as they are better able to understand their condition. Also, a key component of informed consent is not only for the patient be provided benefits and risks but that they understand the information provided.

Reference
Sand-Jecklin, K. (2007). The impact of medical terminology on readability of patient education materials. Journal of Community Health Nursing. 24(2), 119-129. https://doi-org.WWU.idm.OLC.org/10.1080/0737001070316254

Wilson, F.L. & McLemore, R. (1997). Patien literacy levels: A consideration when designing patient education programs. Rehabilitation Nursing, 22, 311-317.

01/05/2026

Clinician Education: subjective history

“We have two ears and one mouth so that we can listen twice as much as we speak.” - Epictetus

Patients have a story to tell of how they came to be in front of you. Unfortunately, especially for patients with chronic conditions, their story has never been heard, as in truly heard. Research has shown that providers often interrupt patients 3 seconds into their story with the average time to interruption between 11-18 seconds (Beckman & Frankel, 1984). This can disrupt the patient’s train of thought where they potentially leave out valuable information. This has become especially problematic with shorter treatment sessions and increase pressure to bill multiple units, even during the initial evaluation. By listening without interruption, the patient can receive a therapeutic benefit of finally being heard; this also helps to build a therapeutic alliance which can improve all future interactions during the course of care.

References
Beckman, H.B. and Frankel, R.M. (1984). The effect of physician behavior on the collection of data. Ann Intern Med. 101:692–696. doi: 10.7326/0003-4819-101-5-692.

01/02/2026

Happy New Year from Dr Steve Middleton and Assess, Treat, & Condition. I look forward to sharing insights into rehabilitation, healthcare, and education in the coming year!

09/04/2019