M ssing L nks

As the years roll by, we accumulate a variety of techniques (“tools”) to apply in the clinic, but when the time to (maybe) utilize these “tools” comes there can arise dissonance in melting together rationales for which “tool” to pull from your “toolbox”. [I’m not a big fan of calling various treatment options “tools”, but let’s stick with it for now] How do we make sense of the different conceptual frameworks and rationales for application of any treatment options? Most of us would likely fall back into our old rut of “that’s what I always did before”. That old rut is immersed in the murky waters of psychological bias and fear of change.

Everyone needs a core set of beliefs to hold onto during challenging times. The thing is, I don’t think we employ these beliefs simply during challenging times, instead it becomes a daily habit. A comfortably familiar choreography of thoughts and actions free us from the thought of “I might be wrong” and the possibility of “I should change how I approach, think about, or perform X”. The question is: “How do we help ourselves get comfortable with assimilation of the new and the novel without feeling lost?”

Having a set of core concepts is essential to germinate a decision tree that can guide you through the decision-making process. The tree then develops branches based on various approaches and styles. As these branches grow, so do the biases and spells of indecision. These branches develop into silos of thinking that never (or rarely) seem to connect, resulting in aisles of thinking models that appear entirely independent. It suddenly seems Black & White, while the reality is that much of the magic happens in the Grey.

A system of connections might allay – and possibly solve – the problem of these monocultures of the mind. Our decision tree doesn’t have to grow branches entirely independent of each other, instead these branches could communicate to each other via context dependent “inter-branches”.

Charlie Munger says it best: (from http://hurricanecapital.wordpress.com/mental-models/)

l’ve long believed that a certain system which almost any intelligent person can learn – works way better than the systems that most people use. What you need is a latticework of mental models in your head. And, with that system, things gradually get to fit together in a way that enhances cognition. However, my particular approach seldom seems to get through, even to people of immense ability. Things usually die after going to the ‘Too-Hard’ pile.

Physical therapy has seen it’s share of explanatory models enjoy their moments in the spotlight, and I’m sure new models will develop in the years ahead claiming greater influence than the preceding models. While none of these models are complete, they do reflect elements of practicality and applicability. Problems arise when passions of the latest models grow into obsessive academic drumbeats. Suddenly all prior developments are overturned and the flag of the latest explanatory model is waived over the heap of “outdated” concepts.

Models are approximations of reality. Reality is far too complex to fit neatly into one model. Therefore, the linking of one model to another in a fashion that allows corroboration of findings and concepts might lead to a greater and deeper understanding than doggedly holding onto one approximation of reality. Whenever new explanatory models arise it seems as if prior models are declared patently false and any links are immediately dissolved (much to our detriment). We’ve effectively turned ourselves into the Man-with-a-Hammer Syndrome: “To the man with a hammer, every problem looks like a nail.”

So, how do we resolve these Missing Links and create a Latticework of Models with which to filter and distill the reality around us? From Munger’s 1994 Speech at USC Business School:

Well, the first rule is that you can’t really know anything if you just remember isolated facts and try and bang ‘em back. If the facts don’t hang together on a latticework of theory, you don’t have them in a usable form.

You’ve got to have models in your head. And you’ve got to array your experience both vicarious and direct on this latticework of models. You may have noticed students who just try to remember and pound back what is remembered. Well, they fail in school and in life. You’ve got to hang experience on a latticework of models in your head.

What are the models? Well, the first rule is that you’ve got to have multiple models because if you just have one or two that you’re using, the nature of human psychology is such that you’ll torture reality so that it fits your models, or at least you’ll think it does…

It’s like the old saying, “To the man with only a hammer, every problem looks like a nail.” And of course, that’s the way the chiropractor goes about practicing medicine. But that’s a perfectly disastrous way to think and a perfectly disastrous way to operate in the world. So you’ve got to have multiple models.

And the models have to come from multiple disciplines because all the wisdom of the world is not to be found in one little academic department. That’s why poetry professors, by and large, are so unwise in a worldly sense. They don’t have enough models in their heads. So you’ve got to have models across a fair array of disciplines.

You may say, “My God, this is already getting way too tough.” But, fortunately, it isn’t that tough because 80 or 90 important models will carry about 90% of the freight in making you a worldly wise person. And, of those, only a mere handful really carry very heavy freight.

Rather than clinging to the latest explanatory model with dear life, let’s leverage this model on the shoulders of previous models. Inoculate yourself from the “Man with a hammer” silliness by linking models together via a Latticework Approach. Connect the dots.

“We’re really good at taking a single sample and blowing it out of proportion. We need to get better at putting single samples into context.” – Carl Richards

The same can be said of applications of models. Let’s adapt that quote for the purposes of this post:

We’re really good at taking a single [model] and blowing it out of proportion. We need to get better at putting single [models] into context.

[Update] – Jason Silvernail just shared with me his article for The Journal of Manual & Manipulative Therapy titled “Manual Therapy: Process or Product?” It rhymes with the thrust of my post, and is well worth the read.



Interview with Dr. Laura Neuburger, DPT

Dr. Laura Neuburger, DPT opened In Motion Physical Therapy – an Out-Of-Network Cash clinic – in 2013. Soccer is one of her huge passions and you’ll soon find out about the strong link between soccer and her physical therapy practice. She also coaches a U14 girls soccer team.

In this interview we get into lessons she learned from starting & operating her clinic in year 1, and lots more. Enjoy!

What lead you into the wonderful world of Physical Therapy?

I was a competitive soccer player my whole life. Although I never had any serious injuries until college I knew that I wanted to do something with sports medicine. I did an internship my junior year of high school at a physical therapy clinic one day a week and absolutely loved it. I applied to Northeastern University for the 6 year PT program and graduated in 2011 with my DPT.

While at playing soccer for the varsity team at Northeastern I injured my back pretty badly that I stopped playing soccer. Although the PTs and ATCs in the training room helped, I felt like I never truly “recovered”. My mission has been to help others overcome their injuries and become better athletes than they were before.

