CEU Review: DN-1 & DN-2

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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.

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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?

https://twitter.com/Cinema_Air/status/682608338383683584

@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.

https://twitter.com/TheAwesome_PT/status/682663763305082880

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

Book Review: You Can Run Pain Free! by Brad Beer

I had the pleasure of interviewing Brad Beer last year. It was a fantastic interview – I learned a ton.

Not too long after the interview Brad published a book titled “You can run pain free!” For full disclosure, Brad provided me with a copy of his book for review – Thank You!

My verdict: It’s worth your time.

Physiotherapists and other clinicians will benefit from Brad’s pragmatic blend of research and reality. The book also provides the general public with a solid background of how to evaluate themselves, progress their running, and communicate better with their Physiotherapist when needed.

5 REASONS THIS BOOK IS WORTH YOUR TIME

IT PROVIDES A GUIDING FRAMEWORK. This framework puts the novice runner into a better first step, and can give him/her a more nuanced view on efficient and pain-free running than the average new runner. Many weekend and seasonal runners can also benefit from this book for the same reason: they are now equipped with tools for faster and pain-free running.

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PSYCHOSOCIAL PERSPECTIVES. Brad does a very nice job integrating the psychology of running injuries and their impact on returning from injuries. His views on this are beneficial to both runners, as well as Physiotherapists who work with runners. Here’s one of my favorite passages on this topic.

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METAPHORS & COMMUNICATIONS. It is becoming ever-more clear that the way we (Physio’s) communicate with our patients has a direct impact on their recovery. Brad uses a variety of metaphors in his book to steer the runner into a healthier mindset that allows him/her to believe in their own potential. This alone is worth the read for clinicians and runners in general. His concept of “Frame Weight” is one of many clever expressions peppered through the book.

MORE THAN THEORETICAL. While Brad cites published literature throughout his text, he manages to integrate the lessons he has gleaned from his personal and professional empirical distillations. A nice example of this is his perspective on overtraining.

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OPPORTUNITY TO LEVERAGE BRAD”S EXPERIENCE. Brad experienced a knee injury that eventually underwent surgical repair and was told that his running days were behind him. Well, time has proved those words false. Brad completed the NYC Marathon in 2015!

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How did he do it? What did he learn through his years since his knee injury? What can you learn from his experiences? You Can Run Pain Free! is a synopsis of what he has learned and applied over the years. It’s more than an academic exercise, it’s a pragmatic text based on his personal & professional experiences.

Here’s a quick blurb Brad posted just prior to his book launch.

You can pick up You Can Run Pain Free! here.

@Cinema_Air

5 Lessons Physical Therapists can Learn from Bruce Lee

I wrote a guest post for Strive Labs. Check it out:

“Bruce Lee is one of my personal heroes. While there are many reasons I admire him, I find his philosophical approach to everything the most salient and magnetic feature of admiration. We can learn numerous lessons from his life. Here are 5 lessons that apply to Physical Therapists as individuals, and Physical Therapy as a profession.”

Continue reading…

Andre Agassi on his Back Pain

Tiger Woods’ remarks about his back pain spawned a rumble in the physio community. This piece by Peter O’Sullivan sums things up nicely. My favorite thing about Peter’s write-up is that it’s aimed at health care providers, not the athlete. Tiger’s latest injury involves his right wrist:

Keeping with the theme of athletes and their bodies, check out the following excerpts from Andre Agassi’s autobiography, Open, describing his experience with back pain. It’s a great first person’s view on the relationship between back pain and emotions.

Now rising from the center of the fatigue comes the first wave of pain. I grab my back. It grabs me. I feel as if someone snuck in during the night and attached one of those anti-theft steering wheel locks to my spine. How can I play the U.S. Open with the Club on my spine?

I was born with a spondylolisthesis, meaning a bottom vertebrae that parted from the other vertebrae, struck out on its own, rebelled. (It’s the main reason for my pigeon-toed walk.) With this one vertebra out of sync, there’s less room for the nerves inside the column of my spine, and with the slightest movement the nerves feel that much more crowded. Throw in two herniated discs and a bone that won’t stop growing in a futile effort to protect the damaged area, and those nerves start to feel downright catastrophic. When the nerves protest their cramped quarters, when they send out distress signals, a pain runs up and down my leg that makes me suck in my breath and speak in tongues. At such moments the only relief is to lie down and wait. Sometimes, however, the moment arrives in the middle of the match. Then the only remedy is to alter my game – swing differently, run differently, do everything differently. That’s when my muscles spasm. Everyone avoids change; muscles can’t abide it. Told to change, my muscles join the spinal rebellion, and soon my whole body is at war with itself.

