…to call your physical therapist. I get it. I’m the one who cleans the apartment BEFORE the housekeeper comes. But waiting to schedule because you’re in too much pain is like telling your dentist, “my teeth are too dirty”, your personal trainer, “I need to lose weight before I start ” or your therapist, “I’m too down in the dumps to see you today.” I can understand the fear that a PT may make you move, but being in pain is exactly why you should see a PT who will assess your movement and choose a treatment to alleviate your symptoms.
You’ve probably seen the black and yellow “straps” hanging in your gym or, if you live in San Francisco, you’re just as likely to have seen them anchored to a stop sign at a busy intersection. Developed by former Navy Seal and Stanford graduate Randy Hetrick, TRX is a San Francisco-based company that is sweeping the nation with a new form of fitness training. Used in the military and found worldwide in professional sports team training facilities, TRX Suspension Training is a tool that allows individuals to use their own body weight to develop strength, stability and flexibility.
TRX can be used to make exercises more challenging by adding instability to a movement, make exercises more manageable by assisting the movement, and allows participants to work multiple areas of the body in all planes of movement. By simply adjusting your body position, you can change the resistance of an exercise, and control how challenging the workout is. But before you start thinking TRX is only for the elite athlete, read on…
I have been working as part of the TRX team for over two years, originally as a client. I knew of the product and even had one in the clinic where I worked, but it wasn’t until a patient told me that his goal for physical therapy was to get back to using his TRX that I started to wonder how it might be beneficial for my clients. A case of perfect timing, TRX was just releasing their Sports Medicine Suspension Training Course for healthcare practitioners and I was asked to become an instructor. Over the past two years I have presented the one day course around the country and have had the opportunity to meet and engage with some of the best and brightest in the rehabilitation and fitness industries.
While TRX is not the only tool I use in my treatments, I can’t think of any client for whom it would be inappropriate. So why exactly do I use TRX in my practice? TRX is a tool that allows me to:
- Teach proper movement
- Assist movement that a client might otherwise have difficulty performing
- Unload healing bones, joints, ligaments, tendons, and muscles during the rehab process
- Combine balance, stability and strength work into challenging full body exercises.
- Provide a workout to the entire body during the rehab process
- Save space and improve compliance due to easy set up and portability
If you would like to learn more about how TRX might be useful in your rehabilitation or are looking for a new form of exercise contact us today!
It seems that just about everyone has an opinion about running. A few years ago most of the questions I’d get were about the effect of running on joints. Now, the talk is focused on footstrike patterns–what part of your foot you should land on when running. Some state that we should be landing on the ball of the foot (forefoot) and that modern running shoes have created generations of heel strikers. Many of these passionate advocates proclaim that heelstriking is bad for the body and can cause injury.
Turns out, the argument is not so cut and dry. According to continued research, there may not actually be one right way to run. This is music to my ears. I’ve always held firm to the belief that there is more than one way to get something done, including parking the car in the garage…ahem.
The question comes up frequently these days, though appears in many different forms-
“Should I switch to barefoot running?”
“Isn’t landing on your heel bad for you?”
…and much more commonly as a statement,
“So, I tried to change to a forefoot strike…”
“Heelstriking is bad for you.”
“If you run without shoes, you will land on your forefoot”
“Landing on your toes prevents injuries”
Seems like everyone knows all there is to know about running and running form. Which is actually quite funny considering the researchers and clinicians are all still trying to wrap their heads around the footstrike puzzle.
When I evaluate a runner who wants to change their form, the first question I ask is, “why?”. We live in an age with endless information at the tips of our fingers and connect with people and groups we don’t even know through social media, many who have strong opinions, seemingly supported by research. The runners with whom I work are tech-savvy, bright, educated, curious, motivated, and sometimes even obsessed. They collect information from various sources and have other influences–friends, coaches, personal trainers, and other healthcare practitioners who may be suggesting one form over another. It is important I understand the motivation for wanting to become a forefoot striker. My general recommendation is that unless a runner has an injury that may be helped by modifying form, there really is no reason to try to change how they are running.
