Daniel Bockmann, DC
@DanBockmannDC
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Renegade chiropractor, rehab heretic x 23y. Research lags innovation. The Fixable Back Course:
Austin, TX
Joined December 2013
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I just finished my white paper outlining my approach to MSK eval & treatment.
Happy to share if you're interested -- just DM me your email.
Welcoming all comments & criticism! 😅
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When a patient feels fragile or fearful of movement, I hand them one of these, with their name on it.
It's a small thing, but they often give a sigh of relief.
Then we talk about how to resume movement safely.
@GregLehman
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Apley's is my favorite shoulder test.
Global ROM check in 5 seconds.
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215 for reps.
No big deal for lots of folks I'm sure.
But 9 mos ago my mom was pushing me around in a wheelchair.
I'm comin' back, baby! 😊
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CT results yesterday not great. Lung & liver tumors growing.
Got back in the sand again for the first time in 2 years, felt really good!
Time to rethink treatment. I've always more productive when I have a deadline lol
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In MSK:
✅ Pain isn't measurable
✅ We don't know what causes pain
✅ No treatments work consistently
✅ Patient improvements can't be attributed to a treatment
✅ Outcomes assessments aren't reliable
✅ Any improvement is likely from contextual effects
Did I get that right?
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Average chiro model: See a few patients, a whole bunch of times.
My model: See a whole bunch of patients, a few times.
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Simplest rehab room ever. I only need 400 sf, no fancy kit.
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Being truly evidence-based means realizing that there isn't very much good evidence.
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Unfortunate plot twist.
Doc is expecting I have 2-6 months left.
Video here:
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@louisanicola_
True! (according to research)
Also true: maijuana definitely helps some people sleep.
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Checked-in for surgery number 7, the one I'm most excited about! (Colostomy means I can eat again!).
See y'all on the other side 😊
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As chiros, the stereotypes about our profession are our own fault.
Want to be seen as a well-rounded healthcare provider?
Then act like one.
Cracking backs for 24 visits ain't that. 😊
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Update: got into an immunotherapy phase 1 trial. Stoked! 🤞
Video here:
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@MattoPT
@gunsnrosesgirl3
$600
Just add the profits 😊
'Profit' means you've already covered investment cost.
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I'll be a senior citizen in 10 years.
I'm supposed to be dead in 1 year.
But, I've got too much fun stuff I wanna do. So...death's just gonna hafta wait.
So far, so good! 😅
#mindovermets
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Me, a year ago.
Shocking for me to see now.
But now life is intensely beautiful by comparison ❤️
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As a chiro, I feel like some kind of weird animal who doesn’t relate to others in my own species.
The way the profession is practiced sometimes seems so foreign and cringy to me.
But — this is changing, for the better.
Shout out to all the enlightened chiros out there! 👊
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Is being honest with our patients about our uncertainty ruining the benefits they'd receive from contextual effects?
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Before & after, post-op & now.
No food for 7 weeks (post-op bowel obstruction) is an effective weight-loss program lol
#ileostomy
#colorectalCA
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Just had an actual breakfast (!), procedure went great, feeling like a brand new man! 💪
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@clairlemon
Is this involuntary imprisonment?
If so, I don’t care if the prisoners are wearing bikinis. I’m out.
If it’s completely voluntary, and everyone can opt out, then have fun :)
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Sporting my Saints kit! A gracious gift from the wonderful
@SissonLearns
who flew all the way to the states to visit me. So great to meet you in person, Jordan! ❤️
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@rickygervais
"After Life" was a precious find for me when I was diagnosed.
Now with 2-6 months to live, according to my doctor, I'm the happiest I've ever been. I'm grateful for you, Ricky! 💜
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It stings to get a review like this, but I try to respond to every review personally.
They didn't actually come in to see us, but were unhappy with us being OON.
Fortunately these are quite rare.
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Just like us, others think mostly about themselves.
Such a bandwidth-saver: not having to worry about each of our little miss-steps for days...
Harsh Truth: Most people don't really care about you.
The Spotlight Effect:
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@Emmyjewel
@clairlemon
Don’t care about influencers.
Being imprisoned against my will? Yes, I care about that.
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Manips don't:
🔹"align" anything
🔹put bones "back in place"
🔹fix "subluxations"
I treat manips as a short-range stretch, and like stretches, they can improve flexibility.
