Mea Culpa

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

You can’t outrun your fork.

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

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

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How to Study for Physio Specialty Certification Exams

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

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

See.

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

Hear.

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

Smell & Taste.

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

Touch.

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

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

Good Luck!

Cinema

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

Interview with Ramona Horton

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

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

Connect with Ramona on twitter @PelvicViscera. Enjoy!

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

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

What led you into the wonderful world of Physical Therapy?

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

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

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

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

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

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

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

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

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

Learn to get over it

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

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

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

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

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

I am hooked on The Outlander Series by Diana Gabaldon

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

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

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

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

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

Ramona, thanks for this great interview!

Connect with Ramona Horton on twitter @PelvicViscera

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

Cinema

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

Flashback: Year 2 of Interviews!

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

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

Enjoy!


Scott Epsley:

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

Mike Horsfield:

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

Kendra Gagnon:

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

Dr. Justin Dunaway:

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

Alyssa Tait:

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

Dr. Stacie Fruth:

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

Dr. Karen Litzy:

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

Chris Johnson:

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

Justin Moore:

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

Michael Mullin:

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


Thanks for another memorable year!

Best Wishes.

@Cinema_Air

 

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

Interview with Michael Mullin, ATC, PTA, PRC

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

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

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

Enjoy!


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Favorite PT and non-PT books?

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

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

 

Non-PT books I like a lot are:  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Connect with Michael Mullin via twitter: @mjmatc

And find me: @Cinema_Air

Interview with Justin Moore, PT, DPT

Many of you (my readers) have requested that I interview Justin Moore, PT, DPT, (@policy4pt) the ATPA’s lead lobbyist on Capital Hill. And, it finally happened!

We touched on a variety of topics in addition to focusing on the APTA’s engagements in the political & advocacy fronts. For more info on things related to the APTA and Political Action check out this page.

Without further delay, here’s the interview. Enjoy!


You’ve got a unique professional story! You went from graduating College with a degree in Dietetics to Executive Vice President of Public Affairs for the APTA. Tell us your story. How did you get to where you are today?

I hope the story is still evolving. The chapters to date have been shaped by merging personal interests with the required education to practice physical therapy and be part of a profession. I came to physical therapy through an exposure and interest in serving individuals with disabilities. Dietetics was an early chapter by introducing me to the role of public policy and its impact on the health of communities.  Once in physical therapy, I found an environment that encouraged me to combine my interest in politics and public policy with my passion for my profession to begin to build a career. This was encouraged by Jayne Snyder early in my career which lead me to volunteer at the chapter level. These volunteer experiences led me to APTA’s federal and state forums. I joked to the Director of Government Affairs at the time, Nancy Garland, that she needed a PT on her staff. About a year later, she called to see if I was interested in joining staff. Being young and cheap, I was able to take this chance and begin to learn public policy, advocacy and government affairs from a great group of professionals at APTA. I hope this experiment APTA took on me 15 years ago has also opened doors for other PTs to seek non traditional career paths. The chance the organization took on me has been extremely rewarding and never short of challenge on a personal and professional level.

Let’s say someone at a non-PT event asks you “What is Physical Therapy?” How would you respond?

Physical therapy is about helping people get back what they have lost in their physical function and health.  Physical therapists are the bridge from what you currently cannot do physically to what you want to do.  Restoring movement to enable individuals to participate in their home, their work, their sport, their pursuits, and their communications is our core mission and purpose.

Since you have such a strong background in the public policy facet of Physical Therapy, what should every current and future PT know about how to push their profession forward?

To push the profession forward, you need a firm footing in the current public policies that define the profession and determine how, where and with whom we can practice. Understanding and appreciating the state practice act that defines physical therapy scope of practice is both the foundation and the opportunity. This policy provides the platform for recognition by payers and public programs, but also set up our potential to continue to advance our profession. To realize the opportunities ahead we need physical therapists to participate in public policy process from advocating on PT issues to community involvement to show our impact on society.

What is the biggest hurdle to complete Direct Access across the nation? What is the APTA doing toward this effort? And, what can PTs do to further fuel this effort?

Direct access is quickly becoming a reality. All 50 states have some form of direct access and we are seeing more rapid recognition by payers and the public at large. Direct access will only be a part of the equation as we will need to use this authority in different and new ways. Direct access has been incorrectly seen as our desire to seek independent practices and not as a mechanism to build collaborations with other healthcare professionals. These collaborations and partnership will be the next phase of demonstrating the importance of direct access to our practice and our impact on health care. APTA is seeking efforts to continue to expand commercial payer recognition, building the data case on direct access to show its use and value and efforts to educate the public on physical therapy and when to seek the care and services of a physical therapist. PTs should engage in their clinical environment, with their patients, and with payers to ensure that direct access is utilized and leveraged to improve our health care delivery system.