A very famous and often quoted research study became gospel truth in 2010 when it was published in Nature. Harvard researcher Daniel Lieberman studied 5 different groups of runners, including some who had never worn shoes and others who had always worn shoes but ran barefoot. He evaluated their footstrike patterns as they ran at an average pace of 5:00/mile on a track fitted with a forceplate. The study concluded that those who had never worn shoes ran with a forefoot strike pattern, implying there would be a difference in the running style of people who wear shoes. The study also showed a decreased rate of loading and lower collision forces in barefoot runners when compared to shod runners. However, while the media (need reference) boldly claimed, “running barefoot was less likely to cause injury as a result of the lower impact forces it caused,” the article concludes with a more accurate statement, “controlled prospective studies are needed to test the hypothesis that individuals who do not predominantly rearfoot strike either barefoot or in minimal footwear, as the foot apparently evolved to do, have reduced injury rates.”
A more recent study published this January evaluated the footstrike patterns in a different group of Kenyans. Though this group is not known for distance running, they are still physically active and, like the participants in the earlier study, do not wear shoes. Similar to the 2010 study, these runners ran barefoot along a track fitted with a forceplate but at a comfortable, distance-running pace, averaging around 8:00 per mile. Contrary to the results of the earlier study, 72 percent landed on their heels, 24 percent on the midfoot, and only 4 percent on the forefoot. However, when the participants were asked to run at a sprint, many landed closer to the forefoot while only 43 percent landed on their heels. The results of this study seem to indicate that pace may dictate footstrike patterns more than choice of footwear.
One interesting observation that may surprise some is that running barefoot does not necessarily create a forefoot landing pattern. In my assessment of hundreds of runners over the years, I quickly learned that this commonly held belief is false. Many runners who think they are landing on their forefoot are actually landing in the middle of their foot or even continuing to strike heel first. Another important consideration when working with injured runners or those interested in trying barefoot running is that while loading of the knee is decreased with a forefoot landing, loads and the foot and ankle are actually increased. This may be a reason why someone attempts to modify their landing pattern, but the recommendation must be specific to the runner, depends on many other variables, and should only be made after a thorough assessment by a qualified professional.
TherapydiaSF offers running analysis through our RunRx program. Call 415.765.1502 or email firstname.lastname@example.org for more information.
Hatala KG, Dingwall HL, Wunderlich RE, Richmond BG (2013) Variation in Foot Strike Patterns during Running among Habitually Barefoot Populations. PLoS ONE 8(1): e52548. doi:10.1371/journal.pone.0052548
Kleindienst, F.I., Campe, S., Graf, E.S., Michel, K.J., & Witte, K. 2007. Differences between fore- and rearfoot strike running patterns on kinetics and kinematics. International Society of Biomechanics in Sports. Ouro Preto, Brazil.
Lieberman, DE, Venkadesan, M, Werbel, WA, Daoud, AI, D’Andrea, S, Davis, IS, Mang’Eni, RO, Pitsiladis, Y. Foot Strike Patterns and Collision Forces in Habitually Barefoot Versus Shod Runners. Nature. 2010; 463(7280):531-535. 12.
…invests in continuing education- While the majority of states require continuing education credit for continued licensure, some therapists complete only the minimal requirements while others seem to spend every weekend taking courses! It is reasonable for a patient to inquire about the therapist’s interest in educational topics. Chances are the PT will be excited to talk about their latest course.
…considers the whole person. An injury is very rarely limited to the specific joint or muscle that hurts. A good therapist treats not only the symptoms, but looks for the cause of the injury and understands how dysfunction in one area of the body may contribute to symptoms in a different location.
…draws from a variety of sources and isn’t afraid to learn from others. Therapists who are willing to collaborate with other practitioners can learn a lot! See this post for further comments on this topic: Lessons Learned
…is directly involved in your care. Some tasks are acceptable to delegate to a physical therapy aide, but only a physical therapist (PT) or physical therapy assistant (PTA) can perform physical therapy. If you only see your PT for a few minutes at the beginning or end of your appointment and spend most of your time doing exercises with an aide or independently, you are not receiving quality care. The foundation of my training and education is my ability to observe dysfunctional patterns of movement and to relate those findings to the patient’s primary complaint. It has taken me a long time to refine my observational skills and the longer I practice, the better I get. Guiding a patient through their exercises provides yet another window of observation and completes my assessment of that person’s problem and is not something I’m willing to delegate to someone else.