Just one tool in the rehab toolbox, and one that isn't needed very often IMO.
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@coloradotravis
We solved that. 15-min cushion between patients and voila -- no waiting!
Also fixed the "5 seconds with the doctor" problem. We set aside a full hour of doctor face-time with new patients, and 30 min with established patients.
Better quality of care, happier patients!
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My numbers for the past year.
Normally average 600 new patients, but working part time because I'm recovering from surgeries.
A practice manager is going to tell you these are terrible numbers. "Need to get those visits up!"
But these are the numbers I'm most proud of.
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"Zero pain, ever" is an unrealistic goal for a patient.
If you have that goal, you may never achieve it, which is discouraging.
I tell patients, "let's shoot for mild, brief & rare." That ensures you have a vibrant, active life, even though you may have the occasional ache.
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Doctor: Unfortunately, we had to remove your colon.
Me Why?
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2 hours post-op liver resection, getting my mileage in…slowly.
Minus 5 tumors, 20% of the liver, 3 tumors ablated. Next up, bowel resection! ☺️
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@kaydaustin
For me, the bell just meant you finished your course of chemo.
I rang it, and I appreciated the cheers and congratulations from the nursing staff, but it didn't feel momentous.
Still an important milestone, though.
6 surgeries later (stage 4 colorectal), and the tumors
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Are MSK providers even needed for chronic NSLBP?
Or could others "amuse the patient" better, while nature cures? Serious question.
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@steveinpursuit
🎯
While it can be hard to find an expert I trust MORE, it's easier to find experts I trust less:
🔹coercive
🔹defensive
🔹closed to questions
🔹 unable to characterize opposing viewpoints accurately
🔹 ignore unintended consequences
Served me well so far 😊
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Give me one reason why a civilian needs access to this.
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@kareem_carr
Good science stands up to scrutiny, political or otherwise.
Relies on it, in fact.
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Woke up 4 hours ago from bowel resection and I gotta say…feelin’ pretty good!
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@hankgreen
@nope_its_lily
Voting involves us in these decisions, no?
We collectively create laws to prevent various harms, and our individual votes support or oppose these laws.
(Seatbelts, speed limits, drinking age, etc)
We are involved in these decisions, whether we think so or not, IMO.
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We probably shouldn't believe patients when they tell us they're getting better.
They aren't qualified to comment on their own experience.
Don't they know that all their progress is an illusion, created by contextual effects? 🤓
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@kcrehabguy
Manips don't:
🔹"align" anything
🔹put bones "back in place"
🔹fix "subluxations"
I treat manips as a short-range stretch, and like stretches, they can improve flexibility.
Just one tool in the rehab toolbox, and one that isn't needed very often IMO.
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Recovery update, for those following 😊
Watch here:
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@Austen
Like most professions, it depends on who you go to.
"Cracking backs" is an occasionally useful therapeutic tool, but unfortunately many chiros ONLY do that.
And oversell the benefits.
The best docs use a full suite of therapeutic "tools" (rehab) and are evidence-based.
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If a chiro says you need manip for life, he's not offering a fix.
He's offering management.
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"Evidence-based" is just old ideas that science finally caught up with.
And where do new ideas come from?
A hunch.
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I hear this from students & new docs all the time:
“All the research seems to be telling us what NOT to do.
But what are we actually supposed to be DOING?”
Without a clear roadmap, no wonder they feel this way.
Like saying, “Ok, now build me a house, but without any tools”
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@StokesNeuro
We don't know each other, Mark, but I just want to wish you peace and comfort.
It looks like you're surrounded by people who love you, which speaks to how you've lived your life.
Much love my friend. 💜
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@GregLehman
So far, here’s my list of muscles that are The Cause of All Bad Things:
- Iliopsoas
- Tranversus abdominus
- QL
- Serratus anterior
- Soleus
- Putin
- G medius
- Piriformis
Did I miss any?
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@joshdcaplan
I love Neil Young's music, and I approve of this decision.
Spotify honored his ultimatum. Just didn't go the way he wanted.
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If someone doesn't understand or follow my recommendations, I always assume it's my fault.
🔹too complicated
🔹too much stuff
🔹not explained clearly
🔹too hard to remember
🔹not convinced it'll help
So I'm always looking for ways to trim, simplify, polish, reassure and explain
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@PaulBliton
@Retlouping
If tolerated and helpful.