The cortosine injection:

I stretched out on the table, face down, and the nurse yanked down my shorts. The doctor said he needed to get his seven-inch needle as close to the inflamed nerves as possible. But he couldn’t enter directly, because my herniated disc and bone spur were blocking the path. His attempts to circumvent them, to break the Club, sent me through the roof. First he inserted the needle. Then he positioned a big machine over my back to see how close the needle was to the nerves. He needed to get that needle almost flush against the nerves, he said, without actually touching. If it were to touch the nerves, even if it were to only nick the nerves, the pain would ruin me for the tournament. It could also be life-changing. In and out and around, he maneuvered the needle, until my eyes filled with water.

Finally he hit the spot. Bull’s-eye, he said.

In went the cortisone. The burning sensation made me bite my lip. Then came the pressure. I felt infused, embalmed. The tiny space in my spine where the nerves are housed began to feel vacuum packed. The pressure built until I thought my back would burst.

Pressure is how you know everything’s working, the doctor said.

Words to live by, Doc.

Soon the pain felt wonderful, almost sweet, because it was the kind that you can tell precedes relief. But maybe all pain is like that.

Perception of our bodies, pains, and injuries can have stunningly strong effects on our daily function.

Andre Agassi’s book is the first autobiography I’ve read cover to cover. And, it’s one I’ll be re-reading over & over. Pick it up here.

@Cinema_Air

Edo, Nelson, & I chat about the new KinetaCore Educational Center

Dr. Edo Zylstra, PT, DPT, MS, OCS, IMSP recently reached out to me about the latest KinetaCore evolution: The KinetaCore Educational Center in Ashburn, VA launching on March 19th.You can find some introductory information about it here, and the interview you are about to read will go in-depth into the intentions, hopes, and experience of the new Facility. He partnered with Nelson Min, PT, MS, ATC to launch this First-Of-Its-Kind facility. Not only is Mr. Min a lead instructor for KinetaCore, but he is also a practicing clinic-owner. Many of you are already familiar with Dr. Edo Zylstra; if not, then check out our first interview.

Congratulation & Good Luck to KinetaCore, Dr. Zylstra & Mr. Min on their latest venture!

Enjoy the interview!


First, let’s get to know Nelson Min. Nelson, what lead you into the wonderful world of Physical Therapy?

Nelson: I am very blessed to be a physical therapist.  I think the PT’s I came across early on were amazing people and they had a strong and lasting influence in my pursuit of being a physical therapist.  I grew up in Delaware and they have an incredibly strong PT program there at the University of Delaware.  These were some amazingly skilled PTs who had such a good presence in the community.  They were also such a close knit group.  I just saw how interactive and rewarding this field can be because of these individuals who were really good PT’s and even better people.

Nelson, tell us about your history with KinetaCore. How did it start? And, how has it grown to where it is today?

Nelson: One of the keys to being a good PT is drive for continued learning.  There is so much to learn and I am continuously amazed at how much good info is out there.  I really enjoy taking continuing education courses and I realized that the more I progressed in my training the more these highly respected educators recommended incorporating dry needling into my skill set.

I took my first course at Regis University in 2009.  The professionalism and expertise of Edo and his staff for that class was such an inspiration.  The immediate results I noticed on my self over a weekend were undeniable.  Dry needling is such a great adjunct to any physical therapist and I knew I had to be a part of this company.

So, Edo & Nelson, there’s a new venture that’s about to launch on March 19th. Tell us about The KinetaCore Educational Center. What motivated its formation? And, what is it that you hope this will do for the profession of Physical Therapy?

Nelson: Functional Dry Needling® has changed my practice and how I practice.  It has made my already successful clinic into an even more successful and thriving one.  We want to share this with as many PT’s out there to hopefully make them even more successful in their businesses.

We also want to share this technique with the public.  It helps with such a diverse number of dysfunction that patients deal with, improved function is the goal but it also helps with pain and increased mobility and muscle function to name a few other benefits.  It has dramatically helped me in improving my patient’s outcomes.