Congrats on the establishment of In Motion Physical Therapy of NY! Why did you decide to start your own practice?
(I’ll also add in some of the how)

Thank you!! After graduating I was extremely excited to take on the world (as most new grads are), so I started working for a PT clinic that advertised that they worked with the semi-professional soccer teams on LI. I thought it would be a great stepping stone into working with high level athletes. Unfortunately, this clinic was not what I expected. I was left unsupervised from day 1, had to treat multiple patients at a time, and worked 11 hours days. Needless to say this left me completely exhausted. I knew that there had to be a better way and that this is not what I went to 6 years of school for. I hit my breaking point one day when the other PT was on vacation and I had “treated” (it was a complete joke) about 50 patients in 1 day. I sat down to talk with the owner of the practice. To make a long story short, his response was something along the lines of “too bad”. I knew that it was time for me to move on.

I knew I was interested in leaving but it wasn’t until January 2013 that I was talking to a PT colleague of mine and he asked me if I wanted 2 treatment tables because he was buying some equipment and could get them really cheap. I didn’t know where I was going to put them, but I agreed. I then asked another friend of mine who is the director at a strength and conditioning facility close by if he had any room for me to move the tables to, and he said absolutely. From that day forward In Motion PT NY was born.

What lessons did you learn as you started the clinic? (things that enterprising PTs who want to start their own practice could benefit from)

I bootstrapped my business from Day 1. I started without any real patients, but I put myself in an environment where I was able to prove what physical therapy can do for people. My first day I saw 2 patients (both other strength coaches that worked at the facility where I opened up). It was a completely nerve wracking experience. I learned that if you put yourself in the right environment, good things will happen. I quickly grew to seeing about 10-15 patients a week less than a month into opening and quit my job. I decided to start a home care job, since I was able to see patients in their homes in the morning and then treat athletes at my clinic in the afternoon. I learned that I really was capable of doing something to help people.

I also learned how important it is to be organized. I used this time in the beginning to create my intake forms, filing system, and create procedures for future staff. The processes have evolved tremendously over the past year, and I continue to change things as the business needs. If something is not working, I don’t hesitate to change it.

Describe the climate for Physical Therapy in NY. How has it changed over the years? What progress do NYers have to look forward to?

Unfortunately I have only been practicing for 3 years and am not very experienced with this topic. I do know that New York is one of the lowest reimbursed states for skilled physical therapy services. Because of this I only take cash or out of network benefits. The reason why there are so many “mills” is because its impossible to stay afloat accepting $27/treatment. (Yes, that’s really what one insurance company reimburses for a whole treatment session). I would love to get involved more with the NY chapter of the APTA to push for higher reimbursements and less restricted direct access (we currently have 10 visits or 30 days before a prescription is needed).

Who/what have been your biggest influences?

Personally and professionally my father has been one of the biggest influences in my life. He started working for my grandfather before he was in high school and eventually went on to become the vice president of a pretty large company that had over 15 stores and did millions of dollars in revenue annually. My grandfather then sold that business to an outsider and my father had to start over from scratch. Even though I was only in elementary school, seeing him go through that taught me a lesson about resilience. He didn’t quit and feel sorry for himself. He was able to spend more time with his family, he has a job that he really enjoys (coaching soccer), and is much happier for it. It has influenced me to strive to do the same.

Favorite books and authors?

My favorite all time book that I can read over and over again is Alice in Wonderland. I probably read it again every year or 2 and always find another part or meaning in the book that I missed previously. Other than that there’s probably too many to list here, I try to alternate between fiction, business, self development and fitness/physical therapy books. I keep a running list of the books that I want to read in my google drive so I order another one off of amazon every month. (I just finished reading Fight Club yesterday, I would highly recommend it)

How did you establish your referral sources for In Motion Physical Therapy?

I get most of my patients via word of mouth. The soccer organization I coach for (which is run by my father) has about 10-14 teams (which is about 200 kids). I get a good number of patients between the players, their siblings and their parents. I also have a great professional relationship with the Athletic Trainer at the local high school. We share a very similar philosophy in regards to treatment so it benefits the athlete tremendously. I also send patients back and forth with the strength coach that originally was one of the reasons why I opened In Motion PT. Unfortunately due to administrative/front office issues I moved about a mile down the road inside a gymnastics academy. I now have quite a few gymnasts as patients as well. I have not done any advertising to this point or marketed to doctors (besides the interaction regarding mutual patients).

Congratulations for making it beyond your first year! I’m sure this is just the beginning. What were the biggest take-aways from Year One??

The biggest take away was not to stress over the little things. Learning the natural ebbs and flows of business has been a little challenging but I have become much better at not stressing out when my schedule is not full for the following week. More times than not, by the time Monday comes around the schedule is full and I have the opposite problem of trying to find appointment times for patients. I have learned that if you are working hard and doing the right thing, success will follow.

Which Continuing Education courses have you taken that you’d recommend? And why?

The continuing education course that has most influenced me thus far has been the SFMA. It is such a powerful tool to make sure I am on the right path with treating patients. I am able to treat true motor control dysfunction much more effectively than I previously was, and I am able to track progress each visit with the patient. Next on my list is PRI…

Life is an adventure. Tell us about one of your life’s adventures so far.

Life is definitely an adventure. There have been so many over the past few years, but one the relates to the physical therapy world is when I went to Ecuador for our capstone project senior year of college. About 10-15 students from our class went to an orphanage in Ecuador for a week. We helped with development programs for the Tias (caretakers) to implement with the children in the orphanage. Some of the children were newborns, others were older (up to the age of 14) with various developmental disabilities. In only a week, we were able to make such simple yet effective changes in these childrens and caregivers lives. It was extremely empowering and made me so grateful for all of the opportunities that we are afforded here. (After buying one of the girls a new pair of sneakers, I don’t think I have ever seen someone smile so much) It is definitely a future goal of mine to continue to give back and create a better quality of life for other people whether it is here or in another country.

Laura, thank you for the insightful interview. Let’s do this again some time.

Connect with Dr. Laura Neuburger via Twitter, and check out her clinic – In Motion Physical Therapy.


Interview with Dr. Seth Oberst, DPT, CSCS

If haven’t been reading Dr. Seth Oberst’s blog, then you’re truly missing out on some quality content. It has become one of my favorite reads lately. I had the opportunity to interview Seth, and it turned into a great introduction to a very curious mind. You can also find Seth on Twitter.