Pick one of the following you want as a Mentor? And why did you choose him/her?

  • Clark Kent (Superman)
  • Wonder Woman
  • Bruce Wayne (Batman)
  • Tony Stark (Ironman)
  • ______________ (your choice)

My knowledge of superheros is sparse, but I’m going to go with Bruce Wayne. I appreciate that he has become a superhero without a significant superpower. His message of leveraging your strengths, being resourceful, and building wisdom through experience and study have made Batman unique in the superhero space and I would love to have that mentorship.

What’s standing in the way of Dry Needling falling under the scope of all Physical Therapists across the US? How can PT’s help?

Physical therapists have been performing this intervention for years and clinician use is increasing. This intervention has also recently been subjected to the classic turf war of one profession seeking to have exclusive rights to this interventions. APTA is seeking legislative, regulatory and legal avenues to allow physical therapists to continue to use this intervention consistent with their education and training. PTs can help but understanding this public policy issue, educating their elected officials, and support efforts in states that are currently defending PTs ability to perform this intervention as part of their practice.

If you could speak to every PT in the US, then what would you tell him/her?

Remember why you choose the profession and keep that front and center every day. It is easy to get discouraged by the changing healthcare environment, the increasing demands, and all the distractions that pull physical therapists away from their purpose of service.

I would also tell every PT to never forgot that your license is yours. You’ve invested the time, energy, and intellect to have the privilege of a license, don’t underestimate it’s value, its potential, or ever compromise it.

Your calling to the profession and protecting your ability to practice by your license will serve you well and allow you to be a part of this great community of caregivers and clinicians.

Favorite books and/or authors? Any recommendations?

I’m not a voracious reader but have attempted to spend more time in books when on the road traveling and in the evening as my children read.   My favorite book is To Kill a Mockingbird (H. Lee). I’m currently reading Go Set a Watchman (H. Lee) and am disappointed in the start and struggling to stick with it.   

I would recommend Boys in the Boat (D. Brown) and Rome 1960 (D. Maraniss), both great story about young men and women coming of age in a changing world. They both have an Olympic thread as well which is an interest of mine as I love the Olympic movement, its history and the drama of each edition of the games. Lastly, I would recommend The Road to Character (D. Brooks). I bought this book for a friend that had just given an eulogy and was captivated by her remarks and the concept of eulogy virtues and how society is moving way from these virtues.   The book has one of my favorite lines and life themes about the importance and value of long obedience in the same direction.

Tell us about the Physical Therapy Outcomes Registry. How has it been going so far?

The registry is the project and initiative that I have been most excited about for some time. It’s potential is profession-changing but not without its significant challenges. The excitement and potential of the registry must be tempered by making it meaningful and easy to participate in at the clinic level. We need to systematically build the registry over the next several years and try to learn from each step and improve its utility and its value to clinicians and the profession at large.

The major hurdle for the registry and public launch of this platform for widespread participation is integration with electronic health records through an established sets of standards. Progress is being made but not at the pace we would like to see.

Do you have any passions or hobbies unrelated to PT?

My emerging and growing passion is about the importance of service and how we can participate in our communities to improve their lives and health. My particular interest is sports, recreation and physical activity for individuals with disabilities or significant impairments. I have two colleagues, one that volunteers with a little league baseball team for children with disabilities and one with a ski program. They both have my admiration and have sparked a desire to spend more time in service. My wife and family also have a passion to address hunger issues locally (comes from both my wife and I’s background in dietetics and nutrition). The number of children coming to school hungry in our neighborhood and community is unacceptable and if we can help one kid start their day a little better off than the day before, we want to help achieve that.

Since we’re coming up on an election year, is there anything we should consider in terms of Impact on Physical Therapists across the US?

The biggest impact physical therapists can have in elections is by actively participating. Educating candidates on the importance of health care and physical therapy to our communities and economy is essential. Our role and potential is still not widely understood, appreciated or leveraged. With the power of our collective profession participating in the electoral process, we can take great strides in realizing our role in improving the health of our patients and our communities. We also need more PTs to run for office. We have 11 in state legislatures but we need support and encourage more PTs to seek public service at all levels.