We started the Kinetacore Education Center to achieve the goal of educating our profession with this technique in a setting that promotes the learning experience.  What typically happens with con-ed is to offer it in a PT clinic or facility and adjust it to the needs of a con-ed course.  In other words, you work with what you have available.  Our teaching center has no associated clinic. The design is for learning.  Three HD ceiling projectors and total surround sound gives any participant clear audio and visual regardless of their vantage point.

The other speakers we will be featuring include some of the most influential and sought after educators in our profession.  These educators have incredibly tight schedules and share a passion of advancing our profession.  We now have a facility where we don’t have to worry about the logistics of closing a PT clinic which often interferes with hosting some of these professionals.

How did/do you choose the instructors for the new KinetaCore Educational Center? What qualifications and qualities are you looking for?

Nelson: We are looking for instructors who have a passion for the advancement of our profession.  We look for skilled, intelligent and caring individuals who invest in the goal of advancing our profession with this technique and want to further our understanding of its mechanism and how to teach it more effectively.

All instructors are trained in Functional Dry Needling (FDN®) and require one year of clinical use before being considered as an instructor.   They are then required to go through a training process over three separate audits to safely and carefully progress them to independence in supervising and instructing. The training process concludes in a final check off with our senior instructors (Edo if possible)  to ensure quality and consistency with what and how is it presented.

We require that you are trained in our technique to be able to teach our system of dry needling.  These gifted individuals usually stand out during training process and it usually comes as no surprise when they first inquire about the opportunity.

I’m glad you mentioned not just the clinical aspect, but also the business dividends of Functional Dry Needling®. What is KinetaCore doing to promote Dry Needling to increase public awareness in the US?

Nelson: Edo has done such behind the scenes work with working with the APTA and several state boards to help incorporate dry needling into the state’s scope of practice acts .  He is one of the individuals who drafted the resource paper on dry needling for the APTA in 2012 and was recently accepted to be a part of the Federation of State Boards of Physical Therapy Dry Needling task force.  I think Edo brings public attention to this skill the right way by approaching this from the top down.

We also want to empower our participants.  Our website is a labour of love with marketing materials and electronic brochures.  The most important part of the website, however, are the educational videos that are constantly being updated for continued improvement of techniques and also the “Find a Therapist” feature.  This allows the clinician to market their practice.  Our google ranking is so fine tuned that our participants who sign up for the website membership can expect to get a number of people finding them through this feature on the web.  Ultimately, we feel the best way to market this technique is by delivering a good product which is a skilled PT  focusing on safety and proper technique.

Our goal is to be the support for all of our participants in this.  We have a system for participants to communicate with our instructors to answer any questions that may come up as they integrate this technique into their practice.  Each lead instructor receives dozens of emails a day from our past participants with solid questions.

How expansive will the course offerings range?

Nelson: We will be offering our course series of Functional Dry Needling® level 1 and 2, and Functional Therapeutics throughout the year.  In addition we will be hosting several manual therapy courses including Extremity Manipulation by Gail Malloy, The Changing Dynamic of the Scientific and Clinical Rationale for the Treatment of Selected Knee conditions by George Davies, Spinal Manipulation by Louie Puentedera, and SFMA for dry needlers by Kyle Kiesel.  I am still working on adding more courses spanning a vast topic range for the remainder of this year and next.

Edo:  I also have a goal to open up this teaching model and center up to other medical professions to give them a cost effective way to host educational courses for their specific professions as well.  That is as goal that we will try to realize over the next few year.

To the best of my understanding KinetaCore requires 200 treatment session of practice/experience after Functional Dry Needling® Part 1 prior to taking Part 2. Why is it set up this way? And, is this something KinetaCore pushes for when lobbying for inclusion of Dry Needling in State Practice Acts across the US?

Nelson: As expected the skill of handling a needle for people coming into our FDN1 course can be pretty limited.  Our bottom line is safety so we limit some of the more challenging muscles to level 2. Muscles that we feel need a more refined skill level to treat are placed into the level 2 course.   We require 200 practice sessions for our participants so that they are better prepared for the requirements of the level 2 course.  We feel that this skill level can only come about with practice.

Walk me through what it would be like to take my first course at the KinetaCore Educational Center. Class size, number of instructors per course, course progression, lab/hands-on time, etc.