In this interview, Seth shares his views on Motor Control, Dry Needling, his PT Residency, and more. Enjoy!

First, what did you have for breakfast today?

4 hardboiled eggs, bulletproof coffee, and an apple

What sparked your initial interest in Physical Therapy?

Initially, I went the cliche route where I had some orthopedic injuries and surgeries in high school that necessitated going to a physio. I remember thinking how cool it was to know so much about the human body and being able to fix it (I’m obsessed with fixing stuff). I went to undergrad knowing I wanted to be a physio so I majored in Exercise Science which really aided my progression as a strength & conditioning coach. When I first started my undergraduate, I thought it would also be beneficial for me to get a degree in Athletic Training. However, I really did not enjoy my first athletic rotation within the ATC courses so I decided to stick with Exercise Science in preparation for PT school. I did have a strong dalliance with going to medical school while in undergrad, however ultimately I decided that PT was the best profession for me to impact the whole person with a holistic approach as I thought (and still think) that medicine was much too reactionary, short-sighted, and narrowly-focused.

Why did you take on a Sports Residency? And was it worth it?

I took on a Sports Residency to gain more clinical insight and mentorship. I am intensely, obsessively curious and thought the residency was the next logical step for me to answer some of my questions and help focus my clinical decision-making. I enjoy treating and training athletes so I decided a Sports Residency was the best way to interact with a lot of athletes.

Overall the residency was certainly worth it. I gained some valuable mentorship, was able to see a ton of clients which helped me with pattern-recognition as well as my manual skills, and was able to better manage the overall care of an athlete.

What were you biggest take-aways from the Residency experience?

Improved clinical practice and pattern recognition. I have been better able to quantify and qualify some of my ideas. I also learned that it is critical to take pride in becoming a great generalist prior to specializing, something that is totally lost in our current healthcare environment.

I love your blog. Why did you start it?

I’m glad you enjoy it. I started SethOberst.com because I really enjoy the process of teaching and disseminating information and I thought that starting a website would be a way for me to do so. It gives me a platform to reach more than just those whom I interact face-to-face. And I love the collaboration it has spurred and the learning opportunities it has opened.

You’ve done some work on Motor Control. What aspects of Motor Control should every Physical Therapist consider & apply?

All of them! Motor control is really the end-goal of our interventions as physios (and as S&C coaches) because the target of our training and rehab is ultimately the nervous system. I think a huge part of what makes manual therapy (whether it’s manipulation, soft-tissue, dry-needling) so effective is that it’s a way into the nervous system that ultimately allows better expression of movement. When you really consider why our interventions work, much of it is neurophysiologic with improved function and decreased pain as a result of improving positional competency to positively impact the motor control system. So I think we need to realize that nearly all of our interventions are, and should be, impacting the motor control system. If all we do is expose someone to an input with no thought or appreciation for the expression of movement, I think lots is left on the table.

I guess I digressed there a bit….to answer your question, we MUST consider the nervous system as “orthopedic or sports” PTs. To me, treating and training an athlete is not a whole lot different than treating a neurological-injury (aside from the obvious pathologic differences). I had a fantastic neuro professor in PT school at Ohio University (Dr. Petra Williams), and she continues to influence my thinking in treating/training athletes. Task-oriented training is the best way to treat neurologically-injured people so why are we not using these same paradigms for our orthopedic clients? Put the client in the best position to execute the task, using inputs as necessary to get them in the right position and have the task drive the right motor program. Then we can improve physiologic variables of performance (strength, endurance, etc.) once we have addressed the rate limiters.

Some important pieces of motor control are honestly some of the basics: saliency, joint centration and proximal stability, developmental patterns and the importance of fixed points, crossing midline, distributed practice, external cueing, breathing and its effect on deep stabilization, sensory inputs. Tapping into these fundamental, rate-limiting components can really yield some ruthlessly optimal output. As physios we are uniquely trained to integrate this into our training pieces because ultimately what matters most to people is they can go faster and go longer without the handbrake on.

Which continuing education courses interest you the most (if any)?

I just took both courses of dry needling thru James Dunning’s AAMT which I thought were fantastic. I also have done some PRI courses and want to do more. I also find the DNS school of thought right up my alley.

Now that you’ve had some Dry Needling course-work and experience, tell us what you think of this modality and how it fits your paradigm of treatment.

I think it’s a powerful input into the nervous system to reset the system and promote improved neuromuscular output. Like any other manual intervention it needs to be used appropriately, with the end goal to improve movement at the forefront of the decision-making process. My appreciation for pain referral patterns has certainly grown after my training in needling as well as how quickly someone can improve when we target the nervous system to facilitate or inhibit motor patterns. But the needling can’t be perceived as a threat; as Charlie Weingroff states so well if the client’s breathing pattern markedly changes during the needling they are likely not integrating the dry needling (or any other intervention for that matter) and full change is unlikely. Overall, it’s a game-changer that can get my clients back to training much more quickly and precisely than some other modalities.

Favorite books & authors (PT & non-PT)?

I seriously love to read as reading has literally opened so many doors for me.

PT-related: Neumann’s Kinesiology of the Musculoskeletal System is a classic.

Anatomy Trains

I thought Kelly did a great job with Becoming a Supple Leopard

Stu McGill’s texts

Supertraining by Siff and Verkoshansky is an absolute beast

Enter the Kettlebell and the Naked Warrior by Pavel

Non-PT:      Blink by Malcolm Gladwell

The Story of the Human Body by Dan Leiberman

I have read every Michael Crichton book at least twice (seriously)

Crush It! by Gary Vaynerchuk

What are your Professional aspirations and how do you plan on accomplishing them?

Positively impact and empower as many humans as I possibly can to take charge of their own movement and performance. For me that happens by growing a fee-for-service clinical practice in the human performance realm with a foot in PT and S&C as well as collaborating and educating with the best minds in disparate fields. All of which are very much a work in progress for me.

