The Physical-Therapy-Education Bubble-Market

Recommended Reading: November 2016 edition of the Journal of The American Physical Therapy Association. It refers to something I’ve been warning about for the last 5 years: there’s a coming inflection point in our industry that could be triggered by a number of things. One of them is the intersection of declining Insurance Payments and increasing costs of Physical Therapy programs across the US.

The University of Saint Augustine (USA) was recently sold to Laureate International Universities. Laureate – the world’s biggest for-profit educational outfit – intends to transition into a Public Corporation (for ~$1 billion) and list on the NASDAQ. You can read the Initial Publics Offering (IPO) here. Laureate’s IPO comes with enough controversy to orchestrate a rocky IPO. The current cost of attendance at USA’s Florida campus is ~12.5k per semester. For comparison it was about $6k 10 years ago.

Has the cost of anything else (maybe, other than your health insurance premium) increased 100% in the last 10 years?

Have Insurance Payments increased? Both of us know the answer. Insurance payments continue to drop across the board. Some insurance pay so little that PT’s actually lose money by treating folks insured by these particular companies.

There are more PT’s graduating in the US now than ever before.The number of PT programs have expanded across the US. In fact, from 2000 to 2016 there has been a ~25% increase in the number of PT programs. Presumably, this is intended to not only fill the supposed demand for more Physical Therapists, but also because it is lucrative business. The total cost of these programs range from $60k to $188k. There are also more applicants than ever before. And, why not? Based on the Bureau of Labor Statistics, the demand is expected to grow at 34% per year.

Combine the growing number of PT’s with down-trending Insurance Payments and imagine what you get?

Is it any surprise that salaries for Physical Therapists have (on average) dropped 2.3% in 2015. This is something that I’ve been expecting for the last 5 years. From a completely objective perspective, this is to be expected. Graduates schools are money-making machines. Guess who isn’t making as much money? You guessed it, the graduates.

Yes, the average salary of PT graduates sounds great, but what about those pesky loans? Potential graduates are considering the impact of rising costs of PT programs more & more. The number of law school graduates at lower now than they were 10 years ago. Could this happen to PT? If it could, then what would drive this trend?

Lower insurance payments has already pushed hospitals to hire more Physical Therapy Assistants than Physical Therapists. PT’s do patient evaluations, and PTA’s carry out treatments. I don’t imagine this trend slowing down any time soon.

Student Loan Debt is by-no-means limited to PT Graduates. In aggregate student loans are reaching climactic proportions. The last time something increased at such a persistent trend was the cost of housing in the 2000’s. We all know how that ended: the harshest economic melt-down since the depression.

This time the amount of money involved is significantly higher. Here’s a graphic pulled from


What pricked the housing bubble? Things started going south when the number of defaults exceeded expectations. So, where are we in terms of Student Loan payment delinquency? Well, it’s not very pretty. The number of Student Loan delinquencies has now eclipsed the number of Credit Card delinquencies.


Here’s what makes these delinquencies insidiously worse: student loans cannot be cleared in a bankruptcy. That’s right. What was the “best loan to have” can quickly transition into the worst loan ever. The bubble is set to pop. The question is when.


First, let’s get the obvious out of the way: Explore Income-Based Repayment Loan Forgiveness Programs. Do your research online. Then, talk to at least 5 different individuals about your options and the best course of action for you.

Now the stuff that takes a bit of elbow grease…

You have something truly priceless: YOU. That’s right, your best investment is in yourself. Let’s make this a bit more actionable.

  1. If you are a recently graduated PT, then I strongly encourage you to consider entering a residency/fellowship program to sharpen your clinical skills.
  2. Ensure that you experiencing personal growth on a consistent basis. If the week went by without any change in your thoughts, perspectives, understandings, or performances, then you are doing yourself a disservice. Get better. Now. The most successful individuals have an insatiable curiosity for something. Uncover your curiosity. Explore it as completely as possible. Read everything you can on the topic. Talk to and network with anyone that feeds this insatiable curiosity. I was (and am still) very interested in sharpening my Manual Therapy skills. I also have a couple other curiosities that I’m fostering and exploring right now.
  3. Make sure that you work for someone you admire. This is especially important in your early professional years. Nothing beats having a strong mentor who guides you in a direction that will likely skirt the pain of monotony and stunted professional growth.

If you are working for a company, then make yourself indispensable.

  1. Learn the company’s ecosystem inside and out. What drives the company and it’s leaders? How can you add fuel to their drive?
  2. Volunteer your time and efforts to take on additional responsibility. This has the dual benefits of learning a new role and embedding yourself in the execution of these roles. So, when they need someone to fill a similar role guess who they’ll turn to? You.
  3. Put yourself in the owner’s shoes. Look at the entire clinical operation from the perspective of an owner. Make decisions (as little as they may be) as if you are the owner. Got an idea to help the clinic owner spend more time away from the clinic without worrying about the day-to-day clinical/administrative routines? Lay it out for him to adopt. Time is valuable to everyone. Be the individual who makes it clear that you are the one who is saving the company and it’s administrators time and money.
  4. Once you’ve managed to pull-off steps 1-3 you’ll have the leverage to increase your paycheck or even better: get on a path to generate your own income.


CEU Review: DN-1 & DN-2


I recently attended DN-1 & DN-2 by the Spinal Manipulation. The courses were fantastic experiences and have provided me with new means of addressing a variety of conditions in the clinic. Both courses surprised me on two fronts:

1. The Research. I wasn’t expecting so much time spent on discussing the research and how it guided their approach. The amount of research presented simply blew me away. Research is research regardless of which geographical region of the world it was done and in which professional journal it was published. And so, they pulled research from all over the planet and thought a decent variety of disciplines. This was strangely refreshing. The lectures were quite heavy on the current relevant research; and, it was presented fairly in that both positive and negatives were mentioned. I don’t know about the nuances & specifics of these studies, but the fact that they exist and haven’t been explored in other courses is very interesting.

2. Pain Science Lectures. Yes, I know what you’re thinking…it’s a dry needling course and they’re presenting lectures on pain science? Oh, yes they did. The phenomenal lectures on pain science as it relates to Dry Needling also caught me completely off-guard….in a very good way! I gotta admit: pain science talks in both courses were in-depth on biochemical and mechanical levels as related to dry needling. It was fantastic and convincingly presented. Very convincing. Tommy presented a very detailed & balanced lecture, and Ray bled passion during his lecture.

Now onto specific critiques on the courses themselves, as well as recommendations for future attendees.

The Negatives.

About 40% of the manual was summaries of research reports. While this provides a nice foundation of research on which to base Dry Needling treatments, it could easily be converted into a PDF to be emailed and downloadable to course attendees. Another issue with the current manual (DN-1 2016) is that it didn’t always correlate with the material presented. In other words, material was presented that wasn’t in our course notes, and there was no way to obtain an updated manual. Why? Apparently the new manual wasn’t yet approved for publishing. It would be fantastic to make this information accessible to 2016 course attendees (with a reduced price) when it is available. Maybe you could save paper and simply email/download it in PDF form; printed manual could be an extra charge.