Nelson: The class size varies but shouldn’t affect the learning experience because of our adherence to an average instructor to student ratio of 1 to 7.  We have a rule with our participants that if they feel they are not getting enough supervision, they need to indicate this so we can fulfill their needs.  It is the responsibility of both the instructor and the participant to make sure they have the optimal learning environment.  Exposure to as many instructors as possible gives the participant a much broader understanding of the application of the technique, so we purposefully rotate instructors and have the participants work with various body types through the weekend.

The first part of the course is our didactic lecture in order to lay down the framework of dry needling with its history, theory, research and integration.  We are then in lab for the remainder of the course systematically covering the entire body by regions in our small group labs.

Each of these small groups is first led by our instructors reviewing anatomy and then demonstrating technique.  We then have our participants pair up and practice the demonstrated technique for that region while carefully sweeping the room providing close supervision.

At the end of the second day, we have everyone go through another review process so that they can pair with another partner and get a different instructor to watch them.  We just want each participant to get as much supervision from multiple instructors as possible.

On the third day, each participant is tested both practically and theoretically.  There is no guarantee of passing and we have options for people who do not pass the testing.  We take this very seriously and give our students as much time as possible to practice, often staying late on Friday and Saturday evening working with our participants and giving them more one on one instruction.

Is there anything else you would like to share about the KinetaCore Education Center that we haven’t addressed?

Nelson: Our teaching center was designed to offer the best in continuing education.  We have some high end AV to show our detailed lecture notes as well as an interactive approach to see the anatomy simultaneously.  There are some high end anatomy apps out there now very conducive for learning and we incorporate them with our lectures and labs for a wonderful learning experience.

Because of the layout of the course, there is no bad vantage point.  You get a great view of the screen regardless of where you sit.  We have high end audio spread out uniformly throughout the venue as well so you get a clear sound regardless of where you are sitting as well.

Edo:  This is our first venture specifically developing a center devoted to higher learning for the medical professional.  If this is successful, I anticipate this as a first of many centers around the United States.  We are so thankful for all the support we have received from our families, friends and colleagues as we go faithfully into this adventure.

Thank you Edo & Nelson for this informative interview, as well as for allowing me the opportunity to share it with my audience. I wish both you the best of luck in your latest venture!

Connect with Dr. Edo Zylstra and Nelson Min on Twitter: @EdoZylstra & @NelsonMin2000

Also, find me at @Cinema_Air.

What kind of runner are you built to be?

Recently the question came up about minimalist shoes and if I was an advocate of them. In general I don’t think they’re a good idea and here’s why: The primary focus of the shoe is to attenuate ground reaction forces of landing. Barefoot or minimalist footwear fails in this prerequisite.

Now maybe you are scratching your head because many people have transitioned to minimalist footwear and have found joy by getting off of their heels?! So why did the shoes work for select percentage of the population and why do we have others that are non-responders and end up with stress fractures?

The key comes back to our anatomy and myokinematics (our own unique activation patterns). The dispersion of ground force reactions to a large extent is managed by how the tibia transitions over the ankle. Some people are blessed with wonderful enhancements to the tibialis anterior muscle. These folks are naturally able to heel strike and allow the tibialis anterior to eccentricly control the foot to the ground. Others are more dominant in their calves & when they attempt to land on their heel, transmit far too much force to their knees. A better way for them to manage the impact is to land in a relative plantar flexed position and eccentricly disperse the load through their calves.

So if you give someone a pair of unpadded shoes and they are not built to manage the forces through their calves (said another way-get off their heels), even with all the transitioning time in the world they will never adopt a pattern that will protect them from injury. Eventually one of two things happens: the energy requirements for that gait style are too excessive or generalized fatigue of the activity brings on a neurologic malaise and the runner breaks down.

Conversely, if you give someone who was always meant to be dominant with their calves permission to do such, it’s a religious experience!

Hopefully in the not-too-distant future, we’ll talk about the softness of the shoes and optimizing your strides.

There is some good data out there that for every ounce you take off your feet, your efficiency increases by 1%. If you want to incorporate some speed training into your regimes-go to a reputable running store and buy a pair of 5K shoes instead of minimalist footwear.

* just don’t go try and run a marathon in your new 5K kicks.