Since you have a strong exercise science background, this might be an interesting case scenario question. While many look to lose weight in today’s world, there are those who would love to gain healthy weight. My friend Genghis is one of them. He’d love to pack on some muscle mass, but has the toughest time gaining weight. He’s one of those guys who can eat whatever he wants without any weight-gain. What advice would you give poor Genghis?

Poor Genghis. Your friend needs to focus on at least some version of the main lifts that promote a big stimulus for growth: pulls, presses, squats, and carries. Isolation exercises just aren’t going to be a great stimulus, rather full body movements exploring large ranges of motions are best here. Also, calories need to be high with avoidance of inflammatory foods (gluten and the like) to promote a positive adaption for mass gain. Also sleep is huge, growth hormone release is predicated on appropriate and adequate sleep patterns.

If you could change Two things about the profession of Physical Therapy today, then what would they be?

One would be that a PT should know their value and that it’s not just the value of a co-pay. We need to move away from dependence on 3rd party payers and referrals as we are letting that dictate how physios operate. Fee-for-service and direct access are great for the profession as they make us more accountable. Stop providing a KIA and asking to get paid for a BMW. We need to take the banner of movement experts and the tremendous opportunity that comes with truly understanding and treating movement dysfunctions (NOT pathoanatomy) and run with it, own it before someone else does

The second would be that in order to seize this opportunity we have to truly understand movement and start intervening on the cause of dysfunction, not the symptoms which often present as pathology. It seems that in most cases pathoanatomy is the symptom with cause being a movement dysfunction. We’ve become really great at treating symptoms which is completely reactionary. Even in post-operative patients, too many physios are just treating post-operative symptoms rather than pre-operative causes. I think we need a holistic approach by empowering and educating the client and to take it upon ourselves to go after resolving and improving human movement not just isolating muscles and using bouncy balls and rubber bands. Understanding human movement is a noble cause and one we need to take much more seriously.

Next question I borrowed from Tracy Sher, MPT, CSCS:

Don’t be so mouthy to your parents and be warned that braces and headgear are in your future, bro!

Are you an APTA Member? Why or why not?

Yes I am an APTA member. I think it’s important because while I don’t agree with everything the APTA says/does, it gives us a professional voice and a seat at the table. It’s like paying for college: it’s expensive and you don’t love every class but you know it’s the best thing for you.

What advice do you have for today’s DPT Students?

Having a reason for everything that we do as physios. Having a paradigm for progression/regression as well as using a test-retest model that exposes the client to the intervention based on your hypothesis and then gauges their response is crucial! It’s what separates the zeros from the heroes. The key is to recognize patterns and that means a lot of deliberate practice. Experience itself does not equate to expertise; deliberate, thoughtful experience while being driven by what we don’t know yields expertise.

Expose yourself to other ideas outside of physio. Yoga, massage therapy, kettlebells, Oly lifting, anything. We try to own these little silos of information without considering other, often very effective, schools of thought. Way too many PTs have no clue about training methods and movements which is rather ridiculous. If you yourself cannot pull, push, press, and squat how the hell can you expect to have face validity when calling yourself a sports physio or trying to coach a patient (and yes everyone should be able to perform those movements in some capacity). Because ultimately PTs are movement coaches so take pride in owning movement.

Which blogs do you read the most?

I love Kelly Starrett’s mobilitywod.com, he has been a big inspiration for me. Charlie Weingroff always has a ton of insight when he posts. Mike Reinold, Eric Cressey, Jarod Carter. Seth Godin’s blog. And obviously….CinemaSays.wordpress.com, your piece on “Evidence-Based” Practice was spot on.

Life is an adventure. Let’s close by you sharing one of your life’s best adventures so far.

Well, I thought about getting all philosophical here but I think I’ve done enough of that already in this interview. So instead I’ll keep it real: I did some rafting with friends on a bunch of class V rapids on the Upper Gauley in West Virginia last year and it was quite an adventure.

Thank you for the incredibly thoughtful questions, this has been a pleasure.

Seth, thank you for sharing your thoughts. I highly recommend checking out his blog; and you can find Seth on twitter. I look forward to more of your work.

Seth recommended The Story of the Human Body by Dan Leiberman. If you have any interest in the human body, then I can’t recommend this book enough – pick it up. Meanwhile, you can read some of my favorite quotes and passages from the book via this dedicated twitter thread.


Interview with Jessica McKinney, PT, MS

This interview’s guest is none other than Jessica McKinney, PT, MS – proud member of #PelvicMafia and Co-Founder of Marathon Physical Therapy and Spine Medicine located in the suburbs of Boston, MA. As you’ll soon read, Jessica has been a very busy lady lately. She even published an article titled “Pelvic Floor Muscle Evaluation Findings in Patients with Urinary Incontinence” in the Journal of Women’s Health Physical Therapy.

Jessica founded Women’s ACTION Initiative – a non-profit that empowers women to prioritize Pelvic & Pre-natal Health in the US & abroad. Her practice, Marathon, also supports Share Mayflowers (Twitter) launched by Women’s ACTION Initiative (Twitter) as a public awareness campaign focused primarily on the topics of female pelvic and perinatal health.

Jessica’s passionate involvement in her field is a huge source of inspiration for me. I encourage you to contribute to and/or participate with the above-mentioned charities.

In this interview, we get into the backstory of her current practice and lessons reaped from the experience so far. We’ve just scratched the surface; I hope to dig a bit further in a future follow-up interview. Enjoy!

What sparked your initial interest in Physical Therapy?

Truth – mom and dad are in healthcare and church ministry, respectively. Add to it that I’m a first child and I think I had no alternative but to follow their example and go into some ‘helping’ profession!!! I seriously started considering healthcare as a profession around 9th did a science project with my mom on the body’s inflammatory process (by scraping my arm, taping glass slides to it for a few days, then looking at the slides under a microscope)…a project that helped me conclude that working at a microscope wasn’t a great fit for me! Meanwhile, my mom hurt her knee skiing and went to physical therapy. After this personal experience, it was her suggestion that I explore PT as a career. I was 15, then, and have been on this career path ever since.

How has your practice of Physical Therapy changed over the years?

