Interview with Dr. Erson Religioso III – Part 2

In Part 1 of the interview with Dr. Erson Religioso, III, DPT, MS, MTC, CertMDT, CFS, CSCS, FMT, FMS, FAAOMPT we explored Dr. Erson Religioso III‘s professional development. Now lets dive into a few of his current ventures. Enjoy!

Edge Mobility Systems is a growing contribution to the world of practicing physical therapists. What drove the development of these tools?

I was treating the son of a local chiropractor college faculty member. He saw myself and my co-workers doing tissue work and manipulation, and later brought in his very expensive set of stainless steel tools for me to use. I loved the way they felt against skin and the sensitivity they had, but for years, never wanted to pay the money for the courses and the tools. So I just made my own! EDGE/EDGEility Tools are now used in every professional sport in the US (that I can tell from my sales by who the tools are going to, or by ATCs contacting me personally), and I have distributors in Asia, Europe, South America, and Canada. I am blessed that all this crazy blogging I do pays off with social media sharing and exposure!

Tell us about The Eclectic Approach – what differentiates it from other approaches?

Well, in my courses, I spend anywhere from 15-30 minutes – you can tell by this interview I can ramble, on giving credit where it’s due to my influences. I am just teaching what many of us do in the clinic, take what works for us, from what we have learned from other clinicians and “gurus” and combining it. I always say in my courses, that I invented nothing, someone was nice enough to say, “But you packaged it together so well!”

The Eclectic Approach is systematic and based on MDT/SFMA plus patterns I have come to recognize over the years. Taking traditional OMPT courses, you’re left with hundreds of ways to assess and treat, and come back on Monday often more confused. It also has touches of modern Pain Science and really emphasizes that patients MUST be independent, because it’s the HEP that really makes them better, along with your positive interaction, not our magic hands. It’s also based on concepts and treatments that are easy, which we tend to take for granted after going to school for years.

You mentioned that teaching The Eclectic Approach has taken you to a number of places (including Chile). What have you learned from your teaching experiences so far? Biggest takeaways?

I learned that it’s not a great time to teach a course right before CEUs are due, I taught one course where literally all the clinicians were done practicing 1-2 minutes after I taught them, just like PT students! Most of the time, I have to tell people we have to move on, but this group I could’ve finished 3 hours early!

One of my favorite things I learned was that you can present pain science, and modern manual therapy in a way and not come across like a smug know it all. “sorry if this offends you but that’s the way it is” is a problem in our current social media.

I also really enjoyed teaching in South America because not only were my hosts amazing, literally great tour guides, but I learned that it’s very different with the chiro vs PT thing there. I also learned that PT when performed poorly, is performed poorly there as well, with an emphasis on physical agents, no hands on techniques, and generic exercises, the same ol’ shake and bake, just different country. I’m looking forward to teaching in Vancouver, the Philippines, and Italy later this year to see how they compare!

I’m curious, tell me more about the difference between Chiropractors and PTs in South America?

The difference is that there are none! Chiropractic is not a licensed profession in South America according to the Physios I teach with. All of the chiropractors are Physios with an additional certification or continuing education. They tried to block my spinal manipulation course – just like some of the DCs try to here!

Give us your overview of the variety of themes (and fads) that weaved through the world of Physical Therapy since your graduation.

Around the time of my graduation, in the ripe old year of 98, everyone was hopping on the TA bandwagon. I never really got into it, but dabbled here and there. In Buffalo, everyone also started doing “functional exercise” a la Gary Gray, which ended up being an excuse to see more patients and spend less time with them. One idiot POPTs doctor even told a little old lady patient of mine that walking was not triplanar, thus it was not a good exercise. HUH? I can then say we moved onto CPRs, still hotly debated. Spinal manipulation ended up being well researched as well as MDT. IASTM taking off with no excellent research behind it, and now modern manual therapy combined with pain science. This was as I experienced it and YMMV.

There is also the ever rising costs of healthcare with our reimbursement rates dropping, getting less visits, and caps abound. I plan on being cash based sooner or later, but my situation is unique, but I can empathize for the private practice owners who this really effects.

Physio Answers – What is it? How did it start? And what makes this a unique online resource?

Physio Answers is my blog for the public. I saw that there was (and still is) a lot of poor information out there on stretching, fitness, health, and pain. I wanted to make it kind of like a WebMD but written by real physical therapists, only in blog format. I have a lot of great contributors and any physical therapist can apply to write for it! Most of them have their own blogs and allow me to take their posts and include them on my site, giving them credit and linking back to their site! It’s win/win! I started having regular posts on it this earlier last year and it’s really taken off with over 10,000 facebook followers and has double the hits of The Manual Therapist – naturally there are a lot more of regular Joes out there than clinicians, as it’s a blog for the public.