@alpineathlete

Interview with Nick Nordtvedt – The Remix

It’s officially the Holidays, and I’m feeling a bit nostalgic. So I decided to catch up with @NickTNpt. I’m extra grateful to Dr. Nick Nordtvedt, DPT, Cert MDT for being my first interviewee and getting my interview series rolling. You can read the first interview here

Enjoy Round 2!


First, what did you have for breakfast today?

Eggs everyday!

What sparked your initial interest in Physical Therapy?

I spent my first two years in college bouncing around between a few different majors. I hadn’t studied anything that really excited me. I started working at a physical therapy clinic for about a year, and I really enjoyed the interaction with people and helping improve their quality of life. I also liked the private practice atmosphere.

What is it about the Private Practice atmosphere that you find so attractive?

I like the idea of “being my own boss.” I have never owned a practice that I’ve worked at, but I have always been involved in day to day operations of running a clinic. I like to drive my own referrals and network with other medical professionals and businesspeople around me.

Per our first interview, you were reading Lore of Running by Timothy Noakes. What did you make of it?

Honestly, I haven’t finished it yet! I think it’s about 6 inches thick. I’ve read it on and off over the last year, and have used a lot of the information to apply to patients seeing me for orthopedic issues besides just running.

I just finished reading The Zappos Experience by Joseph A. Michelli. This is a great book about Zappos focus on the entire customer experience, a must read for anyone in business or private practice.

What ideas or concepts from The Zappos Experience stand out to you?

Wowing customers by providing them with an exceptional customer service experience. Most people don’t go to physical therapy because they want to. Something has happened, known or unknown, where they find themselves in need of rehabilitative services. My first goal, and what I tell all my support staff, is to make every person that walks through the door feel as comfortable and welcome as possible. Next, you have to go out of your way to make the patient’s treatment about him or her, not about you. You can talk about yourself or share a story, but it should always be to engage the patient so you can learn more about them. Finally, give more than they expect. This isn’t necessarily giving them an object or something they can possess. This means taking the time to listen and understand what they are trying to tell you, and going the extra mile to provide them with an unparalleled customer service experience that they won’t receive any where else.

Imagine you had an unlimited budget to set up your Private Practice. How would you spend this unlimited budget on your fantasy clinic?

Wow! I’m not sure where I would end, the possibilities are endless! But, I definitely know where I would begin. I think that the most important things to invest in off the bat in a new business are a great support staff and community support.

If you don’t have the right people in place, your business will struggle. This goes for front office staff just as much (maybe more so) than clinical staff. The initial contact a patient or physician’s office has with your clinic is so important. If they don’t get a feeling of welcomeness and understanding from the non-clinical staff, that makes for a much more challenging experience for the clinician. With my unlimited budget, I would first make sure that I had the right staff with the right training.

Second, I would invest in community activity and support. This should actually not be all that expensive if you look for the right opportunities-community festivals, sporting events, health fairs…the list could be endless. Being a part of the community and talking to people will get you a whole lot further than a fancy TV ad!

Let’s fast-forward to your retirement party. What would you want to be able to say about yourself as a Physical Therapist?

I can’t say that I’m looking forward to retirement anytime soon, but when (if) I retire, my hope is that people say that I listened to them and had a genuine interest in helping them.

Top 3 favorite blogs?

Limit to three?! I can’t limit to any less than 5-in no particular order:

Allan Besselink
Dr. Ben Fung
PT Think Tank
The Manual Therapist
Body In Mind

What are your best ideas to increase APTA Membership?

We HAVE to make students understand the importance of membership and maintaining membership once they become professionals. This has to be done in both arenas of didactic education. Engaging students to participate in APTA events would go a long way to seeing the value of APTA membership. I think PT schools discussing current events in PT practice on a weekly basis would be an easy way for students to further understand the value of APTA. In the clinic, CIs need to take students with them to chapter meetings, state meetings, and legislative events. What worries me is that we will lose some aspect of our practice before people wake up to the need to be an active member in APTA.

How do you decide which Continuing Education Courses you take? What factors play the biggest role in your decision-making?

The biggest factor in deciding which CE courses to take is word of mouth from other clinicians that I know and respect. There are some courses that years ago I would have never expected to take. In talking with other clinicians that have taken certain courses, I discover ways to integrate new ideas and techniques into my current mode of practice to get better results with my patients.