I jumped into orthopedic manual therapy training immediately out of school, while simultaneously beginning to study and cultivate a practice in women’s health (pelvic and obstetrics). It is hardly the case now, but at that time those two worlds didn’t really mingle. As such, I took longer than I would’ve liked to connect the two worlds in my own practice. As the years have passed, I certainly find my own practice of the two “specialties” indistinguishable.

Virtually all of my clinical care is with obstetric and pelvic health populations, but I am just as likely to address persistent postural issues or gait abnormalities stemming from lower quadrant dysfunction, as I am to address the pelvic floor directly. I also am incredibly excited about how contemporary neuroscience and the empowerment of education are influencing my current practice. It is a very exciting time!

What lead you into pelvic health?

Pelvic health is the absolute last place I thought I would be. Honestly, in our very modest exposure during PT school, I thought it was quite possibly the grossest direction my career could take. Thankfully, I don’t always know what is best for me! My last clinical affiliation serendipitously afforded me steady exposure to both obstetrics and pelvic health, and I was hooked. Through my clinical instructor, Genne MacDonald, and our patient interactions, I saw such a human side to women’s health and the effects of treating – or not treating – pelvic floor dysfunction. I was someone drawn to PT so much by the desire to have a career that helped people, and I was hooked. The field of pelvic health requires a brilliant combination of service, emotional intelligence, and clinical problem-solving, plus a dash of social justice…its been such a nice fit for me and I am forever grateful for my unexpected exposure at the beginning of my career!

Congrats on 10 years of Marathon Physical Therapy! What drove you to start your own practice?

This may be the easiest answer of all the ones in this interview, and to which I must acknowledge that it was completely a joint effort with my husband, J. Alex McKinney (physical therapist, massage therapist, and strength and conditioning specialist)! We both began our professional life in Chicago, Alex with AthletiCo and I was with SRI Physical Therapy and we loved our jobs. No kidding…if we still lived in Chicago, I can’t imagine we ever would’ve left those companies! We moved to Boston to be closer to Alex’s family as we were planning starting a family of our own, and neither of us could find a position or company that filled us with the same excitement for innovation and professional growth as the ones we had left behind. So within a year of moving to Boston we decided we were willing to take a run at creating the type of workspace where we could both flourish – and the type of place where others would want to do so, too. It has grown steadily since since inception.

What were the major hurdles you’ve had to overcome over the years (early & recent)? And how did you meet these challenges?

In many ways, the hurdles remain the hurdles.

1. There is a huge challenge in being in the business of PT when your first love – and the only reason you started the business to begin with – is being a clinician. I love being a PT; downright love it. And with Marathon, I wanted to create a place where PTs who love being PTs can flourish, and do it in a collaborative way with other team-members who love what they’re doing just the same (athletic trainers, massage therapists, strength and conditioning specialists, & more). Learning to operate as a business owner in order to make this dream a reality is a hurdle I face continually.

2. Massachusetts is a tough market. High cost of living, lower-than-national-average reimbursement, and closed insurance networks. Hurdle, hurdle, hurdle. It has forced us to adopt a nimble and dynamic approach to programs and personnel and to highly value relationships with the people and communities we serve. Makes me feel its kinda like Broadway….if you can make it here, you can make it anywhere!

3. Family. My husband and I founded and run Marathon together, we had our 1st [baby] 3 months to the day after opening the doors of our 1st first 5 years averaged a new baby for our family for every new clinic (babies stopped at 3…clinics going to 6+!). I’ve tripped over that hurdle and landed face down a number of times! We have a tremendous support system – family and loving childcare providers to help with the children and motivated and passionate staff who encourage us to actually take a vacation!

Rumor is that Marathon has some exciting stuff lined up for 2014. What’s up your sleeve?!

2014 has been and continues to be great! There are three main areas where the rumors are true:

1. Student Athletes: Our summer performance enhancement camps and additional programming had hundreds of participants at the middle and high school levels! The program has been building for years and we are thrilled for it to have such a huge year. Very proud of the Marathon Sports Med Team!

2. Women’s and Pelvic Health Education: Throughout 2014 we have been implementing the new School of Pelvic Health curriculum; a series of topical pelvic and obstetric health educational seminars, as well as targeted group and individual exercise, including a yoga component in partnership with Dustienne Miller of Your Pace Yoga. This added program is proving such a valuable piece of comprehensive care in our pelvic and women’s health practice!

3. New Clinics: We have 3 new clinics on track to open before the end of 2014! We are incredibly excited – both for what it means to members of the Marathon team who are a part of this growth, as well as the opportunity for us to become a part of three new communities here in Massachusetts.

Could you share some of the valuable lessons over the years of owning your own practice?

Man, this sounds so corny, but trust your gut – about people, locations, whether owning your own practice is right for you – all of it. Maybe that isn’t a ‘lesson’ for everyone, but it sure has been one for me.

Don’t hire to fill a slot; don’t try a new program because the next guy is doing the same thing…find authenticity in who you are as a practice and what you stand for. Hire, start programs, etc., accordingly. Finding the right fit is crucial in all aspects of the business. Relationships are imperative. Again, this is with staff….does Sally at the front desk have a true passion for country line dancing…and if she does, maybe this opens up a whole new market. Or maybe that just helps to understand why she wants to leave early on Thursdays. Same goes for patients, clients, and referral sources. A course of care is just that, something with a finite limit. But a relationship is something different and allows for a provider, a practice, or a colleague to be a go-to resource, indefinitely.

I’d like your take on Residencies: Would you recommend it? AND how could it affect your hiring process?

In short, I like them. I’m sure I would really love the experience of being a resident, actually (in my pre-kids days! Would be a little too much to juggle right now!). I think that they afford valuable supervised and directed didactic and clinical education in focused practice areas, which is hugely advantageous to any provider looking to ‘go deeper’ than an entry-level skill and knowledge set. That said, I think that we face a few distinct barriers to having more mainstream residency participation – availability of residency slots and reimbursement – the latter of which gets to the hiring process question. As an employer, I would absolutely be interested in the candidate who completed residency, however I operate – as do many others – in a reimbursement landscape that doesn’t account for this type of added professional training. A PT visit is a PT visit and is reimbursed the same, whether performed by a PTA, a new grad PT, a residency-trained and board-certified PT, or a PT with 20 years of experience and advanced degrees. I suspect that as (if…) reimbursement stratification and/or practice patterns allow for higher revenue per visit this will be a boost to the demand for residency-trained PTs. It is a very dynamic landscape now, and will likely remain for quite some time, as we see PTs specializing and contributing to the field through a variety of paths – residencies, fellowships, independent study, hands-on clinical exposure, and the like. We’re an evolving profession, which makes the proliferation of residencies an exciting development, but means I wouldn’t for a second think less of the candidate who has a resume solid with clinical experiences and professional development courses. “It takes all kinds of kinds” – a song by country singer, Miranda Lambert – would seem to sum it up! 🙂

Running a business can get taxing. What measures have you taken to balance work & family life?