What simple ideas/basic concepts do you believe will help all Physical Therapists become better/smarter/wiser?

Less is more – you’d be surprised how little force you can use one someone to improve their motion

If MDT is not working for you, you either chose the wrong direction, or the patient does not understand end range (or you did not educate them properly)

Find what motivates your patient and realize that patients have different learning styles, visual, tactile, auditory, and try and adapt so they get your message.

Remember the basics, rest, walking, eating, sleeping, hydration, how often do you ask your patients about simple concepts like this?

You’ve just traveled back in time and are sitting face-to-face with your 20 years old self. What advice would you give to him?

Clinically: You don’t know it all, and for God’s sake, stop beating on people to make them move better!

Personally: Start working on your symmetry and stop with the huge pounding overstrides so you don’t have to quit running due to knee pain. Also, invest in something called google.

Now let’s time-travel forward 20 years. Describe the world of Physical Therapy you would like to see in the 2030’s.

Hopefully we’ll have a universal practice act, not state by state, and primary care direct access covered by all insurers. Does that sound ridiculous? We should be able to order radiology and prescribe basic pain meds or anti-inflammatories like the PTs in the military or the Physio’s in the UK (meds).

I hope your vision becomes reality! What hurdles does the profession need to overcome in order to achieving your vision? And what can be done to make this dream a reality?

1) MDs

2) ourselves – many PTs feel like the MSPT wasn’t needed, forget the DPT, and other PTs not in private practice could give a hoot about direct access, they still defer to MDs and often tell patients they need surgery

3) HMOs

You’ve mentioned HMOs twice! Give us your take on HMOs.

Well, like I mentioned earlier, I have a unique perspective from working in HMO Peer Review for 6 years part time. I can say, at least for the company I worked for, we’re not the enemy and many of us were clinicians with our own private practices. From the sample of PTs I could see, there was rampant abuse of PT benefits with patients going for 100s of visits prior to management with no change in subjective or objective measures. I can see why HMOs popped up because without management, it was a free for all in the 80s.

I still hate all the things about HMOs that most of us in private practice do, low reimbursement especially in WNY! Some of the lowest in the country. Really, we often get paid less than $40 a visit depending on the HMO, many of our patient’s copays are higher than our reimbursement.

Life is an adventure. Describe one of your most memorable adventures so far.

Pre-family – Climbing my first multi pitch climb in the Gunks. Climbing 500 feet or so, you often forget to stop and smell the roses, but when you get to the top, what a view! The sense of accomplishment was amazing! When I climbed regularly, digital cameras and cameras on phones were nascent, we only had ass shots from the ground back then.

Post-family – Catching 2 of my 4 daughters, the 3rd in the hospital – instant Niagara Falls coming out of my eyes, seriously the most emotional I have ever been. From dry to huge tears of joy stat! My fourth and most recent daughter, was a home birth. Watching my amazing wife going through labor, coaching her when needed, reassuring her doubts, was really breath taking. It was all her, with very little coaching needed this time. Our midwives suggested she labor in the tub for a bit, then she got the urge to push, and in two pushes, out comes Leila into my hands in the water! Life is an adventure, and I can say I am a baby catcher! That won’t be part of The Eclectic Approach though!

This was an amazing interview. Thank you for sharing your story!

Find Dr. Erson Religioso III on twitter @The_OMPT & @PhysAnswers

Connect me @Cinema_Air

Interview with Dr. Erson Religioso III – Part 1

It’s not very often I’ve met someone with more letters after than in their name – DPT, MS, MTC, CertMDT, CFS, CSCS, FMT, FMS, FAAOMPT. This is a testament to Dr. Erson Religioso III‘s achievements so far; his list of accomplishments with undoubtedly continue to grow. In addition to his clinical practice, he has filled his plate with a number of ventures including Edge Mobility Systems, The OMPT Channel, Physio Answers, Physio Pics, Physio Stories, and his blog The Manual Therapist. Also, connect with him on twitter via @The_OMPT & @PhysAnswers.

This was a fantastic interview filled with enough goodness to turn it into a 2-part series. I hope you enjoy it as much as I do.

Let’s start at the beginning! What initially drew you into Physical Therapy?