The manual had a couple more short-comings. 1) There was very limited space to take notes. 2) The semi-standard protocols weren’t to be found; however, there is ample instruction on palpation, needle placement, and needle technique. It would’ve been nice to have drawings/pictures of the protocols alongside written instructions for future reference within the manual itself.

When it came to lab time, there was often ran into extremes of either excessive or short practice periods. This was the first Dry Needling course for a number of attendees, and spending a little longer on basic needling practice would’ve been more beneficial. Then again, maybe I was just too slow to get comfortable before moving on to labs 2 or 3. DN-2 did a much better job of managing lab time.

Finally, there should’ve been more time spent on the technicals of employing Dry Needling in the clinic – things like how to bill insurance for it, how it’s incorporated into a cash practice, orchestration of Dry Needling into the Plan of Care to address questions of stretch after/before or skip exercising entirely. All these items should be addressed up front and as clearly as possible. I had these questions addressed in DN-2 by asking the instructor during lab time. Be sure to ask this question to multiple folks – instructors & other DN practitioners.

Some Tips & Recommendations.

Take lots of pics from a variety of angles – at least 2 different angles. This will allow you to get a better appreciation of needle placement when you’re practicing it on your friends, family, and coworkers after the course.

If you’re a visual learner like me, then it might be a smart idea to sketch out the lab demo with all the insertion markings. It might also be useful to re-create this on your own after the course is over. This way you feel more confident about inserting the needles, and know exactly what you’re doing before you start poking your friends, coworkers, and/or family members.

Let’s stick with the lab demo for a bit longer. As I mentioned earlier, the course manual provides very little room to take adequate notes. So, it’s a really good idea to jot down instructions/sketches during the lab demo into either a separate notebook or sheets of paper. Using a clipboard with unruled sheets of paper works best for me. This allows freedom to sketch and jot down info as it suits my visuals without the constraints of ruled pages.

Consider reviewing the relevant anatomical regions prior to taking the course. Here’s how I would’ve done it: cover the insertions of major/important muscles and their innervation, trace major nerves (for DN-1 think brachial plexus), and, finally, roughly familiarize yourself with the “spaces” (for example, the quadrangular space) that are created by the framing muscles and/or other structures – no need to be very meticulous about this, just consider the obvious ones.

Finally, bring some cash. They tend to supply needles like your grandmother would supply dinner items: better too much than too little. This allows you the opportunity to purchase some needles right after the course and start practicing right away. $50 worth of needles should be a nice start.

The Positives.

Their conceptual application of combining spinal manipulation and dry needling certainly peaked my interest. It made me want to explore these “segmental effects” deeper on my own prior to taking a spinal manipulation course. I really appreciate the work behind creating these protocols (much of which was lifted directly from research articles).

Both instructors were knowledgeable, presented the material well, AND presented it fairly. They pointed out studies that showed both sides of the argument. Their perspectives on utilization of the literature was refreshing and made me open my eyes a bit more toward how some (many?) folks view the literature through tainted lenses while wearing blinders. 

This course provided me with incorporable content and manual intervention options that can dove-tail nicely with my current clinical framework. While I don’t think wearing the “osteopractor” label is in my future, the concepts were intriguing and definitely warrant more of my curiosity.

Final Take.

I came away from this course with much more appreciation of an intervention that I had ignored just 4 years earlier. Dry Needling seems to have the potential to address multiple fronts at once: save my hands, access structures that are difficult to reach/treat with manual palpation, provide another route to address chronic pains, and provide me with another differentiator with which to market my services for the benefit of my future clients. Good content. Engaging instructors. Worth the time.

Fund #GetPT1st Now!

Many of us have enjoyed the benefits of the efforts of Sean Hagey in coalescing the profession behind #GetPT1st. Some folks were a bit skeptical about it in the beginning, but their skepticism faded as #GetPT1st stayed focused on its message and continued to deliver content that you, I, and our fellow PT’s have shared with colleagues, friends, and family.

Here’s the crazy part: Sean managed to rally the profession while working his regular job and devoting extra hours (and finances!) to the #GetPT1st campaign…his “pet project”!

Let’s rally behind Sean. Check out his video and donate by clicking here.

Who could have predicted #GetPT1st 5 years ago? Certainly not me. #GetPT1st turned into a powerful medium to spread the value and power of physical therapy, and I strongly encourage you to take part in the movement.

What’s not to like? Do it for your patients, do it for your profession. This might just be the most fulfilling money you’ve spent is some time.

Join me in supporting Sean by funding #GetPT1st here.


Premature Accumulation

I once heard a well-known founder of a Physical Therapy specialization certification program state that some clinicians who passed the Certification Exams prepared merely for the exam, and the process of preparation didn’t necessarily make them better clinicians. This made me wonder about those individuals who have accumulated a string of acronyms after their name, but weren’t able to efficiently integrate their achievements. It also reminded me of those clinicians with 1, 2, or no certifications who applied their learnings and are, consequently, more integrated & effective in the clinic.

Letters, titles… For what purpose? Why & for what goal? How has it changed you & your outcomes?

Most clinicians sacrifice time & energy to attain their titles with the intention of sharpening & expanding their clinical skills with the goals of achieving better patient outcomes, and, consequently, greater job satisfaction – among other things.

The decisions of which philosophy and framework of practice to pursue often bottleneck down to whether or not “the juice is worth the squeeze”. “The Juice” is usually some blend of curiosity, cost, continuing education credits (poor reason, but it is unfortunately the only reason for some), and clinical application.

One route some clinicians travel involves certain Clinical Specialties requiring sitting for a computerized exam. One example is the OCS – Orthopedic Clinical Specialist.

Allow me to rant about the OCS for a bit. Feel free to skip ahead…

The OCS is a regurgitation of dated material. I know this to be true because I was preparing for it last year. Although I decided to put it off until some time in the future, I appreciate the amount of time & effort it takes to memorize the required information for the test. Now, why anyone would want an OCS rests mostly on 2 legs: 1. Public Perception 2. Requirement for APTA Credentialed Residency programs. I find both of these reasons false & inadequate. Let me explain.

When it comes to public perception, it misleads the public into thinking those without an OCS are incapable to evaluating and addressing orthopedic concerns. This is blatantly false considering that a majority of our training in PT school is geared toward orthopedic assessment & treatment. Moreover, memorization and regurgitation DO NOT equate to better clinician reasoning skills. This might be one reason many (but, not all) folks are not better clinicians after attaining an OCS.

As it pertains to APTA Credentialed Residency Programs, the last thing you want as a requirement is rote memorization. It should be geared toward clinical reasoning and patient outcomes. An OCS does a mediocre job on this. How can studying for 1 weekend exam compensate or replace the achievements/efforts of year(s) of dedication and practice? It simply can’t. However, it is a nice recurring revenue generator to require Mentors have an OCS in order for a Residency to be APTA credentialed.

Given the benefit of retrospection and conversations with colleagues who have taken a fair number & variety of Continuing Education courses, I feel fairly confident with what I’m about to say.

If the contents of the course do not add to your clinical effectiveness or efficiency, then it probably wasn’t worth your time & investment. Additionally, if it didn’t inspire you to become a better (how ever you define better) Physical Therapist, then it most certainly wasn’t worth your time.