Oy!! See above!! Our children are surrounded by people who love them and are invested in their development consistent with how we are. I talk to my kids a lot about why I work – not, “Mommy has to work to buy groceries, school supplies, and pay for our home”, but “Mommy helps take care of other people, especially other mommies, so that they can be healthy and do what they want in life”. When they complain about homework, I talk to them about homework in the context of preparing you for meaningful work later in life.

More linearly, we also keep a few calendars going, including one that shows the kids where mommy and daddy are out late for meetings or traveling for work. Furthermore, we accept that any semblance of balance requires constant communication and readjustment. We’re readjusting all. the. time.

Most impactful books and/or authors?

I particularly enjoy the writings of L. Lewis Wall, MD, PhD, MA, a urogynecologist at Washington University (St Louis, MO) and founder of the Worldwide Fistula Fund. I appreciate his case for obstetric fistula as an international public health problem, and that it could arguably be recognized as a neglected tropical disease. Half the Sky, by Nicholas Kristoff and Sheryl Wu Dunn, was published in 2009 and stands as a manifesto about the plight of women in low resource countries through the lens of human trafficking, gender-based violence, and maternal mortality and morbidity. It can be a hard read, sometimes, but worth it, completely.

I love returning to read previous course manuals (NAIOMT and Herman and Wallace manuals, in particular), as well as the books, articles and/or blogs and musings of several other great thinkers: Diane Lee, Lorimer Moseley, Mary Massery, David Butler, Paul Hodges, Gray Cook, Lee Burton, Erl Pettman, and James Collins (and so many, many more I don’t have time to name!).

If you could travel back in time and face yourself soon after graduating from PT school, then what advice would you give yourself?

Study, travel, and read more before you start your family and trust your gut in bridging pelvic health and your orthopedic manual therapy training. You’ll know enough to do it way earlier than you think.

There’s more to life than work. Tell us about one of your more memorable life adventures.

Hmmmm, do I work too much/find too much “adventure and fun” in work if I’m finding this the hardest response….???? J One thing that consistently comes to mind is the evolving adventure of learning to surf! I’m from southern WV, and didn’t get any natural opportunity for surfing growing up, but somehow have always wanted to know how to ride. My first exposure was on a quick trip to Costa Rica ~5 years ago, and I’ve spent time on beaches in MA, RI, VA, and SC ever since, trying to learn the art and sport of riding a wave. Most of the time, its pretty sloppy and nothing graceful to watch, but never have I been so bad at an activity and loved it so much! I improve every season, I have fun every time I’m out, and geek out about how great it is for my posture and motor control (trunk extension, unstable surface, reaction time, perturbations – great stuff!!)! And last year my 9 year old son and I rode the same (tiny little) wave side by side…memorable life adventure!

Jessica, thanks for the fantastic interview. Looks like 2014 is a fantastic (and very busy!) year for you and everyone at Marathon! I wish you the best of luck, and look forward to doing this again.

Connect with Jessica via Twitter, and find Marathon Physical Therapy and Spine Medicine on Twitter & Facebook.

I am @Cinema_Air

Interview with Brad Beer of POGO Physio

I had the good fortune and privilege to interview the very sought-after Australian Physiotherapist Brad Beer. His accomplishments are too many to list – read about it here (believe me, it’s worth your time). 2014 was a big year for Brad as his company underwent a re-branding under the new moniker of “POGO Physio” on Australia’s gold Coast. The Practice has won a number of business awards, and Brad has worked with a number of elite athletes over the years. I highly recommend you spend some time poking around POGO’s wonderful website, as well as their Youtube Channel. You can also connect with POGO on Twitter.

In this interview, Brad shares his shares his story as a physio, along with vision of physiotherapy and some valuable professional words of wisdom. Also included are bits on physiotherapy in Australia – public perception, Australian healthcare, etc.

I hope it inspires you as much as it did me. Enjoy!


What kindled your interest in physiotherapy? Give us your beginning story.

My interest in physiotherapy began when my running coach referred me to see a terrific physio named Suzanne who lived and hour and a half north of my country town. I was a frustrated and injured junior triathlete with aspirations of progressing out of the junior triathlon ranks into the professional triathlon ranks.

I can’t recall much career coaching while at high school so when my physio said during a consult ‘you’d be a great physio one day’, the seed was sown. Years later I started studying exercise science at the Gold Coast’s griffith University before transferring into the physiotherapy course.

Physiotherapy was the perfect career in which I could pursue my love for helping people to maximise their physical potential. This passion was borne of my own struggles and frustrations as a junior triathlete.

How has your practice evolved since your early career?

I opened my practice 5 months after graduation, and 3 weeks after resigning from my first job. I quickly resigned from my first job. i was working alongside a sports physio in what I thought would be my ‘dream job’. I felt that the practice I was employed at lacked of culture, professionalism, and there seemed very little vision for career progression. So I resigned vowing to ‘do physio how I thought it should be done’.

I opened on an ‘oily rag’. I had less than $5 in the bank, a newly negotiated lease without a rent free period, and a small overdraft facility for equipment and a modest fit out. The practice would have three consulting rooms, reception desk, and a tiny gym area. I was however full of vision and passion for the physio industry. When I started out I had the vision of building Australia’s first recognisable ‘physio brand’. I thought I would achieve this through franchising.

Three years into practice ownership the practice was rapidly growing and we moved locations. At the same time I came across an emerging franchise system in a southern state of Australia. I was captivated by the leader’s vision and after six months my wife and I made the decision to collaborate with this franchise system. Our visions for an Australian brand were congruent and so were our clinical philosophies.

