National Physical Therapy Month

October is National Physical Therapy Month!  Wahoo!!!  A whole month to celebrate physical therapists - which means celebrating so many of my friends, my coworkers, the providers who keep me moving when I need some physical help, and my old pals from UConn Physical Therapy!  If you're currently seeing a physical therapist for care, wish them a Happy PT Month!

I frequently get asked about what PTs do. The cool thing is that we can do so many things!  PT school is a little bit like medical school in that when you finish, you're a generalist and basically know enough to not hurt people (hopefully)... while you then continue your education to specialize.  The big difference is that PTs don't (yet) have to complete residencies and fellowships for our specialties - we learn them in our choices of clinical affiliations towards the end of school and then we further learn our practice on the job.  Physicians go into many years of residency to specifically learn the specialty they will practice.  

The current specialties for physical therapists - in which you can become board certified - are: cardiovascular/pulmonary, clinical electrophysiology, oncology, women's health, geriatrics, neurology, orthopedics, pediatrics, and sports.  But this is just areas we can choose to further our knowledge in, take a test, and then get some fancy letters after our names.  (Don't get me wrong, I'm working towards this and think this is great - I'm just pointing out that this is only the start of things PTs can do).  

Physical therapists are considered to be the musculoskeletal experts.  We help people optimize their functional mobility - whether that be rehabilitative (trying to gain a function they used to have but somehow lost) or habilitative (acquiring a new function they haven't previously had). This could include treatment for patients with burns and wounds, care for children born with developmental or congenital conditions, adults who have had a heart attack and are regaining their endurance, children who need help at school... so many things!  We can work in clinics, hospitals, sports venues, athletic training rooms, large corporations, nursing homes, schools, in people's homes, at a horse barn!, in a gym or fitness center, in a doctor's office, in the emergency department.  We can work with old or young people, males and females and those who do not identify with either of those, people who just had surgery or who are trying to prevent it, people with all different sorts of pain, and more!

The best part is - we don't really have to choose just one patient population or one location to work, either!  Personally, I only work as a Sports/Orthopedic Physical Therapist.  My full time job is at Seattle Children's Hospital's North Outpatient Clinic and I treat children between ages 5-21 with sports or musculoskeletal injuries.  The most common conditions I treat there are people with knee pain or who had a knee surgery, ankle sprains, broken arms, and back pain - though I also work with children who have been experiencing chronic pain, concussion symptoms, neck pain, and many other conditions.  The ways these kids get hurt varies considerably, too!  On the side of treating patients, I also participate in research projects around the conditions I'm working with, which helps me learn.  When I'm not at Children's, I also treat athletes in the athletic training room or at the basketball arena as well as at a dance studio.  I get to work in three different settings and find that to be cool  In the past I have treated people in nursing homes - and that setting wasn't for me, but some physical therapists love doing that!  And, if I woke up tomorrow and decided I wanted to start working in a different setting, I could change my continuing education and learn more so that I could transition to a different area of work.

Why am I discussing this?  Well... first of all, because so many people just don't know what we do... and that's partially because we do so many different things based on the environment we're working in.  But also because I've previously written about "What Physical Therapists Do" and those were more from my perspective as a Sports Physical Therapist.  This is one of the recurring themes on my blog - and you can check out "What Do Physical Therapists Do? Installment #1: We Look at Mechanics, here.  Or #2: We Listen. here.  And the third installment: "We Strength Train" here.  But truthfully - we do so much more!

One of the big initiatives the American Physical Therapy Association has been working on is fighting the opioid epidemic in the United States.  This is a target because physical therapists help patients who are experiencing pain to get back to a more functional life. Often times, people experiencing pain use medication to try to get rid of the pain... but pain is a symptom!  Medication can sometimes attack the cause of the underlying problem, but oftentimes - it will only mask the symptom, perpetuating the problem.  I've previously written about chronic pain several times: here, here, here, and here.  PTs are learning more and more about the science of how pain works and can help patients better understand pain so that they can move forward and back to their optimal level of function.