Maybe you’ve just experienced a life-altering Continuing Education course, and you’re excited about representing a movement that drives you to practice at the peak of your licensure. Now you’re nervously excited about the certification exam and are wondering if you really should pursue it.

Ask yourself: What are those letters after your name worth to you? To your patients?

Maybe the answer is, “those letters mean nothing to me. All I want is to learn the content, help my patients, and improve my clinical practice.” If that’s your response, then congratulations! You just saved yourself a shitload of stress and expenses by avoiding the brain-bending experience of studying for a certification exam.

If your response is, “I want to know that I’m applying the content effectively and at the highest level possible” then the letters might be worth the effort. If you believe the letters will provide you with leverage in clinical outcomes and evangelizing the Physical Therapy Gospel of the potential to live functional lives with zero-to-minimal involvement of pharmaceutical drugs and surgery, then the juice might be worth your squeeze.

The practicality of accumulating letters can distill down to a signaling mechanism that shouts “I know what I’m talking about!” Or maybe it says “I still haven’t found what I’m looking for!” (say it again with your best Bono impression). Maybe s/he is a genuinely curious individual with a passion to learn & grow as a professional.

Me? Well, I would go with the “Bono option” – I still haven’t found what I’m looking for… In retrospect, my certifications (so far) have been a boon to my clinical practice and experience. It’s been a cumulative and catalytic accumulation that provided me with a foundational conceptual framework on which I can mold my future professional growth.

I’m sure you’ve met individuals with an alphabet soup of letters after their name who do not practice at the top of their licensure/certifications. Even worse, they might have completely abandoned the teachings of these certifications, but continue to grace their business cards with these aching acronyms. False advertising, perhaps. Or… a premature accumulation of efforts with nothing to show for it other than limp advertisement.

A possible cure for this premature accumulation: finding a framework that you believe can last the test of time. This is significantly more valuable than a random accumulation of certifications.

P.S. – As many of you are well aware, I enjoy reading books. Early March 2016 saw the first edition of my Quarterly Readings Newsletter. It is an update on some of my favorite reads of the quarter. Email me with “I love to read!” in the subject line, and I will add you to the email list. 

Mea Culpa

2016 exploded onto the scene, and there’s no looking back. A couple milestones await for me in the next few months. One of them is a Physical Therapy Class Reunion. No, I’m not going to mention how many years have passed, but let it suffice to know that I’m more excited about our profession now than ever.

Emotion and Experience were vital components to my growth as a Physical Therapist thus far, and they will likely continue to play their vital role for the foreseeable future. Emotion and Experience are also vital components of our growth as human beings. Perhaps the Environment we grew though, and will continue to grow in/through, is an equally (or more) significant determinant in our Emotional and Experiential growth.

Either way, here are some thoughts that are crossing my mind in this period of critical change. I hope you find them as useful as I do.

Don’t shy away from asking yourself “What the fuck am I doing with myself?” Don’t shy away because there’s no wrong answer to this question. The reality is a very small percentage of you (no, it’s probably not you) are following a life-plan penciled perfectly in high school. Asking yourself this question is more about self-correcting than proselytizing. It’s a series of continual adjustments based on your long term vision.

Entertain yourself. It’s more fun than you can imagine.

Don’t shy away from intentionally disappointing someone if you know that there’s a high probability that the bread is about to fall jelly-side down. This doesn’t mean you have to be memorably offensive. Saying “no” effectively without crushing relationships is a skill worth developing.

Don’t worry about what people think of you. This simple life-hack will free your mind more than almost anything. Also, it clears your lens on life by allowing you to see how clever or transparent people truly are. You’ll be tempted to gain and keep the recognition of those smart people you think you identify with. The reality is you’re probably fooling yourself into building a self-image that is ultimately painfully unsustainable.

If you aren’t any closer to your desired lifestyle this year than the last year, then hop on that horse and make it happen. It’s incredible how 1 year turns into 3, and before you know it you’ve been treading water…at best. This simple fact will continue to boggle your mind in real-time and in retrospect. Some smart guy once said: “The best way to predict the future is to invent it.” He might be right.

Health is wealth. Yup, the oldies were right. Health truly is wealth.

Consider the impact of all the non-renewable resources in your life. “Time” deserves to be very high on that list.

One of the few constants other than Time is Change. Don’t be afraid to change. It’s going to happen anyway, so why not take the wheel rather than handing it off to people you don’t really know – employers and their management teams, especially their management teams. Don’t be afraid to take the wheel and change lanes.

Sleep. Sleep because feeling well-rested is a glorious feeling.

Don’t “grow up”. I’m still not sure what that term means, but avoid it as much as possible. The “grown-ups” tell me it’s overrated.

Be nice. The world is getting smaller every year…which means Karmic paybacks happen quicker and/or with greater intensity today than yesterday.

Simplicity is priceless. If you can’t explain what you’re doing to a 12 year old, then you’re carrying around unnecessary baggage. Lighten the load, and clear your plate down to the bare essentials. At the very least, simplicity makes it easier to smile.

You can’t outrun your fork.

And, if you’re riddled with indecision, then apply the Regret Minimization Framework.

As many of you are well aware, I enjoy reading books. Early March 2016 saw the first edition of my Quarterly Readings Newsletter. It is an update on some of the more interesting reads of the 3 months preceding publication of the email Newsletter. Email me with “I love to read!” in the subject line, and I will add you to the email list. 

How to Study for Physio Specialty Certification Exams

Having been through 2 certifications (so far) in my career, I thought I should provide current & aspiring certification candidates a birds-eye peek into my study routine. Each section listed below can become more involved based on your learning habits and learning strengths. So, if you have thoughts, questions, or opinions on any of them, then feel free to leave a comment to help make this a more productive post.

Certification can be quite stressful and overwhelming. You have to give it everything you’ve got. Might as well use all 5 senses! Here we go…


  1. If you can rent DVD’s or stream videos of the course, then definitely do so. You’ll become more familiar with the techniques and clinical reasoning process by watching the instructors. Not only will this help you didactically, but it’ll also get you used to seeing the teachers who may be testing you. This way you’ll be (relatively) less intimidated when you’re in the testing room with him/her. Visual familiarity calmed my nerves by giving me a read on their facial responses and general movement patterns. Not only did this help me respond better during testing, but it also allowed me to get a sense of their psychological atmosphere, which cued me to choreograph my performance to fit their disposition at that particular period of time.
  2. Another way to utilize your visual input to sharpen your skills is by watching your study partners. For this reason alone, it might be worth your while to work in a group of 3. Another option is to use mirrors. Since one major way we learn is by watching others, it is important to choose an appropriate partner for visual feedback.
  3. Diagram everything as much as you can. I’m a visual learner, so this helped me immensely. Sequences, lists, groupings… even the page of contents.


  1. Audio record the DVD’s or streaming video. Put them onto your iPod or smartphone so that you can access them quickly during your commute or review it audibly before bed.
  2. Record yourself reading or reasoning through the manual. This would be a much more personalized means of audibly reviewing material.
  3. Verbalize the material by yourself before talking it out with your study partners.

Smell & Taste.

