Lessons From The Precision Nutrition Level 1 Certification

PN Certified Coach Level 1

Back in October 2014 I did two big things:

  1. I started Integrative Osteopathy
  2. I signed up for the Precision Nutrition Level 1 Certification

Since then, only one of them had been getting the attention required to make it a success.

Until recently.

A couple of months back, I decided it was time to do the work and learn something, to benefit both myself and my patients and clients.

So a couple of months ago I started knuckling down, and this week I finally completed the Precision Nutrition Level 1 Certification.

For those of you who are unfamiliar with PN, it is a coaching and education company based in Toronto, Canada.

Founded by John Berardi, PhD., and his business partner Phil, who does the tech side of things, they are industry leaders in nutritional coaching and education for health and fitness professionals.

The level 1 course is broken up into two sections:

  1. Nutritional science
  2. Nutritional coaching

Having studied nutrition for a semester at university, along with physiology and biochemistry, I was more interested in the coaching side of things, but brushing up on the basics is never a bad thing.

I was hoping to learn how to become a better coach, and then apply that knowledge to my practice as an osteopath, in order to be able to better serve my patients.

Here are some of the major lessons I learnt:

1. Knowledge Is Key

Even though I had studied nutrition before, covering the ground again reinforced and enhance my knowledge on the topic.

It might be tedious, especially when starting out, but understanding what is happening at a cellular/biochemical level separates great nutritional coaches from the “Instagram macro coach” crowd.

If you understand what’s happening, then you can modify things for an individual when things don’t go to plan.

You can also experiment intelligently to get that “extra edge”, once the basics have been implemented.

As an osteopath, it has never been enough for me to just “know” that my patients get better.

Firstly, some don’t, but secondly, I wanted to know why this was the case.

Why do some people get better, whilst some don’t?

And, what can I do so that more people fall into the former, rather than the latter category?

2. Define The Goal

Defining a goal means understanding the “why” behind the “what”, and to be honest, it takes skill and experience to be able to elicit this from someone in a way that feels “natural”.

This was probably the biggest mistake I made in my first year of practice as an osteopath.

I would see someone, and not clarify their goals, their reasons for seeing me in the first place.

I made assumptions, and as a result, I’d often do too much or too little for someone, meaning they didn’t get the outcome they were looking for.

Once the why is clear, to both patient and practitioner, the what becomes easy.

3. Assess, Intervene, Reassess, Modify

What gets measured, gets managed. – Michael Drucker

If a person is asking for help to change, then it is important to know exactly where they are at, so you can map out the path for them to get to where they want.

The beginning of any coaching relationship should be all about information gathering.

A coach needs to know what a client needs, but also how to gauge progress.

In practice, I have intermittently used objective measures of assessment along with more subjective measures.

The problem is, there is no clear way to gauge progress, or lack thereof.

Now, pain being what it is (invisible and complex), it is hard to measure it directly, but we can strive to measure function and disability in an objective manner.

To do so, I have taken courses by the Functional Movement Group, and will undertake further study with Functional Movement Systems.

In addition to these movement based assessments, I will systematically use outcome measures more regularly.

4. Behaviours, Not Outcomes

One thing PN is huge on, is that we are all human, our lives are varied and whilst we may have different goals, it is what we do that gets us to our goals.

If you set a goal of having $500,000 of investments in 10 years time, then how much of that is in your control?

Realistically, you can’t control the global markets or economy.

What you can control is your income (to an extent) and how much of that you save and invest.

Nutrition and health coaching is similar.

Whilst you may want to lose weight, feel better or get stronger, you can’t control when or by how much.

What you can control, are you behaviours.

If your behaviours are in line with becoming leaner, healthier etc., then you undoubtedly will. It might happen sooner or it might happen later, but it will happen.

5. Judge on Results

At the end of the day, people hire me for an outcome.

That usually means they want to feel better (less pain), improve their quality of life (less disability) or improve their performance (move better).

I can write the best blogs, produce the most popular social media content and follow the “best practice guidelines to a T”, but if I don’t get the results people want, they won’t come back or refer people to me, and I will go out of business.

Getting good results is a culmination of the above points:

  1. Clearly defining a patient’s goal.
  2. Knowing what they need to do to achieve it.
  3. Translating that into behaviours.
  4. Reassessing and modifying along the way.


We are entering a new age in healthcare.

It is no longer the practitioner on one side of the table with all the power and information.

Now, patient and practitioner sit side by side, with access to more information than ever before.

It is not information that separates the best from the average, but the appropriate delivery and application of information.

When it comes to the body, things are always changing. A year from now you will be different. Thus, your needs will be different.

For a long time, healthcare has been moving towards “standardised care”.

The way I see things, that is just the beginning.

Standardised care, or best practice, is simply the foundation from which to achieve outstanding results.

Outstanding results, will be achieved with the help of outstanding coaching.


This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.


Management Strategies For Chronic Itch


Chronic itch is a frustrating experience. Sufferers of skin conditions like eczema know this all too well.

I know what you’re thinking. Why the hell is an osteopath writing about itch? Shouldn’t they stick to their scope of practice?