My parents were MDs and I was exposed to health care since I was born, being very comfortable with it. I remember kids in school saying they hated the dentist and I could never figure out why! In high school, a girl I was dating was in an MVA and she started attending PT, so I thought, what the heck, I’ll try this and if I don’t like it, I’ll just go straight to med school. After the first day of my first clinical in an acute care setting, I remember calling my parents saying, THIS is what I want to do! I was so pumped! The rest you could say is still history being written.

You’ve gone through quite an evolution as a clinician. Describe your evolution over the years.

Well, it started out having an amazing othopaedics instructor who was an officer and fellow in the AAOMPT. Waaaaaaayyyy back then, in 95, we had 10 credits of ortho, 5 of extremities and 5 of spine. Most of the other programs only had 3 credits and 1 semester back then. It was MDT and OMPT based (sound familiar?). I thought manipulation was just about the best thing since Jackie Chan (being the mid 90s). I told my parents, “I think I want to be a chiropractor.” As MDs, they said they would disown me. My current business partner, who was rehab director of a hospital where I was doing one of my last clinicals asked, “Have you ever heard of Stanley Paris?” So that’s when I entered USA’s now defunct Residency Based DPT program. I took all their courses for credit starting the day I graduated after PT school and finished them in 1 year. I took my MTC back then, and did not pass Myofascial Manipulation – the irony! I just did not have enough experience as a new clinician to answer some very basic questions that experience would have taught me. When I passed 3 months later, from better studying, not experience, I was whalopping on people and having good results. I was also doing lots of palpation for position, manipulating everyone and discarded most of my MDT training.

MDT comes strolling into town and I thought, I should probably get these credentials. I told my Part A instructor, “I’m only taking this course to get the initials, but don’t plan on using it.” So yeah, I was a young, brash, know it all jack-ass. I took all the MDT courses and passed the cert in about 7 months.

I got my start in Soft Tissue work from the IPA, and took four of their courses, enough for their half cert, but was too daunted by PNF to actually get tested. I noticed for the first time, taking time to do STM actually got me much better results that 5-10 minutes of joint mobs. However, I was still bruising people, and had good outcomes, averaging on the 10-20 visit range for most patients for the next several years.

About 8 years into practice, I attended a MDT Clinical Skills Update Course. I woke up with a “stuck facet” and just needed a manipulation. No one at the course would (or is that could) manipulate me, so for the entire day, I actually sat there, and actually really listened…. so end range you say? Let me try that. For the next several hours I did end range cervical retractions with sidebending left overpressure. It hurt like hell, but the more I did, the better I felt. By the end of the day, I estimate I had done about 500, but I was 100% pain free, in other words I did what a patient would do in 2 weeks in 1 day. No one looks at you funny at an MDT course when you’re doing this stuff btw. At that level everyone is a cert, so there is a lot of walking around, pressups, etc. So, this MDT stuff works!

For 6 years, I supplemented my salary as a peer reviewer. I really got a lot of insight into the HMOs and what a good peer reviewer is really trying to do. Not to mention, I got to see so much abuse of a system and terrible SOAP notes! My most memorable example, literally 100 hand written notes of S: No new complaints P: Continue PT – I guess that makes it a SP note.

At some point, I also took all of Butler’s first series of Explain Pain courses, which changed the way I interacted with patients, and this has of course only been reinforced by all the great blogging and research they have done along with Moseley’s group.

Since then, after reviewing literature on the near impossibility of capsular and fascial deformation, I have practiced a lighter and lighter touch, and my OMPT, including IASTM and joint manipulation are only to make the patient be able to perform their HEP, whether it’s MDT based, neurodynamics, or other. I think supplementing MDT as a system with other systems like the SFMA and MDT has been a match made in heaven and recently I have started focusing on real basics, like sleep, eating, and of course, better breathing through the use of a capnotrainer and a feedback approach.

Wait, what, are there other interview questions?

Ha! We just getting started! Tell us more about your Fellowship experience. Why did you decide to take on this challenge? And with which organization?

Well, I got lucky. Since there was no difference at the time in requirements between fellowship and residency (before 2005), my residency hours along with my DPT through the University of St. Augustine counted as fellowship hours, so I was grandfathered in, having met the requirements of the time. My fellowship required 10 article reviews, 10 publishable case reports, and way more hours than the current requirement, so it’s not like I did not put in the time… I did! It was under the mentorship of Dr. Ron Schenk, who started their fellowship, and the MDT fellowship, and it was a great experience. I learned not only MDT, but neurodynamics, some Greenman based MDT, got my first Rocabado type experience, and more, which really helped form the clinician I am today.