Pick one of the following you want as a Mentor? And why did you choose him/her?
• Jason Bourne
• Wonder Woman
• James Bond
• Princess Leia
• Prof. Charles Xavier (of X-Men)

I would have to choose Jason Bourne. I was on the fence between him and James Bond, but I think Bond gets lucky a lot of the time! Jason Bourne is very self aware and deliberate in his actions which is how I try to act in practice. Plus I’m pretty excited about the new Bourne sequel coming up!

Thanks Nick! Hope 2014 was a great year for you!

You can get in touch with Nick on Twitter @NickTNpt

And find me on Twitter @Cinema_Air

Austin Sheldon – Top 5 Residency Lessons

Dr. Bradley Grohovsky, DPT did a guest post on his Top 5 Residency Lessons So Far. If you haven’t read it, then I encourage to do so. Here we have a guest post by Dr. Austin, Sheldon, DPT on the same topic. 

“Austin Sheldon PT, DPT is currently a staff physical therapist working at Box Butte General Hospital in Alliance, Nebraska. While maintaining a busy outpatient orthopedic caseload, he also assists with the Sports Medicine outreach program by providing pro-bono care for high school athletes, provides in-patient coverage, and occasionally helps with skilled nursing facility coverage. Austin is a 2008 graduate of Regis University’s DPT program. In December of 2013, Austin officially graduated from the Andrews University/NAIOMT orthopedic manual physical therapy residency program’s initial cohort. Currently, Austin is enrolled in Andrews University DScPT program and closing in on the dissertation phase of the program and also is a NAIOMT OMPT fellow-in-training. Clinical areas of interest include patient education, the cervical spine, hip/pelvic girdle, conservative management of pars defects, conservative management of avulsion fractures, pain management, and education. He enjoys the rural western Nebraska life and outdoor opportunities with his wife, son, and two Labrador retrievers.”

Enjoy the read!


Perhaps how I arrived at doing a post-graduate physical therapy residency will resonate with some readers: Put yourself in the shoes of a new graduate. You are ready to take on the world, ready to become a vital member of the healthcare force, and let’s be honest, ready to start making some money. You graduated from a great PT program, learned from leaders in the field, and made some great friends along the way. BUT, along the way, while you spent three years working hard to keep your head above water, your other non-PT school friends were already earning money, traveling the world, paying off undergraduate debt.  You, a newly minted DPT, with student loans from undergraduate AND graduate school, are faced with the reality that the grace period for loans is looming like an un-escapable thundercloud, the closer it gets the bigger it appears…

The situation above is what I was faced with and in talking to students and new graduates, the situation above is all too common. Faced with growing debt and diploma, I applied for and accepted the highest paying job I could get: a SNF. I worked in a sub-acute/LTAC/SNF for the next 2.5 years, earning good money. Don’t’ get me wrong, I enjoyed the patients I worked with, each with medical complexities that needed to be acknowledged, respected, and addressed. My heart warmed when the patients succeeded and left the facility for home; however, I felt a deep professional emptiness. I was burnt out with the bureaucracy of RUGS, of constantly being asked to “look for opportunities for more minutes,” of having my clinical opinions and recommendations trounced, lack of professional growth, and absence of any one to talk to about clinical questions.

Long story shortened: I quit feeling sorry for myself and changed jobs. I became proactive rather than reactive. I moved on to an opportunity where I felt I could flourish personally and professionally. After having accepted the position, I looked into residency options that allowed me to keep my current job and ultimately applied to the Andrews University/NAIOMT program. After a series of interviews, I was accepted and began a nearly two-year long residency program that was formative, both personally and professionally. Without further ado, here is my “Top 5 Things I Learned from Residency:”

1) Don’t Forget How to Read

My residency instructor, mentor, and friend told me this the night we first met face-to-face. I was in Seattle, WA for the first class of the NAIOMT component of the residency program. Brett Windsor PT, PhD(c), MPA, OCS, FAAOMPT looked directly at me and said, “If you want to be the best you can be, read. Read everything. And read it for understanding.” It’s through reading pertinent and relevant literature to the clinical questions you are faced with that foundational differential diagnosis skills and clinical patterns are developed. Too many clinicians use the professional journals they receive from their professional associations as coasters for their morning coffee, collecting dust and stain rings. Open those journals if you get them and aim to read at least one article of interest per week that is applicable to a current clinical case you are managing. Don’t forget that, though your library access to journals from graduate school may have lapsed, PubMed is free to everyone!