  1. Build routines into your study. A certain coffee or tea. The smell of a location: bookstore, study partner’s home, etc. Then, imagine or recollect the same smells or tastes as you’re reviewing materials independently or with a study buddy. Make a joke about it. Connect it to whichever material you’re having a tough time recalling. The more sensory neurotags you create around your study content, the better the odds of performing under pressure.
  2. Have some dry finger foods while you study. I have no idea why this made the study process more productive, but I covered more ground and made sharper connections while my hands kept popping food into my face.


  1. Kinesthetic awareness. If your certification includes a hands-on portion, then you should develop an awareness of what it feels like when a technique is done correctly and incorrectly. Feel for the sense of effectiveness both as the tester and tester’s partner. Be able to tell when your partner is on the right track when s/he is working with you. Provide constructive and precise feedback. The more precise your feedback, the sharper you develop your kinesthetic awareness. This in-turn can guide your performance during testing.
  2. Work on as wide range of people as possible. If possible, work on either the instructor and/or others who have recently passed the certification. Also, have them work on you so that you get a physical sense of how it feels when done right, and how they use their body/hands/etc.
  3. Re-write the manual in your own words. I know. It’s a bit strange to put this under “touch,” but the physical act of writing somehow helped coalesce the material better for me. I tried typing, but it wasn’t as effective. Also, writing allows you to draw arrows, smiley faces, or whatever else you’re into, to make connections and highlight important sections requiring further attention.

As, mentioned earlier, you can make this a more productive discussion by leaving helpful advice in the comments section.

Good Luck!


P.S. – As many of you are well aware, I enjoy reading books. Early March 2016 saw the first edition of my Quarterly Readings Newsletter. It is an update on some of the more interesting reads of the 3 months preceding publication of the email Newsletter. Email me with “I love to read!” in the subject line, and I will add you to the email list. 

Interview with Ramona Horton

Ramona Horton, MPT is a pelvic physical therapist who teaches for Herman & Wallace Pelvis Rehabilitation Institute. She is passionate about the impact of visceral and fascial components as they relate to functional activities.

If you share my curiosity about the impact of viscera on your patient’s function, then you’ll enjoy this interview as much as I did.

Connect with Ramona on twitter @PelvicViscera. Enjoy!

Let’s start this off at the beginning of your day. What do you usually have for breakfast?

During the week always the same thing, a small serving of mixed raw nuts.  I am a protein gal the nuts manage to fill me up and give me a good slow burn until lunch time.

What led you into the wonderful world of Physical Therapy?

My own knee surgery at the age of 16 combined with the fact that a career in the medical field was the only thing that attracted me.  I was contemplating the nursing field, and took a job as a CNA in order to get exposure to health care, rehab just became the obvious choice. 

How did you get interested in Pelvic Dysfunction? And, how did this lead into your passion for Visceral Mobilization?

My PT training was through the Army-Baylor program, I was all in for orthopedics and sports medicine until October of 1990.  I gave birth to my second child, an adorable but behemoth  9lb 9oz baby boy.  His delivery, a VBAC (vaginal birth after cesarean) was very traumatic on my pelvis, I sustained pudendal nerve injury and muscular avulsion.  When I queried the attending OB-GYN about my complete lack of bladder control his response <insert righteous indignation here> and I quote “do a thousand kegels a day, and when you’re 40 and want a hysterectomy, we’ll fix your bladder then.”    As for the desire to study visceral mobilization, that reflects back to my PT training through the US Army which was 30 years ago, when the MPT was just getting started.  It was an accelerated program to say the least, we received a master’s in physical therapy with 15 months of schooling.  Given the very limited time line, which included affiliations and thesis, the emphasis in our training was on critical thinking and problem solving, not memorization and protocols which in 1985 was not the norm.  I can still hear the words of our instructors “You have to figure it out, I am not going to give you a cook book”.  

Following my initial training in the field of pelvic dysfunction 1993, as I started treating patients I had a problem, I could not wrap my head around how I was to effectively treat bowel and bladder dysfunction….without treating the bowel and bladder?  I knew that there was more to this anatomy than just pelvic floor muscles and the abdominal wall, but at the time that is what was being treated.  Once I started learning VM principles and applying the techniques to my patients I saw a vast improvement in my outcomes.  I realized that the visceral fascia is a huge missing link in this field and that somewhere along the line the physical therapy community forgot one simple fact.  We are not hollow, the visceral structures attach to the somatic frame through ligaments and connective tissue and have an influence on the biomechanics of said frame.  

Why is the adoption rate of Visceral Mobilization so low amongst Physical Therapists who aren’t pelvic specialists?

Most likely several reasons, first they do not deal with dysfunctions that have visceral structures involved the way pelvic health therapist do.  The second being a paucity of higher levels of evidence on the effectiveness of VM for musculoskeletal conditions.  The third and most difficult issue to deal with is the broad based claims that VM can be an effective treatment for issues ranging from acute trauma to emotional problems.  One website called VM “bloodless surgery”.   The problem simply is when anyone purports their technique to be a virtual panacea for all that ails mankind, without adequate evidence to back up the claims, the clinical world raises its collective antennae.  These critical remarks are coming from a practitioner, published author and educator in the VM field. The reality of evidence based medicine is talk is cheap, research is not.

Could you share an anecdote/story of the effects Visceral Mobilization in clinical practice?

A male patient many years ago that was experiencing constant right flank pain that made physical activity almost impossible and the pain increased during urination.  He had been evaluated by the chief of the urology department at the medical school and was sent to me for biofeedback with a diagnosis of pelvic floor dysfunction and bladder-sphincter dyssynergia based on urodynamic testing.  His symptoms began 3 years earlier while experiencing hematuria, most likely due to a kidney stone but that had not been confirmed.  His exam revealed clear cut muscular guarding with tissue changes in his right psoas, quadratus and gross restriction of the renal fascia.  I went rogue, and did not initiate the biofeedback, instead treating his restricted renal fascia which encompasses the ureter.  He returned for his first follow up about a week later reporting that 3 days following PT evaluation and initial treatment, while urinating he experienced a strong sensation in the area that I had been working felt a rush and had immediate resolution of all pain.  The best part is what he told me next “trust me, this was not a placebo effect because I thought you were a quack”  reporting that he was quite irritated that I had not initiated the biofeedback as his urologist had requested and he was planning on cancelling his follow up appointments and going to another therapist.  He was so pleased with the outcome, that he wrote a letter to the CEO of the hospital about his experience, encouraging them to assist in furthering my field of study.  

You’ve just traveled back in time and are sitting face-to-face with your 25 year old self. What advice would you give yourself?

Learn to get over it

Fascial Mobilization has been another touchy topic for some Physical Therapists. Why do you believe Fascial Mobilization is such an important aspect of clinical practice?

Most importantly because fascia is ubiquitous, it is EVERYWHERE throughout the body and it contains a vast neurological network to include nociceptors, mechanoreceptors and proprioceptors just to name a few.  The fascia was that stuff that we all dissected out of the way in anatomy lab so we could learn the assigned structures that soon would have a pin with a number stuck in it that we needed to know for a lab practical.  We need to move beyond the “myofascia” and understand that the fascial system has multiple layers in the body starting at the panniculus which blends with the skin, the investing fascia surrounding muscles and forming septae, the visceral fascia which is by far the most complex and the deepest layer of fascia, the dura surrounding the central nervous system.  All fascial structures, regardless of layer or location have their origin in the mesoderm of early embryologic development.    