It should be said that not all physical therapists practice the same way.  This has made the general perception of what we do cloudy for many people.  At the end of the day, what should matter most is that you're feeling better and doing more of your favorite activities.  Here are a few things you should consider if you are currently going to physical therapy:

1) Your physical therapist should not be hurting you!  Now - if you just had surgery last week, and we're guiding you with some gentle movement, you may feel some discomfort... but you should only be working within your tolerance and if it's really painful, the PT should stop.  If you don't exercise often and you're starting PT and moving in new ways - your muscles may feel some soreness.  But again, this should remain within your comfort level.  Think about the last time you were having pain.  You tighten up and definitely can't relax. What good is it doing to fight through that?  I can't say this enough... treatment should not be painful.  Nobody should feel like they're receiving torture when they come to PT.  Physical therapy is not the place for cliches like "No pain, No gain." Period.  

2) Your physical therapy treatments should be specifically made to address your issues and goals.  If your goal is to walk without pain - and you're not doing any exercises that look like they're going to get you to your goal, you have the right to ask why you're doing the things you're doing.   Sometimes it's hard to tell how the path you're on may get you to the target destination.  But - in order to run, you must first be able to walk, and to walk, you must first be able to stand up.  When I'm working with patients, I'm breaking down the goal activities into components, and I can explain why I have chosen every single activity.  Healthcare providers should be encouraging their patients to ask questions and understand their own care.  They should also be educating patients/  

3) Physical therapy only works if a) the patient buys into the things the physical therapist is saying and b) the patient commits to doing the program.  You may only spend 1 hour per week with your PT.  That leaves you with a whole lot of time where you're not working with them - but should be working on things to improve yourself.  Take charge of your recovery.  Take charge of your own body! As a patient, it can be hard to understand medical conditions - and that's scary!  Your back hurts and someone you don't know is touching you and then telling you to move in weird ways... you have to feel comfortable and there needs to be a little bit of trust to be successful.  This is really difficult when patients have previously seen a different physical therapist and didn't get better.  Maybe it wasn't the right fit for you... give another PT a try and make sure they treat you differently than the last one.  

4) You have the right to "fire" your physical therapist.  At Seattle Children's, I often share the patients I'm treating with one other physical therapist.  There are pros and cons to sharing a patient - but my favorite pro is this: if you don't like me - see the other therapist!  My feelings won't be hurt... I just want you to get better!  I can promise you we won't do things exactly the same way.  The best way is the one you like most as the patient.  Sometimes I even recommend patients see one of my coworkers because I think they'll be a better fit.  I'm a female... sometimes young male patients just do better with a male physical therapist.  I'm very direct and tend to be pretty loud... sometimes the more shy kids need one of my more gentle or softer spoken coworkers.  Any PT who gets upset that you would prefer to see someone else isn't looking out for your best interests.   

5) If you feel like you've been going to PT for months and not making gains - you should see if you have a better outcome with another PT.  Don't give up hope!  I think - because health insurance often pays the bulk of the costs - and because people are having pain - they forget that their healthcare providers are PROVIDING SERVICES.  We only have jobs because patients find us to be helpful.  You wouldn't use a carpenter to fix your toilet instead of a plumber just because they both know how to use a wrench... don't settle for a physical therapist who isn't fitting your needs.  

Now that you know more about Physical Therapists, make sure you reach out to your favorite PT and let them know that you're celebrating them this October.  If you're experiencing pain or having trouble with one of your favorite activities - sports or otherwise - find a PT near you to get treatment.  Having trouble finding the right fit? I'm happy to help you find someone near you.  Reach out with questions.  And know that the biggest compliment you can ever give to a physical therapist is to send your friends or family members to see them.

Shoulder Care with Eric Cressey

Last weekend I jetted off to Denver for a visit with family and a continuing education course.  The family time was fantastic - a few hours of biking around Denver - far more than I'm used to doing as I'm not a fan of bike seats - some really delicious tacos - beautiful art and the backdrop of the Rocky Mountains!