…revises or progresses your treatment. If you are not seeing changes in your condition, are doing the same exercises, or receiving the same treatment at every appointment from week one to week six, you need to consider finding a new therapist.
I’ll never forget talking with a good friend who was looking for a physical therapist a few years ago. His doctor had given him a few local names but he wasn’t sure how to choose. So, he picked up the phone and started calling. But, he wasn’t calling to schedule an appointment…he was calling to interview the therapists! At the time, I remember laughing and him and his surprise when I told him pre-interviewing a physical therapist wasn’t a common practice, however I now understand why he felt the need.
How do you choose a physical therapist?
Is the list your doctor hands you the best guide?
Is Yelp the place to go to find the right fit for you?
1. Trust the testimonials of family, friends, coworkers, and other healthcare practitioners. Ask for their recommendation of whom they would visit should they or a loved one need physical therapy. Many people have had a previous experience with a physical therapist. Some remain loyal patrons of one practitioner, while others have been treated at multiple clinics, by several different therapists. Read review sites with an open mind. Many times, negative reviews focus on billing misunderstandings or office policies
2. Understand a PT’s credentials. Most consumers have no idea what the letters behind the therapist’s name mean. I address this in an earlier post found here: Alphabet Soup Don’t be fooled by the number of certifications and credentials listed after your therapist’s name—they often little to do with the quality of the therapist.
3. Establish a rapport. You’re going to be spending a quite a bit of time with your therapist, so it’s helpful to get along, while maintaining a professional relationship of mutual respect. You should feel that your PT is listening to your concerns and involves you in the goal setting process. It is great to find a PT who has similar interests as you, but if they don’t, they should at least be willing to understand the demands of the activities that you enjoy. Although I’m a runner, swimmer, and cyclist, I have treated fencers, ballet dancers, surfers, and hockey players. If you don’t connect with your therapist after the first couple of visits, it’s reasonable to consider involving another in your treatment.
So now you’ve chosen your therapist and begun treatment. When you’re ready to compose a testimonial, what will you write?
Stay tuned for steps to determine if you chose wisely in: One size fits all? Part 2: What makes a good PT? Aren’t all therapists the same?
Are more letters better?
The question brings to mind the popular AT&T commercial currently airing which features a guy in his 30s sitting around a table in a classroom with a group of four kids. He asks similar questions, “Is bigger better?”, “Would you rather be faster or slower?”, “Would you rather have more or less?” while the cameras roll, catching the excited answers of the kids and his deadpan responses. I bet if he asked those kids (or a group of adults, for that matter) if more letters behind a name were better than fewer letters, they would all agree that more is better. But is that really the case? Are the number of letters after a therapist’s name related to their skill as a physical therapist?
No other profession knows their alphabet better than healthcare. Only in healthcare do you find such a mix of letters designating specific licenses, degrees, and certifications extending beyond a practitioners name, often coming close to Twitter’s 140 character count limit. Sitting around the table at the Sports Physical Therapy Section conference in Las Vegas one year, several of my colleagues and I began quizzing one another on just what all of those letters meant. One physical therapist even had a running list he kept on his iPhone where he wrote down every combination of letters he came across after someone’s name. We stumped each other with a few, which made me wonder if consumers were just as confused by all of those letters.
In this month’s edition of Today in PT, writer Terese McUsic describes several different certifications and states, “PTs are increasingly finding that adding specialty designations can increase their patient base and enable them to explore cutting-edge therapies.” John Lowman, PT, PhD, CCS, chairman of the American Board of Physical Therapy Specialties claims that certification can increase credibility in the eyes of referral sources though, from my experience, referral sources rarely know what even the most common physical therapy credentials stand for.