There are a few reasons:

  • We treat people manually, usually to exposed skin, so we often come across people with skin conditions who aren’t managing them well, or are suffering from a persistent itch.
  • Itching associated has a lot of parallels to pain. Both pain and itch are outputs of the brain and both can be caused by either peripheral causes (in the skin), central causes (in the nervous system), or a combination of both.
  • Many of the general recommendations surrounding itch are within the scope of practice of an osteopath to recommend.

If you suffer from chronic itch, it is important to consult with your GP, and possibly a dermatologist, in order to get a diagnosis of your condition.

Your itch/skin condition could be the symptom of some underlying pathology that gets worse because you tried to self-treat.

Itch Physiology

We’ve all had an itch that needed scratching at some point in our lives.

Whether it was after being bitten by an insect or due to social contagion – like yawning, we tend to scratch ourselves when we see others doing it – or some other reason.

For some people though, itching is a daily occurrence, and the desire to scratch is often so strong that sufferers of chronic itch cause damage to their skin trying to find relief.

It used to be thought that itching was a sub-group of pain, but it’s now understood to be a separate entity, though they share many similar traits physiologically.

There are different mechanisms of itch, which we can classify as peripheral or central, just like pain.

This is an important concept to grasp, because most medical treatments are only directed at peripheral drivers of chronic itch.

There are 4 classifications of itch:

  • Dermal or pruriceptive itch: refers to an itch that results from activation of itch receptors in the skin. This activation is often caused by histamine (which is also the main driver of hayfever).
  • Neurogenic itch: is an itch that originates in the central nervous system, where itch-mediating pathways are activated. This can occur with the spinal application of opioid medications, or more commonly in skin conditions, inflammation within or affecting the central nervous system.
  • Neuropathic itch: also originates in the central nervous system, but is caused by diseases of the nervous system.
  • Psychogenic itch: is related to illusional states.

When it comes to itch associated with eczema and other similar skin conditions, we want to focus on dermal itch and neurogenic itch, as these are the mechanisms involved.

Why does it feel good to scratch?

Normally, when we are exposed to a scratching stimulus, we withdraw, as we perceive it as either painful or unpleasant.

However, when we are itchy, we welcome the scratching sensation as relieving.

When we scratch an itch, there are multiple brain areas that are active, including areas involved in both pleasure and pain.

Both active (scratching yourself) and passive (having someone else scratch you) forms of scratching have been shown to relieve itch.

Interestingly, scratching nearby to the site of the itch also relieves the itch, suggesting a central inhibitory effect, rather than a local effect from scratching.

Chronic Itch Is More Than Skin Deep

Dermal/pruriceptive itch is mostly mediated by sensory nerves that are embedded in the skin called C-fibres.

There are two kinds of dermal itch:

  1. Histamine mediated.
  2. Non-histamine mediated.

Histamine mediated itching

This typically occurs when we are bitten or scratched, and there is a release of local histamines as part of the immune response.

This also occurs with conditions like hayfever.

With chronic itch related to skin conditions, this is often managed with topical steriods and over the counter anti-histamine tablets (the same ones you would take for hayfever).

Non-histamine mediated itching

This occurs in people with certain diseases (cancer, HIV/AIDS, liver disease) and as a side effect of certain medications.

It is also a big feature of the itch associated with chronic skin conditions, like eczema, though it’s not commonly discussed.

This type of itching is a massive issue – it’s difficult to treat and causes lots of distress for the suffer.

One key feature of this form of itch seems to be neurogenic inflammation. Mentioned above, this is itch that originates in the nervous system.

Setting off positive feedback loops, this inflammation is self perpetuating, as long as the stimulus is in place.

Topical treatments don’t work well for this, which is why many eczema sufferers get short term relief from creams, but in the long term may continue to suffer.

In order to get lasting relief, the root cause of the neurogenic inflammation must be addressed.

This could be down to a number of factors (or combination of), including:

– Dietary
– Gastrointestinal distress
– Psychological stress
– Environment exposures

Considering the systemic nature of most chronic skin conditions, and their relationship to other conditions (such as asthma and hayfever in eczema sufferers), it makes sense that there is an underlying physiological dysfunction that is common to all.

One such proposal is the relationship between cellular energy and inflammation. Cellular energy is needed on a constant basis for our cells to function and reproduce optimally.

It is increasingly apparent that bioenergetic function and inflammation are interdependent processes. (2)

This simply means, when cellular energy is low, due to lifestyle factors or illness, inflammation results.

Without addressing lifestyle factors that could be contributing to chronic inflammation, most sufferers of chronic itch related to skin conditions will not get complete respite from their itch.

How To Treat Itch

The best approach to resolving a chronic itch associated with a condition like eczema would be multi-modal and address all the causative factors.

  • Topicals as directed by a dermatologist, to provide symptomatic relief and manage flare ups.
  • Anti-histamines to address the histamine component of the itch (usually in eczema the two kinds exist in tandem).
  • Dietary modification: detection and elimination of dietary irritants, which can be determined by performing an elimination diet with the assistance of a dietitian other qualified health practitioner.
  • Supplements as directed by a health practitioner based on testing, to address any nutritional deficiencies (commonly Vit D and magnesium when it comes to neurogenic inflammation).
  • Meditation/mindfulness or relaxation to alleviate and manage psychological stress. Alternatively, go for a walk in nature, which has proven stress relieving effects.