You serve as an adjunct faculty at D’Youville College, Daemen College, and SUNY at Buffalo Doctor of Physical Therapy programs. How did you get involved and what motivates you to devote your time to academia?

I owe almost all my opportunities I had early on in my career to my aforementioned mentor, Dr. Schenk. After fellowship, I had no job, and he was leaving DYC, and suggested I apply for that job. So only 1 year after graduating, I became full time PT  faculty, and ended up teaching a lot of the kids I used to hang out with. I did say in an interview I would not hesitate to fail a friend because the lack of knowledge or performance could mean someone’s health or worse. Dr. Schenk left for a few years and came back and started teaching at Daemen, and recruited me to teach Neurodynamics for the fellowship program, plus some an in clinic course called Clinical Exposure, where students come in and observe once every other week for a semester prior to their clinicals. Really makes them more comfortable so they’re not deer in headlights on their first day of actual clinical. For UB, a student visit by the ACCE was enough to have me start teaching ortho labs there for about 6 years.

I can say now that I have really scaled back on my adjunct work, and no longer teach at UB or Daemen. I just did not have the time once I started having my own practice, blogging, and the (inter)national teaching tours. I still love having students in the clinic and they keep me on my toes! I still teach at DYC (my alma mater) 3 times a year in their Advanced Ortho Program, a kind of mini certificate for students interested in more than what their ortho class offers.

Congratulations on everything you’ve accomplished so far! How do you balance career aspirations and family life?

After starting my travelling, I cut back on my clinical hours. My family are the most important thing to me, so I only work 3 days in the clinic now. It’s enough to still see a wide variety of patients, but I get to hang out with my girls and wife a lot and really help around the house. My wife is very supportive of my teaching and told me 5 years ago, someday I think you’ll be teaching all over the country! Even though when I called her from the Buffalo airport to tell her I was boarding for my first tour, she said “I miss you already, how long do you plan on doing this?” Lol! I couldn’t do it without her support.

Another way I balance is to take off a significant amount of time from the practice when I have a new child. This time around I’m off until the second week of May. If this is my last child, I want to make this time with my family count! I am still seeing concierge clients on a cash basis intermittently as sleep allows.

How can Physical Therapists avoid professional burnout? What has kept (and will keep) your fire blazing?

I had the unique opportunity of being a clinician, PT faculty, and peer reviewer. Now that I am onto private practice owner, international lecturer, and online mentor, I just try to keep it varied. I’d say to avoid burnout, you need to take courses that really light your fire. Take something totally different and not just more of the same. For me, learning about different ways to help others is what keeps me going. There are always different ways to look at things and what works for some does not work for others. It’s why I’m against the odd trend of Advanced Clinical Reasoning vs. Toolbag arguments we see online. Why can’t it be both? You also want to select your patients if you can. Gone are the days for me that I see worker’s comp patients who do not respond more than 2-3 visits, that helps!

Favorite books and/or authors that impacted you the most, both personally and professionally?

Professional: David Butler/Lorimer Moseley – really changed the way I interacted with patients, what words I chose, etc…

Personally: I used to love Michael Crichton years ago but feel that his last 2-3 books prior to his passing were written with movie adaptation in mind. I love RA Salvatore and his Forgotten Realms characters. During my last clinical, one of my best friends and fellowship mentee years later introduced me to his books. I read about 10 years of his books on one clinical!

I just finished Guillermo Del Toro’s The Strain Trilogy, amazing read! It’s about vampires viewed as a disease and how fast it can spread like a pandemic. Btw, vampires are for killing, not loving! After that, I started The Martian, kind of like Gravity on Mars… it’s one of the most gripping books I’ve read in a long time… highly recommend all four of these!

Next week (in Part 2) we’ll find out more about Dr. Erson Religioso III’s travels to South America, Edge Mobility Systems, and more.

Find me on twitter: @Cinema_Air

#FutureShock – PT Pub Night & Telekinesis

“Expect the unexpected, or you won’t find it” – Heraclitus

What follows are speculations intended to spark questions and explorations on the many possible futures of Physical Therapy, and retrospectively contemplate how you and I can prepare for and adapt to the unpredictable. There will be aspects to this post that I have either overlooked or am unaware of, so please offer your feedback.

As Yogi Berra once said, “the future ain’t what it used to be.” The future. Something many of us would love to foresee and plan accordingly. Unfortunately making predictions is both difficult and usually (not always) futile. Gazing into the crystal ball can be a dangerous venture, so lets keep our distance without completely ignoring the evolving current macroeconomic climate.