5 years into life as a multi site franchisee and also QLD Franchisor (building a practice network) it became very clear that life as a franchisee was not for me. What ensued was an 18-24 month legal process of unwinding my franchise obligations that ended with me ‘buying back’ my original practice to ‘free it’ from the Franchise network. This has proved very costly.

I see what could have been a ‘set -back’ with my forray into life inside the former franchise group as being a great ‘set up’ for what we now as a newly rebranded practice POGO are setting out to achieve!

It took several metamorphoses to arrive at POGO Physio. What drove many re-births? And what are you trying to accomplish with the new venture?

Yes it did. The original practice name when launched in 2006 was My Back’s Physio (MBP). The vision was to only treat lower back pain-hence the name. This vision was quickly diluted when my first client asked if I could help her with her knee pain. With rent to pay and no savings I said ‘absolutely I can help you with your knee pain’. Sadly the vision was instantly diluted! We traded as MBP for 3 years and under this trading name won a local business award for excellence in customer service in the professional services category.

In late 2009 I joined the practice to a national Australian franchise group (Back In Motion-BIM) becoming QLD’s first franchisee. Our practice was then known as BIM Mermaid Waters. One year later I also became the BIM Area Director for the state of QLD. In my role I oversaw the launch of 3 QLD BIM practices: Bundall, Mt Gravatt, and Bribie Island. We traded with BIM for nearly 5 years.

In late March of this year (2014) I ended my association with BIM and franchising. I exited my franchise agreement for Mermaid Waters and surrendered my QLD Area Director (master franchise) just inside of its first term. This wasn’t an easy or particularly pleasant experience but it was certainly the right direction for me.

In April this year we have rebranded the practice to its third iteration POGO. In short through POGO we are looking to empower people to live pain and injury free so that they can do the things they love to do. On an operational front we are looking to pioneer a new methodology of delivering physiotherapy to the Australian public. We have coined what we call our ‘3P Approach’. The 3P’s being: Pain Free, Performing at an optimal level, and Prolonging the health of one’s physical body. Everything we clinically do is based around this 3P Model.

We will shortly be launching an industry first method of accessing services that overcomes one of the greatest problems that I believe limits the private practice physiotherapy industry in Australia; that is the booking of client from session to session. Such bookings does neither the client nor the therapist any favours. We have come up with a way to ensure that clients get all the care that they need and most importantly their goals are achieved.

Share some of the most important entrepreneurial lessons you’ve learned over the many years of doing business.

Lesson 1: Just start! I like the maxim that ‘production beats perfection’. This has always been a value that I have lived by. In business if you wait until it is perfect you will miss many opportunities.Looking back if I had of known the rigours that awaited me after opening my practice I possibly would not have started! Fortunately I took action and here I am today.

Lesson 2: Take Massive Action. Taking action is one thing. Taking massive action however is where the momentum and magic happens.

Lesson 3: Put people before the task. I used to have this written on my whiteboard. In the fullness of business it’s easy to get overly task focussed. There’s a price to pay when a leader’s focus is taken off their people and tasks become the number one focus the price is normally the underdevelopment of team members, and a culture that reflects that tasks come before people. We’re in business for people. It’s counterintuitive when we forget this simple truth.

Lesson 4: Customer satisfaction is worthless, customer loyalty is priceless. Nowhere is this more relevant than in health care. The lifetime value of a loyal client can be enormous. Too many practitioners and practices forget that the only way to develop client loyalty is to consistently exceed the expectations of a client. Loyal clients will ‘fight’ to leave you based on the high level of trust that has been developed over time. They will also be strong referrers and word of mouth advocates for your service.

Lesson 5: Start with Why. Simon Sinek says that there are leaders and then there are those who ‘lead’. The best leaders are the ones who start with ‘why’. They regularly and clearly articulate the ‘why’ of their organisations. Starting with ‘why’ gives people a sense of purpose and belonging, and a cause for action.When what an organisation does is in sync with why the organisation exists the organisation will ‘stand out’. These organisations will have the most loyal staff and also customers.

How did you come up with “POGO”? I like it! “POGO” sounds interesting & fun at the same time!

The name POGO was derived through a brand creation strategy and process that we undertook with a leading creative agency. The name matched the criteria I was looking for on all levels. Best of all the name embodies movement and being memorable-two key components of what we do.The feedback we have had from our clients has been terrific.

The essence of POGO is to empower people to live pain and injury free so they can have daily fun. We have three founding values and they are: 1. Excellence in delivery, 2. Our customer is our hero, and 3. Have Daily Fun. Having fun is a core value as we really do want to inject some ‘zest and energy’ into the private practice sector.

I noticed POGO offers a “100% Money Back Guarantee”. That’s a pretty brave lure. How does this guarantee work? Is POGO a cash practice?

Having a service guarantee has always been something that I have strongly believed in. I see it as a way of ensuring that client’s know we believe in our ability to deliver results. POGO’s guarantee is a Results or We’re Free Guarantee. This means that if we fail to get the client the result they are after we will happily refund their consultation fees. You can read more at The POGO Way.

Most of us in the US aren’t very familiar with Australian Healthcare. Tell us about how physio works within the Australian system today.

Physiotherapy has a proud history in Australia. Physiotherapists are first contact practitioners . This means that the public can come direct to their local physio. They do not need a doctor’s referral to make an appointment. There are times when a doctor’s referral is necessary such as for third party insurance claims.

The Australian government runs an initiative known as the Enhanced Primary Care (EPC) Plan. This enables sufferers of chronic conditions to access up to 5 physiotherapy sessions bulk billed each year. The scheme is funded by Australia’s Medicare.

Patients can access physio services in private practice and claim private health insurance rebates on the spot via their health insurer. As of the 24th July 2014 11 million Australian’s have private health insurance. This is up from 9.8 million people in 2009. The government pays a 30% rebate on annual private health insurance premiums. Privately insured clients are the largest clientele group we see at POGO.

What is the relationship between physios and other healthcare providers? (General physicians, surgeons & specialists, etc.)