A statement I hear with increasing frequency is, “He’s a DPT.” No, he’s a PT. The fact is, most consumers believe that a physical therapist with a DPT is more skilled than one who earned their Masters of Science or even Bachelor’s Degree in Physical Therapy. I would argue that the difference in degree is more a reflection of how long the therapist has been practicing, since the DPT degree was far less common as little as 10 years ago. However, this is not an article meant to discuss the value of a DPT, but rather to point out that referral sources and patients alike need to be informed about the various credentials after your name, and how those certifications may not only differentiate you as a therapist, but also influence your treatment philosophy and style.
Credential List (special thanks to Bryce Taylor, PT, MS for helping out with this list):
PT-physical therapist (not personal trainer)
MS-Masters of Science
DPT-Doctor of Physical Therapy
DPTSc-Doctor of Physical Therapy Science
DHSc- Doctor of Health Sciences
DHS-Doctor of Health Sciences
CCS – Cardiovascular and Pulmonary Certified Specialist
ECS – Clinical Electrophysiologic Certified Specialist
GCS – Geriatric Certified Specialist
NCS – Neurologic Certified Specialist
OCS – Orthopaedic Certified Specialist
PCS – Pediatric Certified Specialist
SCS – Sports Certified Specialist
WCS – Women’s Health Certified Specialist
FAAOMPT-Fellow of the American Academy of Orthopedic Manual Physical Therapists
FAPTA- Fellows of the American Physical Therapy Association
DMT-Doctor of Manual Therapy
MOMT- Master of Orthopedic Manual Therapy
CSMT- Certified Spinal Manual Therapist
GDMT- Graduate Diploma in Manipulative Therapy
MCSP- Member of the Chartered Society of Physiotherapy
CFMT-Certified Functional Manual Therapist
COMT- Certified Orthopedic Manual Therapist
OMT-Orthopedic Manual Therapist
MDT- Mechanical Diagnosis and Therapy
CMP-Certified Mulligan Practitioner
CSCS-Certified Strength and Conditioning Specialist
CLT- Certified Lymphedema Specialist (not to be confused with Certified Lab Technician)
CPE- Certified Professional Ergonomist
CVT- Canine Physical Therapist (yes, our best friend needs PT too!)
CERP-Certified Equine Rehabilitation Practitioner
CDMS- Certified Disability Management Specialist
LMBT- Licensed Massage and Bodywork Therapist
MMT- Master Massage Therapist
LMT-Licensed Massage Therapist
RYT-Registered Yoga Teacher
CPI-Certified Pilates Instructor (though there is no one Pilates Certification Board)
PES- Performance Enhancement Specialist
HFS-Health Fitness Specialist
ART-Active Release Technique
CKTP- Certified Kinesiotape Practitioner
CGFI-1- Certified Golf Fitness Instructor Level I
Unable to find these:
An oldie but a goodie–using Pilates as assessment and treatment in the rehabilitation of runners: http://ow.ly/jOFmU
I had an ah-ha moment the other day. Ah-ha moments are interesting—I can’t predict when they’ll surface or how powerful they’ll be. The one thing I can always count on, is that they will teach me something I hadn’t considered before.
This particular moment came as I was instructing a patient in a breathing and core muscle activation technique. He and I have worked together, on and off, for the past 5 years for rehab, to wellness, then back to rehab.
As he concentrated on my cues and tried to do as I instructed, he suddenly stopped.
“You know Sydney, this is really frustrating,” he said.
“I know. It takes practice but you’re getting it,” I replied.
Then the ah-ha moment.
“I think you think it’s really great that you’re always learning new things, but for a patient, it’s really frustrating.”
And then I understood.
I had never considered that my excitement about having a greater understanding of the assessment and treatment techniques we employ could be a source of frustration for my patients. What I was teaching 5 years ago, may, in fact, be very different that what I am teaching today. There isn’t a one size fits all treatment approach for a given condition and every day we’re learning more and more.