Like most chronic conditions, there is no single cure-all for chronic itch, thus a multi-modal approach works best.

Whilst most medical approaches can work well for symptomatic relief, there is yet to be any treatment approach that delivers a change to the underlying pathology.

With this in mind, long term strategies to deal with neurogenic itch related to skin conditions should address factors related to both chronic lifestyle related inflammation as well as local skin irritation.


This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




(1) McMahon, S.B., et al, Wall and Melzack’s Textbook of Pain, Elsevier Saunders, Philadelphia, 2006

(2) Bioenergetic dysfunction and inflammation in Alzheimer’s disease: a possible connection.

Stop Blaming People For Their Pain


This post is directed at the friends, families and health professionals of chronic pain sufferers: stop blaming people for their pain.

It is really common, whether overt or subtle, for people suffering from chronic pain to be blamed for their pain.

I would argue that this stems from a lack of visibility (you can’t see low back pain or migraines) and a lack of understanding, which I’m hoping to change.

Previously I have posted about both personal responsibility and pain as well as mindset and pain.

In these posts, I am not blaming people for being in pain.

Rather, I am urging people to take responsibility for their actions in the face of their pain, because that is the only way things will ever improve for them.

Chronic Pain Is Nobody’s “Fault”

Whilst you can definitely contribute to, or even cause your pain in certain circumstances, when it comes to chronic pain, it isn’t anyone’s fault that they have become “victims of their own nervous system”.

Let’s look at how most chronic pain arises:

  • Post surgical
  • Post physical trauma
  • Post major stressful event
  • Secondary to disease (e.g. rheumatoid arthritis, cancer, dengue fever etc.)

Now, we don’t know why certain people develop chronic pain whilst others don’t, despite having the same experience.

All we know is that each person has a unique psychological, emotional and physical makeup.

And that there is something about the event’s effect on that individual that sets their nervous system off on a path of persistent pain.

We can look at factors that are correlated with chronic pain, but again, very little is predictive.

In fact, in terms of pain epidemiology (which is the study of health and diseases across populations), it seems the two biggest correlates are out of anyone’s control:

  • Age
  • Gender (females suffer from more chronic pain than males)

So whilst we can definitely control how we act and react in the face of pain, we can’t control the onset or presence of chronic pain.

It’s Human To Judge

It is a human instinct to judge others, based on our own perceptions of the world and experiences with people.

Equally, it is important to recognise that all of us have limited experiences, and our judgements are made on limited (if any) factual information, and lots of assumptions.

We have evolved this way for survival reasons, but it can often get us into trouble when dealing with humans – we don’t know what’s going on in our own “unconscious mind”, let alone others’.

Considering this, it is easy for our brains to lump people into categories and assign blame – it makes our worldview “neater” and simpler, but it does so at the cost of making things simplistic, when often that is not the case.

Whilst you can’t (and shouldn’t) stop judging, you have to acknowledge the limitations that are inherent within our judgements and use your cognition (yes, you’ll have to think), before you act and speak.

What To Do Instead

You’re probably thinking, “gosh, this is hard, I’m going to feel like I’m walking on eggshells any time I have to talk to someone with pain”.

When someone is constantly complaining about their pain, they are expressing a need.

This need can be for attention, care, acknowledgement or reassurance.

Pain is rooted in fear; our brains have decided that there is danger (real or not), and that pain is the best motivator for change.

Unfortunately, chronic pain is the dark side of neuroplasticity (the ability of the brain to change), where the brain has become more efficient and skilled in the pain response, and so pain is not indicative of any damage within the body, but rather a heightened sensitivity to normal stimuli.

Instead of blaming someone with pain, try practicing empathy – that is, understanding what that person is experiencing, from their point of view.

It could be a loss of independence, a frustration at lost capabilities, a fear for the future, a combination of all three or something else entirely.


Pain is a normal part of the human experience.

We will all experience pain at different points in our life, and we hope that it is brief and not serious.

However, for many people, pain is not brief, but daily and ongoing, and a great disruption to their lives and their personality.

The vast majority of sufferers of pain have not done anything to “deserve it”, and so should not be blamed for their condition.

Instead, practicing empathy and acknowledging someone’s suffering is a better approach, without dwelling on pain and making it a focal point of your interaction.


This blog post was written by Dr Nick Efthimiou (Osteopath), founder of Integrative Osteopathy.

This blog post is meant as an educational tool only. It is not a replacement for medical advice from a qualified and registered health professional.




(1) McMahon, S.B., et al, Wall and Melzack’s Textbook of Pain, Elsevier Saunders, Philadelphia, 2006

(2) Chronic pain epidemiology and its clinical relevance

(3) Preventing chronic pain following acute pain: risk factors, preventative strategies and their efficacy

(4) Risk factors associated with the onset of persistent pain