The course was "Shoulder Assessment, Corrective Exercise, and Programming" presented by Eric Cressey of Cressey Sports Performance and it was hosted at Landow Performance in Centennial CO.  Loren Landow is the newly hired Strength and Conditioning Coach for the Denver Broncos and his facility is beautiful with state-of-the-art equipment and autographed jerseys all over the walls from numerous professional athletes.  His bio says he has trained WNBA athletes, too - so extra points in my book!  If you're not familiar with Eric's work, he's a Strength and Conditioning coach with facilities in Hudson, MA and Jupiter, FL and, though he is most well known for his work with professional baseball players, he also works with the general population and is considered to be an expert in the shoulder.  He's published tons of research and has a blog with articles posted starting in 2002 with regular high quality content.  I previously wrote about one of his older blog posts here.  Most importantly, Eric is a UConn grad, so I've followed his work since I first learned about him somewhere around 2005 when I was in a class with Dr. William Kraemer, one of Eric's mentors, and have been looking forward to meeting him and attending one of his seminars for a long time.

With Eric Cressey June 24, 2018

Why did I want to take this class?  Beyond wanting to hear Eric speak live and get the chance to ask him questions, I previously took a course with a strength and conditioning coach (Matthew Ibrahim) in conjunction with a physical therapist (Zak Gabor) which I wrote about here, and felt that learning from people with different backgrounds was really impactful for me.  The audience was primarily strength and conditioning coaches who work with baseball players... but there were also a handful of physical therapists, chiropractors, massage therapists, personal trainers, and baseball coaches.  People had traveled from Australia and Korea and all over the United States, some of which trained athletes from unique sports like Professional Disc Golf or MMA fighters. The variety of people present was really neat... but also, the content is applicable to so many other sports.

More importantly, I have been treating a lot of patients and athletes with shoulder injuries and recently completed Mike Reinold's shoulder seminar, but also wanted a live course to better observe how other providers evaluate and treat shoulder pathologies. Eric's approach to shoulder treatment does not look like Mike's.  They have different "favorite" screening tools and exercises that they use.  If you observe their social media, you could probably pick up on these differences and similarities.  I'd say the biggest overlap I observed was that both of them regularly use the prone low trap exercise for rotator cuff strengthening which Eric has a video for here.

When it comes to my work with the Seattle Storm, though, we also have to consider that we're working in an overhead sport with repetitive action.  Shooting a basketball is nothing like the motion of throwing a baseball, but it still requires significant mobility and stability - and very different from baseball, it requires the athlete to be reactive to opponent players slapping at their arms while they're doing it.  The arm care programs used by the Seattle Storm should not look like the arm care programs used by the Boston Red Sox - but the principles involved in developing them do match.

I learned a lot from this course which I'm still processing, but was able to immediately use some of the skills in the clinic. Here are my top 5 favorite Eric Cressey quotes and take-aways from the weekend.

1) The biggest key for the shoulder is "Keep the ball on the socket." Simple.  Having a better biomechanical understanding of the force vectors of the rotator cuff is vital. If the scapula is sitting in a depressed position, the lats may be over-active which will influence upward rotation when getting overhead.  Similarly, if the scapula is tilted anteriorly, could there be shoulder impingement with elevation or is there enough muscular balance to safely overhead press?

2) Rehab and training are the same thing!  I've previously written about physical therapists' role as strength coaches here - and this came up in the course.  Eric Cressey is not a physical therapist and he discloses this and discusses how he interacts with PTs all over the country.  So it surprised me to see the differences between what Mike Reinold and what Eric Cressey do considering this statement, but I would not expect Eric to be seeing athletes post-op day 1 following labrum repair.  So, I took this to mean that once the acute healing phase is completed, rehab and training are the same thing.  There is a need for progressive loading to tissues and a need to understand periodization, even if your PT treatment sessions are not written like a periodized training program.