There are no dangerous exercises, only dangerous doses.
i.e., we need water to live. You could drink so much it kills you. Does that mean water is bad? No. It just means the dose was wrong
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Trailer park life in 1979. The Bockmann boys, left to right: Me, Mark, Rob & John
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Why does overtreatment happen?
Because it pays better.
When overtreating is incentivized, it will happen.
Then mythology is created to justify the overtreatment.
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We have an "open door" shadowing policy for chiro/physio students and MSK providers.
If you're ever in the Austin area and would like to observe, give us a call -- we can talk shop and grab lunch after!
Open invitation.
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When it comes to posture, comfort is king! 👑
Any position that consistently produces symptoms is worth changing.
Any position that feels better, is better.
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I think the only reason patients care WHY they hurt is because they’re afraid it might be a scary condition.
Then a huge sigh of relief when they find out it’s not a scary thing after all.
Next they care about how to get rid of their pain, resume activity & prevent recurrences.
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About to go live with our LBP self-treatment course!
Exact same approach I use with patients in-clinic.
Juicy pre-sale discounts happening now 😊
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My 5 elements of recovery:
🔹 reduced pain severity
🔹 reduced pain frequency
🔹 reduced pain duration
🔹 resuming activity
🔹 increase activity volume/intensity
Trending better in one or more of these over a week = continue.
No change = pivot
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"Where am I supposed to feel this exercise?"
Doesn't matter!
If you're doing the movement, the muscles are working.
No need to feel something "activating" or "engaging".
Telling someone they need to "feel" a specific thing is counterproductive.
Distracts from the important
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Full new patient encounter -- acute LBP. (1:25)
(Thanks to our patient for his gracious consent!)
Video here:
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@drcalebburgess
Do we have anything to offer that 80%?
I say yes:
🔹confirm that it's not a scary condition
🔹reintroduce movement
🔹beat natural history if we can
🔹teach skills to prevent recurrences
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Much of my day is spent convincing people to do things that feel scary to them.
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(Shared with gracious consent!)
A new patient from today. (39 min)
Video here:
Questions/comments/excoriation welcome! 😉
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Thomas Sowell's 3 questions to evaluate a claim:
🔹compared to what?
🔹at what cost?
🔹what hard evidence do you have?
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@Lentini_PT
This has always been a mystery to me.
Docs refer to the physio, because the physio knows things the doc doesn't.
Then, strangely, the doc proceeds to TELL the physio what is "needed".
EVALUATE & TREAT. That's all they need to say.
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@_realanna
@EM_RESUS
I agree.
As a stage 4 cancer patient, I've experienced that firsthand, unfortunately.
The patient's feedback is a hugely untapped resource.
They are the only ones who feel what they feel.
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A full new patient encounter. 1-session plan.
He just checked-in and said his knee has been doing great.
(Shared with gracious consent!)
A new patient from today. (39 min)
Video here:
Questions/comments/excoriation welcome! 😉
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I don't write treatment goals.
The patient does.
(From our intake form)
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I see myself as a HEP coach.
Do it once in clinic, then they own it.
HEP beats in-office rehab:
🔹 can be done at home (no squat rack or fancy kit needed)
🔹 free
🔹 done on their schedule
🔹 builds autonomy
🔹 reproducible for life
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CASE STUDY:
🔹46/M
🔹Radiating pain left arm x 1.5 mos, mod/severe
🔹Onset after long car trip, no trauma or 🚩🚩
🔹Forced to stop all workouts (P90x, biking, RT)
🔹Pain awakens from sleep
🔹Worst in evening; WFH
🔹Ortho eval: dx cervical radic, 6-8 wks rest + NSAIDs
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CASE STUDY:
🔹28/F
🔹Right hip pain, altered gait for 2 yrs
🔹Severe at worst
🔹No trauma, suspects posture, inactivity contributory
🔹Forced to stop: running, RT
🔹Goals: resume running, RT, Pilates, ballet
🔹"Feel like I haven't been taken seriously about my hip"
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Just because someone comes to see me, it doesn't automatically mean I'm the right provider for them.
My job, as I see it:
🔹 Identify the problem
🔹 If it's within my skills and scope, fix it
🔹 If it's not, refer to the person who can
There's a cost for being wrong or late.
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