2) Don’t Stop Listening

This is applicable to both the patients/clients you interact with as well as the instructors in your residency. When interacting with the patient, take the time to listen to the story he or she is telling you. Don’t interrupt. Part of the therapeutic process is allowing the person in front of you to tell you why he or she is seeking physical therapy to began with. Don’t look at the clock or the phone (that shouldn’t be in your pocket anyway, right Dr.?) or talk through the curtain to a colleague about last night’s “Mad Men” episode.

Part of participating in a post-graduate residency program is to better yourself as a clinician. Again, in the words of my mentor Brett Windsor, “to become a better clinician, you have to learn from someone better than you.” Listen to your mentor and consider what he or she is telling you. Be open to constructive criticism and leave the ego at home.

3) Don’t Discount Mentorship and Relationship-Building

You don’t need to complete a residency or fellowship program to find an invaluable mentor or to build positive relationships with colleagues; however, I am of the opinion that mentorship and relationship-building skills are integral parts of a residency program that will only better your professional development and satisfaction. One of the precipitating factors that lead to my dissatisfaction early in my PT career was the lack formal mentorship. I did not have a senior colleague to bounce problems, ideas, successes, and failures off of.  My mentor and residency instructor made himself available to me via phone, text, email, and in person throughout the program. He selflessly gave of himself at the expense of his time and resources to mentor me. Find a mentor that will challenge you rather than stroke your ego and coddle you.

Social and inter-personal skills are important to become a successful clinician and businessperson too. As part of the residency program’s requirement, I interacted with orthopedic surgeons, interventional radiologists, MSK radiologists, physiatrists, physician assistants, and nurse practitioners.  Understanding other healthcare professionals’ perspective and being able to communicate effectively and positively can only lead to improved inter-disciplinary care.

4) Don’t Become a Technician and Don’t Pigeon-Hole Your Learning

Realize that the primary reason to participate in a residency program (in my opinion) is to improve clinical reasoning and critical thinking, first and foremost.  Upon returning from the AAOMPT conference in Cincinnati last year, I was sitting on a bus at Denver International Airport on the way to long-term parking when I noticed the conference program sticking out of a fellow bus rider’s gigantic purse. I then asked the fellow attendee what she thought of the AAOMPT conference. She looked at me aghast and asked me how I knew she was there; I just pointed at the program hanging out of her purse. Turns out this colleague was Kristin Carpenter, a fellow-in-training through EIM. We had a great conversation and compared our experiences with EIM and NAIOMT as well as our experiences and take-aways from the conference.  The biggest take-away from our conversation was the agreement that clinical reasoning and critical thinking are more important than the psychomotor skills of mobilization, manipulation, dry-needling, etc. that may be learned in a residency program. If you critically think and reason through clinical problems, then the psychomotor skills/techniques you arrive at (if you choose to do anything at all) will develop. Don’t carry out a particular technique and then retrospectively ask yourself why said interaction succeeded or failed; think about what you are doing before, during, and after the interaction.

I think the mark of a good residency program is the realization and openness of the faculty that, while the instructors and mentors may have some answers, insights, and techniques for most clinical situations most of the time, NOBODY knows what do all with every situation 100% of the time. So, as a resident, I was encouraged to participate in other learning opportunities with other programs, institutions, and continuing education providers. In this way, I wasn’t pigeon-holed into uni-lateral group think. Be open to other approaches. Use what you like and what seems to work and forget the rest.

5) Add Value (for the patient/client) to Your Clinical Encounters

Quite simply: What do you add to the patient/client’s well-being that they have not already received? Listen, engage, interact, and connect with the patient. Patient education and activity modification, in my opinion, are two of the most valuable interventions a physical therapist can provide. By educating the patient/client about what is going on (and perhaps more importantly, what IS NOT going on), you are providing re-assurance that improvement is most likely going to occur and providing a “green light” to the patient to explore the world in a safe and pain-free manner. Aside from patient education and activity modification, you also may be the first person to touch the patient and provide a comprehensive examination. Providing hands-on care that facilitates pain-free movement that can then be reinforced through active and independent exercise is also key to adding value to the clinical encounter. The patient/client has “bought in” to physical therapy.