Why do you think there are more cases of Endometriosis today than 10+ years ago? Given the hormonal component (estrogen dominance) involved, how do you counsel your patients on what you can do for them, and what they can do for themselves?

I am pretty straight with these patients about their options as far as hormone suppression goes, surgery, pain control and fertility. I also advise them to take a very good look at their household and eliminating endocrine disruptor chemicals in their environment.   

Favorite books & authors? (these don’t have to be PT-related, but they certainly could be…)

I am hooked on The Outlander Series by Diana Gabaldon

Tell us about your relationship with Herman & Wallace. How did this start? And, what are the biggest challenges to creating a course?

I did my initial pelvic dysfunction training with Kathy Wallace and Holly Herman in 1993.  While  attending a course on pudendal neuralgia in Seattle in 2007 Kathy Wallace was there as well.  We got talking about our practices and as the topic of VM came up, when she learned of my level of education on the subject, she asked me to consider writing a course for H&W.  

For me, the biggest challenge is trying to decide what information to leave out.  I am terrible about trying to cram in way too much content, too many techniques and too many clinical pearls in a limited amount of time.  Students can only absorb so much, and I have a tendency to overwhelm them with information.

If you could have dinner with any famous individual who is no longer with us, then whom would you choose? Why?

Sorry, I can’t pick one.  For me, the great dinner would be with Jesus, Mohammed, Gandhi and the Buddha and I would ask them how they feel about mankind killing each other in their name and how we can make it stop.

Ramona, thanks for this great interview!

Connect with Ramona Horton on twitter @PelvicViscera

Hope you got as much out of this interview as I did.


P.S. – As many of you are well aware, I enjoy reading books. Early March 2016 saw the first edition of my Quarterly Readings Newsletter. It is an update on some of the more interesting reads of the 3 months preceding publication of the email Newsletter. Email me with “I love to read!” in the subject line, and I will add you to the email list. 

Flashback: Year 2 of Interviews!

It’s time for a flashback into 2015. Once again I’ve been lucky enough to Interview some incredible individuals. A big “THANK YOU” to my interviewees and readers. These interviews gave me a kaleidoscope of perspectives and practical advice on life & work…among other things! Check out 2014’s Flashback.

Below are some memorable quotes. The links will take you to the respective complete interview.


Scott Epsley:

I came across the concept of “Surpetition” by Edward De Bono.  The premise is that one doesn’t attempt to compete with others, but focuses on being better than oneself, while still being aware of what your competitors are doing.  This has since become not only my philosophy in business, but in life.

Mike Horsfield:

Failure needs to be embraced in an organization as a great learning opportunity.  Do something!  Act!  It is too easy to be paralyzed by analysis.  If something feels right and the potential downside is not fatal then go for it and learn from the experience.

Kendra Gagnon:

The rise of high-speed internet, mobile devices, and WiFi has brought the possibilities of “anytime, anywhere learning” to almost everyone and gives instructors the opportunity to use video to create and share more engaging learning materials and provide synchronous, real-time learning and interaction.

Dr. Justin Dunaway:

We know nothing… or at least very little. There are so many beliefs and concepts out there that people cling to so strongly. They dig their heels in, defending certain concepts as if they were solid ground. There are a multitude of different camps in our profession and so many explanations for the same occurrence or outcome that are so different. And when we dare to venture outside of our profession, we are challenged with entirely new sets of justifications and approaches to the same concept that are again so different.

Alyssa Tait:

I continually make discoveries – new paradigms, new insights –  that I think are going to revolutionise my practice, and they do…but the longer that goes on the more in awe I am of some of the experts in these innovative fields, especially in functional medicine, and I choose to consolidate my role as more of an “integrator” of fields than a top expert in any of them – and I would see this as my particular strength.

Dr. Stacie Fruth:

So many studies that do get published have such narrow inclusion criteria that it’s quite difficult to apply the results to any of my patients (my folks have lots of comorbidities and biopsychosoical issues). So, it can be incredibly frustrating to create a study that tries to capture typical clinical populations. I think this is why so many studies that were once considered gold standards now can’t be reproduced – that fascinating variable called “the human being” is awfully tough to control.

Dr. Karen Litzy:

Know what you are good at and what you are not good at.  If something is not in your wheelhouse and/or you do not enjoy some part of the your business then outsource it!  I did not do this enough in the beginning and I regret that.  Even if it means spending more money (which it most certainly will) it frees you up to concentrate on the things you are good at and this will only strengthen your business.

Chris Johnson:

Take money, sex, and power out of your decisions and you will never make a bad one.

Justin Moore:

Slow down to listen and learn. I was at times in a hurry when I was younger and didn’t take the time to observe, learn, and listen to some experienced leaders in the profession and public policy. Looking back the time spent talking with friends, listening to leaders, and learning by observing how one approached an issue, carried themselves and developed their thoughts was never wasted. Those opportunities always centered me and prepared me to be more aware, more knowledgeable and more engaged but I didn’t always seek them or appreciate them at the time.

Michael Mullin:

Take pride in the work you do and do not be swayed by what you believe others may think of you.  It is easy to get hung up with the societal pressures of acceptance, not wanting to stand out, or even compliance.  Life is too short to not take full advantage of everything it has to offer. Work hard and have fun….

Thanks for another memorable year!

Best Wishes.



Twitter Interview!

I decided to close out 2015 with an interview with questions from twitter.

Check it out!

@therapyinsiders: Which Bourne movie was your favorite and why?

This is a tough one. I really enjoyed all three – yes, I’m excluding the one with Jeremy Renner. I’ll choose my favorite Bourne flick based on 2 things: villains and motorcycle scenes. And the winner is… The Bourne Ultimatum! Desh was the perfect roleplaying villain. I loved his fight scenes which seemed like a mix of Wing Chun Kung Fu and Capoeira. The motorcycle scenes were incredible! Watching Bourne ride through Tangier at a fast clip while negotiating daunting street obstacles in narrow alleys was thing of beauty.

@MattBobman: Biggest professional regret and/or failure?

I should’ve casted a wider net in my first few years as a PT. While I was lucky enough to have a role and gain experience on both sides of the business, I could have developed a wider view and started developing a Framework of thinking and action much earlier than I did. Here’s what I would recommend:

Experiment enthusiastically with different approaches of treatments.

Connect with a wide variety of professionals within driving distance and through social media.

Take more risks in terms of: creating new products, developing new platforms, re-inventing yourself.

Read a kaleidoscopic selection of books and authors. And, follow Jeff Bezos’ “Regret Minimization Framework.”

This is a great question! Jeff Goldblum – not because I look like him, but because he plays some interesting roles and for some reason his personality resonates with me. Anyway, check out his Top 10 Moments:

Anonymous: When are you going to Haiti with STANDHaiti?

Hopefully some time in 2016. In the meantime, check out STAND’s 2015 Re-cap and this inspiring story.