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

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

Why doesn’t the PT profession have a super-PAC where anyone can donate money for the cause of strengthening ourselves on the political stage?

The physical therapy profession has an established and well regarded political action committee, PT-PAC. PT-PAC is the political action committee of the American Physical Therapy Association and a connected PAC. This means the PAC is limited to soliciting funds from a restricted class (APTA members) and distributing those funds in a transparent and regulated process to directly support candidates that are friends of the physical therapy profession. PT-PAC currently is a top 10 health care provide PAC with about 10,000 donors annually.   Our position on the political stage would be enhance by a greater market share of licensed PTs being members of APTA and a great percentage of these members contributing to to PT-PAC over the creation of a Super PAC in my estimation.

Super PACs are independent expenditure committees that do not make contribution directly to candidates but engage in unlimited political spending independently of the campaigns. These PAC are not subject to donor limitations as well and do more broad base issue advocacy. Due to limited resources and the cost of operating a Super PAC, APTA has focused its efforts to build the strongest, most effective connected PAC (PT-PAC). I also believe for a professional society that a connected PAC is most consistent with the role and purpose that these societies have in advocacy and public policy. Nothing restricts a SuperPAC from being established with its focus to advance physical therapy but I am also unaware of any significant or serious developments to form a Super PAC in PT and would encourage more widespread participation in PT-PAC over creating a Super PAC.

Share something about the APTA that most Physical Therapists across the country would/wouldn’t think of.

I think most physical therapists think of APTA as theirs and that is essential. APTA is and has always been the organization that physical therapists can call their own. APTA  is a collection of PTs that are set on protecting and advancing the profession. It will not solve the problems of PTs today or achieve the profession’s priorities without participation. Over our history many PTs as part of APTA have build a great foundation that all of us benefit from today. It’s our responsibility to participate, shape and add to the story of our profession for the next generation and continue to make APTA all of ours.

You’re a busy guy! Do you have any daily routines that keep you on task?

My daily routine is always better when I get a run in. I run for both mental and physical health and need that time on the trail or treadmill to think, plan and dream. I notice when I miss more than a day or two of running, I begin to slide in productivity and time management. I also like to run for solitude, no running partner, no iPod. My wife is the perfect running partner as we have trained for a marathon together and I bet we run for hours without saying a word, just both thinking and enjoying the steady pace. Another daily routine I’m working on is becoming a morning person. I have always worked late and been more of a night owl, but I am beginning enjoy starting the day earlier, doing some daily reading and getting my kids on the bus. My 9 year old son likes to play catch (baseball and football) as we wait for the bus and nothing starts the day better than tossing the ball around before meetings, emails, and time at a desk.

Justin, thank you for taking the time to share your thoughts & experiences! It was very informative and spotlighted the importance of a united effort on the political front.

Connect with Justin Moore via twitter: @policy4pt

And, find me @Cinema_Air

Interview with Chris Johnson, PT – Part 2

This is Part 2 of my interview with Chris Johnson – @ChrisJohnsonPT. Read Part 1 here. If you haven’t already, then head to his extensive library of Youtube videos that are well worth your time if you’re interested in specific exercise drills for rehabbing a variety of running injuries and more.

You can find Chris in person at Zeren PT in Seattle, WA.

There’s quite a bit of practical and pragmatic advice in here. Enjoy Part 2!


There’s an interesting overlap between coaching & being a Physical Therapist. Tell us about it, and how you’ve blended the two together.

First off, I’m glad that you see and appreciate the overlap. Being a physical therapist as well as a certified performance coach puts me in an incredible position to help athletes of all ages and abilities.

Considering the fact that we are human, and most likely have some remarkable past medical history or happen to possess subclinical pathology or certain risk factors for injury, it’s critical to first identify and address those risk factors so they do not come back to haunt us down the road. The bottom line is that things exist on a spectrum. All too often, I have athletes who are looking for coaching that really are candidates for physical therapy. Being able to effectively triage an athlete is critical to foster outcomes and reaching performance objectives. As I always like to tell folks, “you rehab to train, you train to compete, and you compete to redefine your limits.” It’s also funny that I’ve somehow gotten pigeon holed into being known as a running injury expert.