So, those are my “Top 5 Things I’ve Learned from My Residency.” I hope that some of the insight, experiences, and opinions I’ve provided resonate with some of the readers. I’d encourage anybody that strives to become a better physical therapist to explore residency options. Structured learning is important to a point; however, the mentorship, clinical reasoning, and critical thinking that residencies provide are priceless and set the stage for life-long fulfillment in the physical therapy profession.

Find Dr. Sheldon on Twitter: @ASheldDPT


I am @Cinema_Air

Brad Grohovsky: Top 5 Lessons from the Residency Trenches

I am a big proponent of doing a Residency program upon graduation from Physical Therapy school. Not only does it contextualize what you learned in PT School, but it also gives you valuable mentorship that fast-tracks you on your journey to become a better clinician (and more!).

Dr. Bradley Grohovsky, DPT serves on the APTA Private Practice Section Government Affairs Committee and is currently a Resident studying with the Institute of Physical Art at Encompass Physical Therapy in Annapolis, MD – specializing in Functional Manual Therapy™. Brad received his Bachelor’s degree from Western Kentucky in his home state prior to moving to Boston, MA for physical therapy school. While attending Simmons College he also served on the APTA Student Assembly Board of Directors prior to graduating with his Doctorate of Physical Therapy in 2011.”

You can read more of his thoughts here. I recently asked him about the top five lessons he learned from his Residency so far. He responded with this generous guest post. Enjoy!


“Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by external evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient. The practice of evidence-based medicine is a process of life-long, self-directed learning…” (Sackett)

​Physical Therapy is a rapidly evolving profession that is experiencing some revolutionary transitions both in our position in the healthcare system, but more importantly in our clinical skills and approach to patient care. Our profession currently stands at a great pinnacle with an opportunity to integrate into a vital (and missing) medical role in our society as both movement and lifestyle experts. Residency education is a catapult towards clinical expertise – if our profession is truly going to step into this role then we must step up to the plate as clinicians. If you are a student who is about to graduate (or just passed the NPTE..congrats!), a new professional, or a burnt-out experienced veteran I encourage you to check out a Residency in a specialty that interests you!

Here are the top five most valuable lessons of my Residency:

1. There is nothing more valuable than a mentor you respect and who challenges you to be your best.

-Because if you are not being challenged to be a better clinician everyday, then really what’s the point? Having an experienced mentor that challenges you to be your best improves both your skills as a clinician and your patient’s outcomes.

2. Attempt to prove yourself wrong with EVERY patient.

-Develop a hypothesis and use objective pre/post tests to validate your treatment and direct your plan of care. This allows you to develop and test your hypothesis every visit – if your theory isn’t correct, then change your treatment next visit (don’t wait until the next re-eval)! Every treatment becomes evidence-based and the objective information can provide immediate positive feedback for the patient!

3. Use your eyes, but trust your hands.

-More often than not, we are the first clinician to actually touch a patient’s pain. Learn to trust what your hands are telling you – they are your most valuable tool. In the book Outliers, author Malcolm Gladwell claims that 10,000 hours is the amount of time it takes to master a craft and achieve “greatness”. You can’t be Yoda – a Jedi Grand Master PT without mastering the force – and you can’t understand the force without putting in your time in the Jedi Academy.

4. Make every patient understand that this is a team effort.

-This reinforces compliance and accountability, which will encourage long term success. We are the mechanic who can repair broken parts, provide a tune up and clarify sections in the owner’s manual, but it is up to the patient to maintain the condition of their vehicle to the best of his/her ability.

5. Be an intelligent teacher, but an excellent pupil.

-Evidence continues to mount in support of the neuromatrix components of chronic pain involving neural, psychological and social components in addition to the physical presentation (Butler, Moseley, Wardlaw). Patients often teach us how to best treat them, whether intentionally or unintentionally. During treatments, be an active listener – both treat and educate each patient based on his/her individual learning style!

For further Residency reading please check out my recent post on PTHaven.com – To a Residency and Beyond!

Follow me on twitter @DrG_PT

Resources:

1. Sackett: Evidence Based Medicine: What it is and what it isn’t, BMJ 1996;312:71

2. Butler, D: Explain Pain

3. Wardlaw C: Taming Pain

4. Moseley: A Pain Neuromatrix Approach to Patients with Chronic Pain, Manual Therapy 2003


I am @Cinema_Air