The world around us is becoming more complex everyday. New data is mined, new dots are connected, and in the spaces between discoveries, inventions, and everyday life some very unpredictable things sometimes (often?) occur. These events, while unpredictable, can have significant consequences. For example, an asteroid impacting your planet. One of Nassim Taleb’s books, “The Black Swan,” is about these improbable events and their impact. He call these events “Black Swans”. Here’s why:

“Before the discovery of Australia, people in the Old World were convinced that all swans were white, an unassailable belief as it seemed completely confirmed by empirical evidence… It illustrates a severe limitation to our learning from observations or experience and the fragility of our knowledge. One single observation can invalidate a general statement derived from millennia of confirmatory sightings of millions of white swans. All you need is one (and, I am told, quite ugly) black bird.”

He goes on to describe a Black Swan as an event with three characteristics:

1. “…it is an outlier, as it lies outside the realm of regular expectations”

2. “…it carries extreme impact…”

3. “…in spite of its outlier status, human nature makes us concoct explanations for its occurrence after the fact, making it explainable and predictable.”

Black Swans can have positive, negative, and (predictably) unpredictable consequences. They emerge much like the ISOs from Tron: Legacy. Kevin Flynn explained it best:

Kevin Flynn: The Miracle… You remember. ISOs, isomorphic algorithms, a whole new life form.

Sam Flynn: And you created them?

Kevin Flynn: [Laughs] No, no. They manifested, like a flame. They weren’t really, really from anywhere. The conditions were right, and they came into being.

Let’s tie this into the PT world with 2 Black Swan events.

First, my favorite emergent movement in Physical Therapy: PT Pub Night. Could anyone have predicted this 7 years ago? I believe PT Pub Night has the potential to make strong impacts within the profession in ways that top-down directives have failed. What excites me most are the unpredictable offshoots from this movement. If you haven’t been to a PT Pub Night, then what are you waiting for? Look here to find a location near you. Can’t find one near you? Then start one.

Second, there’s been growing enthusiasm regarding pain science, graded motor imagery, and the subsequent importance of changes in cognitive perception to bolster patient progress. Let’s push this brain training a bit further. What if you could harness the patient’s ability to visualize their own success to manifest improvements via technology for integrated graded motor imagery? What if you could train the brain by just visualizing or imagining manipulation of physical objects in space and, ultimately, the user themselves? Update: Augmented reality is here (also see here, here, and here) and rapidly evolving.

If you haven’t heard of Tan Le, then you’re in for a thrill. Watch this TED talk that introduces eMotiv – “A headset that reads your brainwaves”.

Seems years away? Guess again. The first generation headset is available in 2014. It bestows the user with potential telekinetic powers – the ability to manipulate physical objects by thought. Forget wheelchair joysticks. And forget game controllers all together. Just think it.

Another budding theme that blends nicely with these fancy telekinetic powers: robotics. Cybernetic integration is inevitable, and evidence of it is plenty and growing. In fact, it’s already here: “A Prosthetic Limb, Controlled by an Amputee’s Thoughts”. All that’s truly needed to springboard this into public consciousness is a bubble, like The Dot Com Bubble of the late 90’s. This propelled the internet forward into what it is today. A similar path will likely be needed for robotics. And it has already begun. Google has been on a buying spree in the last 6-9 months buying up EIGHT robotics companies. Late 2013 debuted “ROBO“, an investment vehicle for you to place your bets on a growing field.

Imagine a future Physical Therapy specialty constitute neuro-cognitive rehabilitation for cybernetic integration. It might not be as far away as you might imagine. All the pieces to the puzzle are starting to form…very quickly.

Physical Therapy will continue to evolve and adapt to the changing healthcare landscape. There are definite trends in US Healthcare. Mixing in exponential progress in medical technology could just ignite a future we now consider pure fantasy, an impossibility. Then again, impossibilities and unexpected events manifest all around us in unpredictable fashion.

While you can’t predict the future, you can prepare for it. My questions:

1. What could Physical Therapy look like in this potential future?

2. How different could it be from what it is today?

3. What can you do today to prepare for this tomorrow?

Meet up with you colleagues, organize meaningful action, and work today for a greater tomorrow.

What you just read are speculations intended to spark questions and explorations on the many possible futures of Physical Therapy to retrospectively contemplate how you and I can prepare for and adapt to the unpredictable. Again, there will be aspects to this post that I have either overlooked or am unaware of, so please offer your feedback.

More #FutureShock speculations to come…

I am @Cinema_Air