Considering that triathlon is a head to toe sport in every facet of the phrase I must have a solid command of the lower extremity but also of the spine, shoulder girdle as well as various bodily systems and how they interact. While I feel like I do a good job of staying current with the medical literature, I work tirelessly reading the performance literature to put myself in the ultimate position to ensure my athletes are ready come race day, or as I like to call it “harvest day.” In addition to being in a good position to help those seeking my services, I have also greatly benefitted from being a PT and coach when it comes to my own training and racing. When people ask me why I race, I often respond, “To find out how good my understanding and application of the medical and performance literature truly is.”

What are some of the most prevalent myths surrounding Performance Training?

In terms of triathlon, the greatest myth is that athletes are at a lower risk of injury considering the multi-disciplinary nature of the sport. The unfortunate reality, however, is that triathlon is a “triple threat” for injury, as Bruce Wilk likes to say. Triathlon involves three separate disciplines each with unique performance demands and risk factors for injury. Throw them all in the same pot and you invariably get a lot of over-trained, injured athletes who fall into the deep, dark abyss of a medical system that lacks the understanding to properly helm them. The other common myth as it relates to multisport endurance athletes is that weight training will only bulk one up and impair performance. The research shows that nothing could be further from the truth. Strength training has been shown to almost halve overuse injuries while improving economy of motion and rate of force development. Needless to say, if there is one thing that an athlete should do beyond their usual training for their discipline(s), it’s strength train. People would be surprised if they spent a week with me to learn how much I lift and perform drills. The irony of the situation is that most of the athletes that I work with always think I have a contrarian view until they realize that most everything I apply to their programming is based on the available body of medical and performance literature. The last myth, which continues to amaze me, is how much water endurance athletes think that they need to consume. I always laugh when people ask me how much water I drink when I compete in Ironman races. The answer is always zero, aside from occasional rinsing to clear any residual sugar from the gels and sports drink. Water does nothing beyond slosh around in your stomach while racing. It particularly leads to problems on the run secondary to all the jostling. Lastly, one of the myths among endurance athletes is that one can maintain race ready fitness year round. One of my greatest pieces of advice is to briefly lose fitness for a month. Once people get on the wheel, however, they can’t bring themselves to step off. As I always remind folks, if you don’t take planned time off and rest days, you will end up taking forced time off and rest.

This might be my favorite of your blog posts! Let’s dive into a parallel story: your knee that beat conventional thinking & carried you through the Ironman. Tell me about the journey you took to overcome your knee issues. What have you learned? How have these lessons affected you as a clinician and as a competitor?

This response could easily turn into a novel so I’ll spare you and give you the condensed version. At the age of 16, I remember the first time that I sought orthopedic consultation for a knee injury, which was aggravated by stair descent as well as when I was lining up to hit a backhand while playing tennis.

Naturally, my mother dragged me to local orthopedist for further examination. The physician’s office was a cold, sterile, and unwelcoming environment. After waiting for what seemed like an eternity, I finally was called back to see him. After talking to me for no more than a minute, and taking my knee through an orthopedic examination, he sent me for xrays down the hall. Once they were ready, he placed them on the stereogram and proceeded to point out an osteochondral lesion involving the right femoral condyle. He then muttered that I would most likely have to give up tennis and would never be able to run the rest of my life, “unless a miracle had occurred.” I did not place much faith in his words as I thought to myself, this guy talked to me for what felt like a second and failed to offer any meaningful solution to my problem. Fortunately, I sought a second opinion from Dr. Freddie Fu, a world-renowned orthopedist at University of Pittsburgh. Upon walking into his office I knew I was at the right place as his waiting room was filled with autographed pictures of world-class athletes. When he came in to see me, he also exuded professionalism, which was not hurt by the fact that he had a team of literally 10 residents and fellows following him around. He ended up having me go non-weight bearing for eight weeks before scoping my knee. Following surgery, he prescribed PT and recommended that I connect with Steve Hoffman, a well respected PT in the greater Pittsburgh area, who helped me return to playing tennis at an even higher level than before. Fast forward to my senior year of college when I was playing tennis in Florida as part of a Spring break trip which our team took every year. I was in the middle of a tight match and running full speed when I abruptly stopped and felt a sharp sensation in the anterior aspect of my left knee this time. Although I somehow managed to finish the match, I went to step into the team van afterwards and felt a strong, stabbing sensation and saw stars.