3) Scapular winging is a garbage term. It does not describe what is going on with the scapula.  I document scapular winging all the time - so this will be a change I need to consider moving forward.  Is the scapula winging because it is anteriorly tilted?  Upwardly rotated?  Because there is a flat thoracic spine so the medial border is just more pronounced?  And is this inherently pathological?  Or just a finding that you're documenting.  I can't promise I'll stop using the term scapular winging entirely, but I can commit to adding at least one descriptor of the scapular position to better describe the situation moving forward.

4) Stop telling people to bring their shoulder blades down and back.  It would only be a slight exaggeration to say that Eric Cressey is begging people to stop using this cue.  Too many people use this resulting in patients pulling their elbows back with anterior humeral head translation and improper mechanics that we could be creating problems!  I asked him what cue he likes instead - and he said he manually puts people into the position he wants them to be in, using optimal muscle activation, until they can do it independently.

5) Push:Pull ratios are not accurate nor are they adequate.  It has been well ingrained into my training that for every push exercise, you should be doing at least 2, probably more like 3 pull exercises.  I've been trained to teach that focusing on the back musculature 2-3x more than the front helps combat many of the anterior shoulder issues that are seen in the clinic.  However, Eric points out two key points that make you think about this more carefully.  First, the push:pull ratio is almost always considered for front:back motion and ignores top:bottom... but both planes need to be considered.  I think John Rusin tries to deal with this by including upper body push, upper body pull, and carries into his 6 foundational movement patterns, but the balance needs to be considered for both planes.  Second: not all pushes can be considered alike.  The bench press is a push exercise that necessitates the scapulae being blocked on a bench... compared to the push up where they are moving freely on the body.  This is also an important consideration as you're not getting the benefit for scapular control through the pushing motion when doing a bench press - and Eric says he doesn't have his baseball players bench pressing.

I'd be lying if I said this even touched the surface of all the things I learned at the class... but these were big takeaways that made me think and will change how I operate to some degree.   Thanks for an awesome course, Eric!

What Do Physical Therapists Do? Installment #1: We Look at Mechanics

Recent scenario evaluating a high school-aged patient: let's call him Bobby and pretend that he's referred with a diagnosis of shin splints. (We can get into "Shin Splints" not being an actual medical diagnosis on a different blog post).  The conversation went something like this:

Abby: Hey, what brings you in today?

Bobby: I'm here for biomechanics testing.  I want to get back to running ASAP.

Abby: That's awesome that you like to run. 

Bobby: I run track and cross country but my leg hurt a whole lot at the end of the last season.  I saw the doctor and he shut me down from running while I did 2 months of physical therapy elsewhere.  When I went back to the doctor, he said he needs the physical therapist to clear my biomechanics so I can return to running.  My physical therapist said they don't do that, so my doctor gave me a referral to come here instead. 

Abby: Wait.  WHAT????

Bobby: Can you test me so the doctor will know I can get back to running?  I feel a lot better.

SO MANY THOUGHTS running through my head.  Primarily - what did your previous physical therapist do if they didn't look at your biomechanics?  Is that really what happened? 

This person came to me after having physical therapy for several weeks because they had experienced pain while running.  He had done all of his prescribed exercises and was now pain free with walking outside of the boot, but returned to the referring doctor for clearance. At no point during the rehab process had he ever been on a treadmill, tried to participate in a return to running program, or been to the track. 

What did I do?  I proceeded to conduct a complete initial evaluation of this patient - no different from any other initial evaluation I would normally do for an injury to that body region. I am a full body-focused physical therapist, so I never examine an ankle injury without looking at the lumbar spine and the hips in addition to the ankles followed by full body motions and balance. 

Bobby's parent: Wait - why are you looking at his back?  And his hips? We already did physical therapy and his leg is what hurts.  And what difference does it make that it hurts his knees when he squats... he doesn't want to squat or lift weights, we're here to get back to running. When is the biomechanics portion of this session?
Abby: Let's do that right now!