Doesn’t matter. Just get moving in anyway that you enjoy – play sports, lift heavy things, dance, run, yoga, climb things, conquer things… If I were forced to pick team or exercise, then I’d say go with whichever fits your personality the best.

@DrBenFung: If you could change one thing about the person that annoys you the most, what would it be?

This is a tricky one, and here’s why. If you find someone that annoying, then odds are this person means something important to you. Maybe s/he is someone you want to hold onto and have agree with you. Maybe s/he is someone you want to impress. Maybe you believe changing him/her will make your professional or personal life complete. Here’s what I think: maybe you should work on yourself & your environment before you think about think about changing someone. Changing someone is often a futile effort. Changing yourself is a much more powerful endeavor with compounding returns over time. Book Recommendation: The Education of a Value Investor by Guy Spier.

@Eric_in_AmERICa: If you could put a billboard anywhere in the world where would it be and what would it say?

@rupalPT: what is your pride and joy?

Spending time with my family & friends and providing as much value to the world as I can are my prides & joys.

Careful whom you marry.

Explore wider and faster. Do not ignore your instincts. Learn widely from outside the field of Physical Therapy. You need a framework – work hard at developing a foundational framework on which you can build further. And, don’t fear failure. Just make sure you learn from it. You might get more out of my interview with Dalin.

Hello. My name is Indigo Montoya…

Thank you everyone! And, best wishes for a fantastic 2016!

Connect with me @Cinema_Air

Interview with Michael Mullin, ATC, PTA, PRC

This interview is a first: my first interview with a Physical Therapy Assistant. Michael Mullin is one of my favorite follows on twitter because he makes me view the human movement system through a variety of lenses.  We dive into his unique and varied perspectives in this interview.

While concepts from a PT Continuing Education called PRI are mentioned, I want it to be clear that this interview is not meant to promote nor support PRI.

One last thing:  Check out Michael’s blog for larger conversations on topics touched on in the interview.


Let’s start at the beginning…the beginning of your day. Do you have a morning routine? What do you usually have for breakfast?

I am an early-riser as I find myself to be very productive early in the day–like, really early.  I typically get up, have some coffee (coffee is always, not typically) and check messages from various sources (i.e. e-mails, Facebook, Twitter).  I look forward to when my wife gets up, I like to make breakfast for my daughter and often send a text to my son at college.  Breakfast?  Usually eggs with some quinoa, potato or rice, maybe some leftover roasted vegetables as I’m a bit of a veggie-holic, followed with some oatmeal with nuts and seeds.  I have a lot of food allergies (celiac disease and therefore very strict gluten-free for 15 years, no dairy, very low sugar/yeast/additives, etc.) so I actually eat quite healthy.  With all my dietary considerations, it certainly helps that my wife is a dietitian.

You’ve come across a variety of concepts to assist in understanding and applying various approaches & treatments in the clinic. What are some of your favorite?

First and foremost, understanding the role that the respiratory system has on our body.  Having the ability to take the involuntary act of respiration (gas exchange) and be able to voluntarily modify it through ventilation training (air exchange) is one of the more powerful tools we have in the management of our organism.  I have been amazed at how establishing volitional control of this can positively–and significantly–affect performance, recovery, muscle tone, joint position, resting heart and respiratory rate, physical and psychological stress, as well as many of our other internal systems.  It is our environment which is often the big driver of the amount and degree with which we lose the ability to effectively manage this, so being able to take ownership of this mostly involuntary action is huge.

From an intervention perspective, without a doubt Postural Restoration® has changed the way that I look at human structure and function.  It is the lens I look through when working with patients and clients.  It is the direction I go to when providing activities, exercises, cueing, as well as providing other avenues of our system to tap into to aid in progress.  That does not necessarily mean that it is the only “treatment approach” or training I do, but I bias my intervention strategies around this methodology.  I feel strongly that our inherent asymmetrical structure and function, the inherent polyarticular chains that the Institute describes, their work and educational programs on how the different systems are integrated and how this influences the way that we move and position ourselves during the day, provides an invaluable roadmap for people to work with.  It is a complicated science, but by the same token, the body is quite complicated as well.

I incorporate the work of other great approaches as well, such as “corrective exercise” interventions (Gray Cook and Lee Burton’s Functional Movement System activities and FMS/SFMA principles), some the principles and reflex mapping of Janda, Lewit and Kolar from Prague School of Rehabilitation and Dynamic Neuromuscular Stabilization (DNS), and definitely good ‘ole fashion strength training!  I feel that a large portion of our population, including our young athletes, are generally weak and as such, have a difficult time negotiating gravity and its affects on our system.  Our society has changed dramatically over the past few decades and we have not developed well along with it.

I am also a big advocate of manual interventions and use a lot of hands-on work with patients and clients as well.  It could be called the Hruska (PRI)-Jones (strain-counterstrain)-Roth (Positional Release Therapy)-Mulligan (MWM’s, NAG’s, SNAG’s)-Johnson (IPA)-Myers (Anatomy Trains)-Weiselfish/Gimmatteo (IMT)-Rolf (Structural Integration)-Chaitow-Trager-Feldenkrais-Leahy (ART) approach.  I use components of manual interventions to supplement a treatment session for most conditions with varying degrees and amounts.  It is also very helpful in being able to quickly mobilize an area if a client is having difficulty feeling something or they are having an issue getting into a position during a training session.  I find it most effective after I have been able to achieve a zone of apposition of the diaphragm, as achieving this ZOA alone cleans up all sorts of tone and positional faults of joints and tissue.

I’ve been blessed with what I feel is an innate sense of touch with the body, (certainly the same can’t be said for my luck with machines), for as long as I can remember.  I am one of six children and growing up we all had to take turns giving my mother a back rub each night.  To this day she mentions how I always seemed to know where to work and how much better she would feel afterwards–and who can argue with the word of your mother :).  While I fully recognize that manual interventions are neither truly reproducible or measurable, I also feel that when I read articles or opinions debating the effects of the application of some of these methods, I have a hard time holding merit in their conclusions with something that helps almost every person I use some of these techniques on.  While I am not suggesting any type of “guru” component, the careful application of hands-on interventions provides–and human touch also helps with–creating a sense of connection, involvement, empathy and other very powerful responses with my patients and clients.

This is one of my favorite posts on your blog. What are filters do you use when reading research with the intent of clinical application.

I am cautious with direct application of studies that are performed on cadavers that provide information related to movement, as things change once it is applied to an organism that is trying to manage gravity, gas and pressure.   It is good information to understand the arthro- and osteokinematics of how things move, in a vacuum, but once the chaos of our environment is added, things change.  

Conclusions that try to create prescriptive (versus diagnostic or prognostic) clinical prediction rules as the way to do something I have some difficulty with, as there are too many variables that cannot possibly be accounted for in a living, breathing system.  It can’t possibly allow for behavioral influences, nutritional components, patterned bias’ and the like.  I mean, maybe they were hung over or had a fight with their spouse, either prior to their involvement in the study or as a patient sitting in front of you on the treatment table.  If a classification-based system were to become the standard, then we will have created practitioners who will not be able to use their ability to modify, adjust or adapt well to changes in a person’s presentation.  Clinical thinking is much different than critical judgement.