I do think it’s great that we haven’t figured everything out and we understand more about the human body every day. How dull would it be if we knew all there is to know and that was all there is? Over the course of my 10 years as a physical therapist, I have grown and changed my treatment strategy. While my core philosophy remains the same, my techniques and understanding have evolved as I’ve continued to learn from research, from experience, and, let’s face it, from trial and error. I will continue to learn and quite possibly change how I do things from time to time, in the hopes that I’m creating an ah-ha moment for someone else.
This post has been a long time coming, and I’m not particularly sure why. Perhaps I was worried I might ruffle some feathers, but when I read the recent editorial by Jas Randhawa, DC and DPT student Kyle Balzer, I was ready to write. If you haven’t yet read the post, you should:
PT’s in California are facing a fight in Sacramento that threatens to take away our ability to perform techniques that we have been practicing for years. SB 381 would prohibit physical therapists in California from performing joint manipulation, reserving the right to this technique to licensed chiropractors, physician/surgeons or osteopathic physician/surgeons. I don’t know about you, but I don’t know many physicians trained to do joint manipulation. However, HVLAT techniques are a part of physical therapy school curriculum. See this editorial for more on the history and training of the two professions:
But…I digress. The intent of this post isn’t to discuss SB 381, it is to share a lesson I’ve learned over the past couple of years.
The interaction between chiropractors and physical therapists has often been contentious, but over the past several years, I’ve asked myself if it really needs to be that way. PT’s and Chiropractors (we may as well throw Athletic Trainers into the mix) get so hung up on territory and competition and scope of practice, but the way I see it, it’s not only a waste of time and energy but leads to many missed opportunities for learning.
Some of my closest friends in the rehab world are not PT’s. Some of the people I respect most as clinicians in the rehab world are not PT’s. Some of my mentors are not PT’s. The one thing we have in common is that we’re not afraid to learn from practitioners outside of our discipline. As a result, I’ve been exposed to continuing education courses, have learned techniques that fall outside of the world of traditional PT courses and have become a better clinician because of it. I’ve been fortunate to have conversations with other rehab specialists, been able to discuss complicated cases approached from different perspectives and am a better clinician because of that.
Rather than staking claim to certain techniques or being worried that someone will take business away, we should spend our time and energy learning from one another to improve the health and optimize the function of our patients. Let’s face it, there will always be plenty of people who need our help.
I can’t escape it. My work follows me wherever I go. Everyone always talks about how PT’s get to leave their work at the clinic. Once we’re done with the daily documentation there really shouldn’t be anything that has to be done at home. The one thing no one talks about is how hard it is to take off your PT hat to see the world through different eyes.
It used to be fun. In graduate school we’d be given assignments to go out in a public space to observe people walking and completing daily activities. Now I watch people wherever I am, evaluating their every move. It’s so normal for me that I don’t even realize I’m doing it, much of the time. It’s not until T and I are on one of our epic urban hikes and I’m performing running analyses on every poor runner who happens to bound by, gleefully unaware that I’m scrutinizing their every step and he tells me, in his kind way, that he’s heard enough. It’s even gotten to the point where he calls out mechanics he doesn’t like in runners passing by and sometimes I have to tell him, in my kind way, that I’ve heard enough. Ever the entrepreneur, he recently, and only half-jokingly, suggested I set up a booth on The Embarcadero and offer my services to the scores of runners passing by.
I have, however, begun to see this “problem” as more of a blessing than a curse. I do believe it’s made me a better PT by exposing me to all types of running styles. I didn’t need to read a running magazine a few years ago to forecast the growing popularity of the minimalist shoe. In the past few years, I have seen a noticeable increase in the number of people running without shoes or in minimal shoes, and with that, a rise in the number of runners who come to me with an injury related to running because they haven’t transitioned correctly or may not be appropriate for minimalist footwear. I also now see more runners landing on their toes than I have in the past, independent of shoe type, and while some runners look so natural moving down the road, the effort is palpable in many others.
I feel fortunate to work in a city where running is so popular, a job that involves the rehabilitation and prevention of running injuries, and in an era when research on running mechanics, styles, and trends is constantly emerging. I look forward to sharing what I see and learn…just as soon as I get back from my run.