After returning to campus after the trip, I sought orthopedic consultation by the top knee surgeon in Delaware, who initially injected my knee, and had me undergo a bone scan as well as an MRI. Upon reviewing the results, I was told that the bone scan “lit up like a Christmas tree” and that I “had the knees of an 80y/o.” He diagnosed as having an avulsion fracture of the inferior pole of my patella. I also managed to get a copy of the MRI to read, which stated that I had no medial meniscus, severe degeneration of the lateral meniscus, severe chondromalacia of the patella, and bone erosions. I can’t think of anything more threatening! Although it took nearly a year before I could finally ride a bike without pushback, I finally took up road cycling. I used to always mountain bike before that, but shifted when I stopped to consider the smooth cyclical nature of the activity and how it would engender a great environment to restore the health of my knee. After a few years and several thousand miles under my belt, my knee started to feel really good again. I was no longer having any issues with walking around the streets of NYC, where I was living at this point in time, and was also tolerant of climbing stairs. Naturally, this prompted me to make an attempt to return to running.

Over the next several years, I slowly build my capacity and tissue tolerance to the point where I was running consistently while developing even great confidence in my knee. It was in 2007 when I competed in my first triathlon. Since taking up the sport, I have been injury free while racing for the past eight years and have been to Kona twice without having any signs of slowing down. I always make it a point to share this story with my patients to remind them of a few key things: 1) the body has a remarkable affinity to rebound from injury, 2) be careful of getting too attached to diagnostics as anytime you go into a tube there is nothing good that you will find out and 3) always remain patient and pro-active while ensuring that you have an accurate understanding of your situation.   

Pick one of the following you’d want as a Mentor? And why did you choose him/her?

  1. Jason Bourne
  2. Wonder Woman
  3. James Bond
  4. Tony Stark
  5. ____________ (not listed)

Bourne was the ultimate combination of intelligence, strength, skill, and getting himself out of seemingly impossible situations.

You have an incredible collection of Youtube videos! How do you come up with so many clever drills??

I first got into video recording when I used to spend my days skateboarding, snowboarding, pitching, and playing tennis among several other activities. I was always blown away by how much information one could pick up from going back to watch the tape. It’s pretty funny that I’ve continued to capture video through my professional career. While still in NYC, I initially started recording video of exercises and drills that I routinely prescribed to patients to ensure that I was providing a solid model of performance. I would record an exercise then go back to the camera to watch and would always find some aspects that needed to be changed or refined. Not only did these vids improve my own movement skills but they also started to comprise a video library for patients that I was working with in the clinic as well as a resource for folks across the globe. While we are on this topic, I think that is one of the greatest opportunities for improvement among clinicians and graduate programs. Therapists, similar to kids, need playtime and exploration to really enhance their skills when it comes to exercise prescription and demonstration.

One of my rules of thumb is that if I can’t demonstrate an exercise that I’m prescribing, then I need to either find a video that highlights keys to success or refer that person out to someone who is in a better position to help them reach their goals.

Let’s stick with the videos for a bit. Tell me what I need to do so that I too can produce sharp videos like yours.

First off, no need to spend a lot of money on fancy gear. At this point in time, all you need is a smart phone to be honest. Otherwise, everything is pretty much free. I suggest creating a Youtube or Vimeo account, get acquainted with Imovie, and start setting aside one day a week to shoot a bunch of videos. Of greater importance is to keep the videos, short, sweet and relevant. Also try to minimize clutter in the background to avoid distracting the viewer. No need to make the videos flawless either. It also never hurts to give people context. A prime example of this is when the police sirens would start up in NYC around 4pm (most likely when happy hour at the bars got underway). I used to always try to reshoot the videos, but I started to just keep the siren background as it gave viewers context considering that NYC is known to be a noisy, chaotic city. Lastly, if you plan to put the videos online, make sure to stay consistent with posting content otherwise your viewership will fall off a cliff.  

Favorite books and/or authors? Any recommendations?

Shel Silverstein: Where the Sidewalk Ends.

Otherwise David Sedaris is perhaps my favorite author. I remember reading his books while traveling on the subways of NYC and cracking up. I also like Jon Krakauer’s books in addition to any of Mark Twain’s stories. These days, however, I find myself reading “What to Expect When You Are Expecting” considering that my wife and I are expecting a baby girl in Jan 2016.

[Congratulations on your upcoming baby! She’s a very lucky girl!]