Thinking from my Postural Restoration®-based brain, I have some difficulty looking at articles that don’t specify right and left arm or leg, and I am not referring to “dominant” arm or leg.  I firmly believe and have found that our underlying polyarticular chained patterns have a tendency to make us use the two sides of our body differently, so I read critically things which do not glean this information out.  I read them, apply as I feel indicated, but with a discerning eye.

I do believe very strongly in the model that evidence-based practice and practice-based evidence share a place with each in their applications to the clinical world.  As soon as evidence is doing more than just guiding treatment, but is what is necessary in order to be able to render care, that is when I feel we are going to get into trouble.  It is unfortunate that there are those of the mindset that unless it can be validated through research it should not be employed–and I am speaking of health professionals as well as those who dictate payment.  As long as intervention strategies have the least possibility of producing some kind of iatrogenic response, on that particular person at that particular time, then no one should be able to tell a professional they are not allowed to employ that strategy.

You work with a variety of interesting populations including dancers and skiers. Let’s say I’m interesting in working with these populations. How do I make it happen? How did you end up working with them?

First would be to educate yourself on some of the things that are essential to know about that activity.  When I went to work at The Stone Clinic in San Francisco in the mid- to late nineties, the surgeon I worked for was a physician for the U.S. Ski Team as well as a number of dance companies, including San Francisco Ballet.  I had zero experience with dancers and didn’t learn to ski until college, so essentially, through baptism by fire, I had to do a lot of self-education on activities I was not as familiar with–in particular what it took to work with athletes at that level.  I spent time going to dance classes to observe, read trade journals and had discussions with teachers/instructors/coaches, spent more time at the ski mountains observing as well as spending time with experts who were willing to allow me to tag along.  I was responsible for coordinating dry land training camps for the U.S. Ski Team and World Pro Ski Tour so I had to figure out training protocols.  I was responsible for doing pointe screens for Marin Ballet so had to understand what it took to be able to do that.  I feel very fortunate to have been able to have had these opportunities and have been doing similar programs since coming to Maine as well.  

Second would be, as I alluded to above, it is pretty much volunteer work on your own time.  You have to be willing to put yourself out there and put in the time to become an expert at it.  Programs have less and less money for ancillary services so many dance schools or companies would love to have someone willing to help them out or organizations who might be willing to have someone come in to do an inservice or training program.  There can also be a tremendous amount of carry-over as well to other things which have similar movements or mechanics (i.e. ice skating with dancing).

I am able to apply a significant amount of the work I do to most populations and specialties if I understand the essential tenets of those activities and am confident in my understanding of the biomechanics and integration of multiple systems.  For example, if I am working with a ballet dancer who is in for “X” injury, and I watch them at barre or doing some of their movements, they likely have some underlying micro-pathology.  “Micro-patho” is the phrase I use to describe things which have happened to the body over time, or from an event, which creates a laxity, or imbalance, or response, that would not necessarily require surgical or extreme intervention, but does need to be managed.  I then apply activities and cues to address these in their particular situation.  Having the PRI roadmap, for example, to recognize their likely bias’ helps as well.  For example, most dancers like to turn clockwise onto their left leg so it would be easy to think that it is because it is their “dominant” leg, but it is actually due to their ability to use their dominant right leg while it is in close to their body to manipulate and balance them out, create more stability when turning, and also because of their turning bias to the right.  With skiers, patterns dictate–and research has shown–that right footed turns (turns to the left while skiing) produce more force, have easier time to transition into and are smoother, even at the highest levels.  Again, pattern driven.  Being able to use interventions which help to correct this on the base level and then apply it at the activity level is tremendously empowering for these athletes.

Another key aspect is that when you can “talk the talk”, or speak on aspects of their activity in their language, then that is also a huge buy-in for them.  When I speak about inclination and angulation and edging principles with skiers or 1st-5th positions in dance or ask them to do something like releve into passe or a rond de jombe, they realize that you “get it”.  From there, you can even then ask them things about positions, movements or even what a coach or instructor is doing so you can get a better understanding of the activity, as they will be more than willing to provide that info at that stage.  Everybody benefits.

We are biomechanics experts and with that we are able to impart a significant amount of change in how people are performing their activity or art.  I am not going to necessarily coach someone on their sport, but the things I can teach them about how to apply what I feel is best for their bodies from a biomechanical perspective, this will have a significant positive impact on their performance as well.

Favorite PT and non-PT books?

PT books:  Historically, I like, in no particular order:

  • Assessment and Treatment of Muscle Imbalance:  The Janda Approach (Page, Frank, Lardner)
    • Great book looking at the impact muscle imbalance has on on structure, function and movement
  • Positional Release Therapy:  Assessment & Treatment of Musculoskeletal Dysfunction (D’Ambrogio, Roth)
    • As far as I am concerned, the resource to have under your treatment table as after the manual techniques I use based on Postural Restoration®, this is one of the basis’ of my manual techniques.
  • Movement: Functional Movement Systems: Screening, Assessment, Corrective Strategies (Cook)
    • What Gray Cook has done and his views of movement and function are tremendous.  He is also one of the better orators there is out there.
  • Frankly, I spend a lot of time currently reading through my Postural Restoration course manuals.  These are, in my opinion, one of the most comprehensive course manuals out there in describing anatomy, physiology, assessment and intervention techniques, etc.
  • Anatomy Trains (Myers)
    • Thomas Myers has done an incredible job of mapping out and identifying various fascial lines and the influences these have on us.  I also believe that they are also influenced by other factors, but his descriptions and strategies for managing are quite good,
  • Functional Training for Sports (Boyle)
    • Mike Boyle has done groundbreaking work in the field of performance coaching and does an amazing job in this book on providing his methodology to the public.  I am fortunate to call him a friend and have learned a great deal from his work.   
  • I also like PT-ish books which discuss the influences other things have on us such as:


Non-PT books I like a lot are:  

I like books that follow a storyline, but also educate the reader on aspects of the topic they are discussing.  In the books listed, one learns about the space race and the Apollo spaceflight project; scuba and deep sea wreck diving and finding a U-boat within a few miles from our eastern shore; piracy within the fishing industry and the longest nautical chase in history; natural running and influences of a culture on how we function; and meteorology, storms and the influences on our environment.

Given that you’ve been in the field for 25yrs or better, what fads and themes have you observed over the years? Any favorites? Any keepers?

It has been very interesting being part of what I feel is the time where there has been the most significant amount of change and growth in our various industries–from a rehabilitation perspective, medicine, as well as strength & conditioning.  I think back on seeing my first ACL reconstruction patient in 1990 and how that person was one of the first the surgeon did where he did not cast them afterwards, this patient’s slow return back to activity, learning the more accelerated rehab methods and how the insurance paid for months and months of rehab, 2-3 times per week, for about 9 months if I remember correctly.  Certainly things have changed since then on many levels

For me, one of the biggest has been position training and education.  From the upright, stiff posture I learned in school and my early years, to knee position when bending under load and not allowing “knees to go past toes”, to what would be considered a “neutral” spine, there has been a lot of misinformation with the best of intentions.  We are a living, breathing organism that is designed for movement which has had to conform to societal influences that is, frankly, breaking us down.  We should not have to work as hard as we do trying to achieve some good postural position to sit, stand and walk–there just shouldn’t be the amount of muscle activity involved as many of us try to aspire to.  Knees have to be able to go past the toes when loading to some degree, as long as the body is able to decelerate it from going more forward than the pelvis and ankles can support (I tell people that with feet flat on the ground, drive weight through your heels and push your knees forward and that is where they should be).   And being “neutral” is not a single-plane strategy–it is positional and respiratory balance and a nonspecific area for the systems to reciprocally circulate around and alternate through in an attempt to negotiate gravity, pressure and movement.