Alright... I already know from my examination that there's no way I'm clearing someone for return to running based on intolerance to a double leg squat that doesn't even hit a 90* knee flexion position.  Running is basically repeated single leg squats so if you can't double leg squat, there's got to be a problem with at least one leg in single leg squatting - but, I still need to see how the running looks because I'm going to give them a new home exercise program and need as much information as possible.  Also - the patient came with a specific request - so I'm listening to their demands and being thorough.  The more time spent in evaluation - the more effective the treatment can be later. 

This is the moment when I cut the previous physical therapist some slack and think that they knew this person should not be permitted to return to run but both the patient and parent are pushing for it and so they're sending him back to the doctor.  Who am I to judge another physical therapist I don't even know based on a patient sitting in front of me?  I fear that we, as a profession, are often guilty of blaming our colleagues without considering the whole scenario.  I'm nowhere near an expert - and I also don't have any clue what this kid looked like before 8 weeks of physical therapy.

So I put him on the treadmill and had him run.  Fortunately, it didn't hurt... but it also didn't look good.  I recorded it so I could play it back to him and his parent.  Of course there are really excellent pieces of equipment available and there are physical therapists who are highly specialized experts who work with elite-level runners.  I am not one of those therapists and I don't have any special equipement.  I know the basics of what running should look like and when I watch someone running, I can make modifications to form based on the errors they demonstrate and help them progress back to running when appropriate.

At bare minimum, all physical therapists working in outpatient orthopedics and/or sports medicine facility have the responsibility to learn how to observe and correct basic mechanics of a squat, hinge, and running pattern in order to help their patients.  I'm willing to look the other way if you can't break down throwing mechanics and specialized sport activities like gymnastics moves and ballet positions.  But the squat, hip hinge, and running patterns are essential to far too many athletes and the general population.  There are tons of courses and materials on how to do it - or you should find a colleague who can help you out.  Again - I'm no expert.  I don't spend much time studying running mechanics because the basics are pretty easy to spot once you take the time to learn those. 

I don't know if the other physical therapist ever actually said they didn't do biomechanics assessments.  Perhaps the therapist was a new grad who wasn't comfortable clearing an athlete for return to activity - as this is often a responsibility left to the physician that barred them from participation in the first place.  Regardless - because this has happened multiple times (and potentially has even happened with patients I have seen that then went to a different physical therapist... I would never even know!) - my new reoccurring segment of "What Do Physical Therapists Do" has been launched with Installment #1: We look at Mechanics. In a future post, perhaps I'll even outline some of the common faults to look for - so stay tuned for that!

Take Home Messages:
1) If you are a physical therapist - it is your job to be assessing your patients mechanics - in numerous ways - to make sure they are properly moving. 
2) If you don't know how to assess running form, there are several courses available: on Medbridge or in person, so you can learn the basics.  Truly - the basics help clear up problems in a large number of people.
3) If the basics don't fix your patients' issues, find a physical therapist nearby who focuses on running mechanics and refer.  But you should know that it is a physical therapist's job to be "the movement specialist" and as such - we need to better inform the public of what exactly we do.  You could also record your patient running (with permission - from the back and the side) and get the consensus of your clinic colleagues so you can collaborate and improve your assessment skills. Or re-evaluate the patient using a body-wide system like the SFMA to see if you're missing something.  Or send them back to the doctor to make sure an underlying pathology is not present.
4) Take the time to listen to the patient and target their treatment to the goals they have stated.  I can't always put a patient on a treadmill and watch them run at an evaluation because sometimes that isn't appropriate - but if they're going to return to sports, they're definitely going to do it at some point.
5) Find Physical Therapist colleagues who focus their energies on different areas of expertise and develop relationships with your referring doctors.  For example - I know exactly who to call when I'm looking at an athlete with pelvic floor dysfunction. And I know which doctors I can call and say - hey - I just looked at Bobby - and here's why I don't recommend he return to running at this time.

Let's fulfill the role we are intended for and serve as The Movement Specialists.

(Disclaimer: No identifying or specific patient information is being released here - as this would be breaking the law.  Names are changed, injury is different, and lots and lots of patients want to run.)