The current breed of both general practitioners (GP’s) and orthopaedic surgeons tend to embrace the value and expertise that physiotherapists bring to the health-care sector. Long gone are the days where some medical practitioners did not refer to physiotherapists but rather sought to maintain clinical sovereignty at all times. Even if ultimately this was to the patient’s less than ideal clinical outcome.

What about the public perception of physios? How has it changed over the years? What do you think helped or hindered this image?

I believe the public perception of physiotherapy and the role that physios play in the Australian health-care sector has continually grown over the last decade. One of the key drivers for this I believe is the love affair Aussies have with sport. Stories of our most successful and high profile sporting champions being helped by team physios has been of great benefit to the physio industry.

Australia also has an ageing population. Over the next 40 years the percentage of Australians over 65 yrs is likely to double to around 25% of the total population. With the baby boomers moving into early retirement and seeking to maintain an active lifestyle the overall percentage of Australians visiting physiotherapists will also increase. This presents great opportunities.

You also write for Run For Your Life Magazine. How did this relationship start?

I was approached by the magazine to write a series of articles in 2010. I have enjoyed a great relationship with them over the last several years. It is a terrific magazine.

What lessons have you learned about the writing process and do you have any do’s & don’ts when it comes to writing?

Writing I believe is a key skill that anyone who leads people or a cause needs to have some ability with. Writing is like any skill it requires practice in order to improve.

In today’s content marketing rich world there has never been a greater need or opportunity for those who write well to command a following an influence within an industry.

It’s imperative that you identify your ‘editorial mission’. This is basically your strategy that you will espouse when you write and generate content. I have discovered that writing minimising jargon, with some personality, and with the intention of helping people yields the greatest results.

Favorite books & authors? Reading recommendations? (personally & professionally)

Great question!

I love reading. It has long been a hobby of mine. I fell in love with books whilst still a university student.

Numerous books have impacted me throughout my physio career. Of note would be:

1. How to Win Friends and Influence People (Dale Carnegie). This book really turned the ‘switch on’ for my quest to develop ‘people skills’. It seeded my interest in personal development.
2. The 21 Irrefutable Laws of Leadership (John Maxwell). Once I realised that my effectiveness was determined by my leadership ability I became a student of leadership. John Maxwell’s many books have always yielded great learnings.
3. The Disease to Please (Harriet Braiker). This book helped me to overcome my pathological problem of people pleasing-it set me free to say ‘no’!
4. 100 Great Businesses and the Minds Behind Them (E Ross and A Holland). This book inspired me to dream!
5. Too Busy Not to Pray (Bill Hybels). Self explanatory-it’s easy to get so busy that you neglect to make room and time for that which in my life is ultimately the most important.
6. Ordering Your Private World (Gordon MacDonald). This is a book about living life from the inside out. It’s about cultivating the inner victory required to be publicly effective.
7. A Resilient Life (Gordon MacDonald). This book draws on the metaphor of running life’s with intentionality and grace just as a gifted runner approaches a race. It taught me the value of spiritual self discipline to build stamina and grit for the challenges that lie up ahead.
8. EntreLeadership (Dave Ramsey). A great book that shares terrific leadership lessons cultivated through being in the trenches of growing a world class business. It’s a rule-book for doing business well.
9. The 22 Immutable Laws of Marketing (Al Reis and Jack Trout). As student of marketing this is a classic. These are laws violate them in your marketing and you will pay a penalty.
10. Personality Plus at Work (Florence Littauer). Harnessing the power of personality equips a leader to revolutionise their relationships. Business is all about people and therefore all about relationships.
11. The 5 Dysfunctions of a Team (Patrick Lencioni). A great and memorable leadership fable.
12. Customer Satisfaction is Worthless Customer Loyalty is Priceless (Jeffrey Gittomer). Helps develop a real sense of the value of loyalty over a satisfied client.
13. Think Bigger (Michael Hill). A great read about not limiting your vision of the future.
14. Good to Great (Jim Collins). Vital ideas for any business that is looking to stand out.
15. Axiom (Bill Hybels). This is a such a fun but impacting read.It contains 76 easy to digest and memorable axioms of leadership.
16. The Entrepreneur Revolution (Daniel Priestly). The rules of business have changed and continue to change. The new revolution has begun!

Most recently Simon Sinek’s ‘Start with Why’ has me absorbed!

You have a full plate! How do you manage to maximize your life – professional & personal – given how busy you are?

It’s a full week! I start early at 4am with marketing and email answering. I also treat with a full time case -load. In addition I train for my running endeavours and also ensure time for my wife and beautiful daughter Bella. My wife is a GP who specialises in nutritional medicine (www.drcris.com.au) which helps in understanding each other’s work responsibilities.

It’s a constant juggle. You really do have to at times ‘fight’ to maintain boundaries. It’s so easy to make work your idol. Even more so when you love what you do!

Imagine if you could pick up the phone and call your younger self right after graduating physio school, then what advice would you give him?

Great question. My advice would be two-fold:

1. To not ‘look side-ways’. Avoid the comparison game. The grass may appear to be greener but it rarely is!
2. Be patient. Success is developed through the navigation of an array of challenges and various learning opportunities that life both professionally and personally generates.The degree to which you succeed and progresswill be determined by the degree that you stop to evaluate your learnings and lessons.It has been said that experience is an OK teacher but evaluated experience is an even better teacher.

Visiting Australia is on my to-do list. What are your top 3 must-do/see/experience items in the Gold Coast? (Other than stopping by POGO!)

Ha ha! Yes a POGO visit is number one!

Other great experiences here on the Gold Coast would be:

1. A surf at Surfers Paradise or one of our famed surf breaks (Kirra or Burleigh).
2. A visit to our renowned theme parks (Dreamworld, MovieWorld, SeaWorld etc).
3. A trip to the top of the Q1-the tallest building in the city. It will give you unprecedented views of this great city!

Brad, thank you for your time and valuable insights. I feel like there’s a lot more ground we could have covered. Let’s do this again sometime…preferably on a Gold Coast beach with drinks in hand!

You can connect directly with Brad via Twitter. Also, be sure to follow POGO Physio on Twitter & Facebook.

I am @Cinema_Air