“Good ergonomics” is another thing that has changed and is repeatedly being discussed and evaluated.  Many times it is in an attempt to get people to be able to sit for longer periods of time, which is incredibly ironic, and frankly many times not done correctly, in my opinion.  Vertical positioning with joints locked into a position which decreases the ability of our bodies to be able to move or breath merely feeds into our stressed out systems.  I wrote this article for Eric Cressey last year ( which describes the affects long term sitting, inactivity, stress and a sedentary life can have on you and some strategies which can be employed to better manage it.

The use of modalities has changed dramatically as well and interesting in how my schooling spent an entire semester on their use and applications and how I use few to none of them anymore.  I haven’t used ultrasound in I don’t even know how long, e-stim on a rare occasion for pain as I think interferential/TENS can be beneficial for some at times, iontophoresis if indicated can be helpful in focal, more superficial inflammatory cases, but again far less than in the past.  Even cryotherapy I use and recommend considerably less than in the past.  Moist heat I think can be beneficial in the right situations, but that’s about it.  I don’t use IASTM or creams for manual rx, not because they are wrong, but I just haven’t found them beneficial for me personally.  I know some very good IASTM practitioners, I’m just not skilled with it.

Static stretching, as I learned it in school and early in my career, and even PNF stretching, has taken a big backseat in my treatments and training.  I will have people “stretch” some areas at times, but I feel it is just as much as for an inhibitory effect as it is muscle lengthening.  When I do stretch most anything, I have them hold the stretch for 3-4 full breaths vs. a set time.  More common areas would be:  calf musculature, hip flexors, posterior hip capsules (usually left), posterior mediastinums, pecs, and maybe hip external rotators (usually right and inferior focus).  I do, however, do a lot of mobility work which is markedly different.

What was it like to work with the Miami Dolphins? How did you get that gig?

It was and is an incredible experience.  Dave Puloka, who is the Assistant Strength & Conditioning coach for the team reached out to me, as he had received my contact info from Mike Boyle.  Dave wanted me to go to lecture the S&C and medical staff on Postural Restoration® and applications to that population.  (I think it’s important at this stage to clarify that I am not on faculty for the Postural Restoration Institute and as such do not teach their specific courses.  I do, however, lecture regularly on their principles, teachings and applications to rehab and training and am in regular contact with the Institute on the programs I offer.)  I have been down a couple of times and have also done some consulting on some of their players, both while I was done there as well as FaceTiming and working with the staff and players in that capacity.  That is a great staff and seeing the inner workings of an organization like that has been incredibly rewarding.

You’ve taken a ton of Continuing Education courses. I’m sure you’ve found some better than others. What makes for a good Con-Ed course?

Early in my career, anything I took was worthwhile and filled with information I didn’t really learn in school.  I learned a significant amount and have been able to apply some really excellent things from various programs over the years.  A good continuing education program, to me, is one where there is lecture and lab, as so much of what we do is activity based.  Practitioners have to be able to feel things on their own in order to be able to effectively apply them to their patients from a manual perspective or effectively cue them from an activity standpoint.

Certainly programs which include some of the most up-to-date research and evidence is important in terms of being able to understand and apply what has been found to be most effective (and for me, staying within the parameters that I listed above with respect to reading research). 

I also feel it is important that a quality course manual is provided.  I like to go back and read through material as I can’t take in nearly as much as I would like during a one-day or weekend program.  Having great references and resources to refer back to is also important to me.

Staying in the world of Physical Therapy, what important truth do very few people agree with you on?

Well that is an interesting question, CinemaAir, and I hope that there is nothing that very few agree with me on 🙂  I do think that the influence respiratory imbalance has on our system–both the system itself as well as our other systems–is the most under-appreciated thing in the medical and rehabilitation fields.  It is my observation that the strength, conditioning and performance world has been much more open to start doing respiratory training as part of their programming strategies which only makes sense, but I do find it incredibly unfortunate that more rehab practitioners have not studied, tried to implement components of it–let alone embrace it as the incredibly powerful tool that it is.

Taking that one step further, the respiratory imbalance piece I would further specify is the ability to achieve a Zone of Apposition, on both sides of the thorax, probably is the number one thing I have found which helps my patients the most, regardless of their condition.  Now unless someone has taken Postural Restoration® coursework, knowing what this is can’t be summed up just in an explanation or definition, and therefore whether others “agree” with me, I almost find irrelevant.  It is something that has be felt and seen in order for it to be appreciated.  But as a rehab practitioner, if I am doing most any activity, or if I have a patient who is getting stuck, once I achieve–or re-achieve, as some lose their understanding of its importance–a ZOA, then things just keep progressing.

Taking that one step further, I am amazed and confused by the sometimes almost visceral response some practitioners have towards Postural Restoration®.  Research and a basic understanding of anatomy and physiology clearly demonstrates the asymmetrical structure we have and the influence it can have on function, and yet to not at least recognize that this might play a role in even some of our patient’s symptoms and problems I find unfortunate.

Time for my time-travel question: You’ve just traveled back in time and are sitting face-to-face with your 30 year old self. What advice would you give yourself?

Take pride in the work you do and do not be swayed by what you believe others may think of you.  It is easy to get hung up with the societal pressures of acceptance, not wanting to stand out, or even compliance.  Life is too short to not take full advantage of everything it has to offer.  Work hard and have fun….

I work with a brilliant PTA. I’ve learned valuable lessons from her. As an ATC and PTA, what is that you would want any/all Physical Therapists to know or recognize?

First, I commend you on respecting and recognizing your co-worker’s skills and knowledge base.  I think that one of the biggest things for me that I feel very strongly about is that it really isn’t about what your credentials are.  The rehabilitation environment should be a supportive and interactive one where everyone learns from each other.  Humility is one of the more challenging emotions we all struggle with and being able to take a step back and ask questions without an ego getting in the way is huge.  There is no way we can all know everything so work alongside with who is in your clinic versus individually.

I also would want them to recognize that there are many bright minds out there that do some incredible work with none of the more recognized post-nominal lettering that some practitioners seem to think matters a lot.  I have seen some amazing things and some really smart people who are performance coaches or massage therapists, for example, that I would send people to before some of the allied health professionals that I have seen over the years.  It is about what is best for that particular person at that particular time in what they have going on that matters the most.  If you are good at what you do, then you should never have to worry about what others are doing.

Thanks so much Cinema Air for the opportunity to do this interview with you.  I learned a lot about myself and hope that some of the information will help others as well.  Cheers….

Michael, thank you for this incredibly in-depth interview!

Connect with Michael Mullin via twitter: @mjmatc

And find me: @Cinema_Air