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

  1. Remember that health and friends are the ultimate currency.
  1. Take money, sex, and power out of your decisions and you will never make a bad one.
  1. Read one research article per week.
  1. Never start your day checking email or social media.
  1. Make sure to read something funny before you go to sleep every night.
  1. Have transparency with others even if it upsets them as it will ultimately foster trust.
  1. Never buy more than one car per household and avoid it at all costs if you can.
  1. Make sure to learn another language.
  1. Spend a lot of time around professionals in other disciplines as it will only give you more refined understanding of your own.
  1. When you sit down to eat, make sure to do nothing else.
  1. Cardiovascular exercise and strength training are very important and one should never be done entirely to the exclusion of the other.
  1. NOW HERE or nowhere. I recently learned this from a friend, who used it when he was the MC of a wedding. I can’t think of any greater piece of advice considering the distracting world we live in. When you spend time with friends, family, and colleagues, make sure that you are present with them. You never know what you might be missing.

Chris, thank you for taking the time to do this fun & detailed interview! I learned tons, and I’m sure my readers have gleaned some great info. Thanks again!

Connect with Chris on twitter: @ChrisJohnsonPT

Find 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

Interview with Chris Johnson, PT – Part 1

If you haven’t heard of Chris Johnson (@ChrisJohnsonPT), then you’re missing out. First, check out Zeren PT, then head straight to his extensive library of Youtube videos. Chris was also interviewed by Karen Litzy on her Podcast on Working with Endurance Athletes.

The interview provides a glimpse into how Chris has accomplished what he has so far, and what we can glean from his experiences. It’s so jam-packed with practical info that I decided to break it into 2 Parts.

Here’s Part 1. Enjoy!


So, how do you start your day? (breakfast, routines, etc…)

In all honesty, it depends on how much I had to drink the night before. By no means am I a boozehound but I do like drinking beer and happen to be in one of the best places in the world for doing so. I’m definitely not a typical endurance athlete, who is a slave to their training schedule and wakes up at 5am to train. Rather, I prefer to have a cup of coffee and read some research or catch up on world events. I also find myself doing a significant portion of my writing in the morning. One of the biggest mistakes I used to make in the past was top check my email or get on social media first thing in the morning. This undoubtedly stifled my creativity, as I’m definitely more lucid during the morning hours and need to take full advantage of this time.

Tell us about your orthopedic/sports graduate fellowship. Why did you decide to do it? And, given the benefit of hindsight, how has it impacted who you are today?

I had the distinct privilege of working in Dr. Lynn Snyder-Mackler’s lab in the UD PT department as an undergraduate, which morphed into a sports/orthopedic graduate assistantship at First State Orthopedics under Dr. Michael J. Axe. All in all, I ended up spending two years completing a Peter White Fellowship under Lynn as an undergraduate, which allowed to be a co-author on a couple manuscripts while spending nearly three years with Dr. Axe. Dr. Axe had an incredible work ethic so I was able assist him in seeing patients. He really taught me everything about clinic care and daily operations of running an orthopedic practice from the bottom up. These two individuals undoubtedly shaped my work as a clinician and demanded me to stay on top of the literature. I became very well versed in clinical reasoning pertaining to lower extremity injuries, post-surgical care especially involving the shoulder and knee, and develop a refined understanding of exercise prescription and weight lifting modifications for the injured athlete.

You spent 8 years in NYC at the Nicholas Institute of Sports Medicine and Athletic Trauma as a PT and researcher. How did this shape you as a clinician? Also, how did those 8 years shape you as a future business owner?

Having the opportunity to work at NISMAT was incredible for a number of reasons. First off, NISMAT was the first hospital based sports medicine facility in the country so it has a rich history. I also had the privilege to spend time with Dr. Nicholas Sr. (“Big Nich” as we used to call him). He was considered to be one of the original founding fathers of sports medicine and was a wealth of information. He had such a presence. I vividly remember him storming around Lenox Hill Hospital sporting his ring from the time when the Jets won the Super Bowl in which Broadway Joe Namath guaranteed the victory. He used to always remind me that “the research did not start when I was born,” and “everything in medical research comes with a date.”

Additionally, I also had the chance to interact and shadow several world-class surgeons starting with his son Dr. Stephen Nicholas, who was a pioneer in shoulder arthroscopy. I also developed a close professional relationship with the other surgeons in his practice. One particular surgeon, who I learned a great deal from was his partner, Dr. David Matusz, who is an exceptional spinal surgeon. Spending time amongst such high caliber and brilliant docs, demanded nothing shy of excellence from a rehab and communication standpoint. I was essentially their eyes and ears and always maintained close communication with them regarding all of their patients. I used to always joke with them by saying, “My goal is to disrupt your operating schedule, and cost you money,” to which they replied, “Be my guest!”

One of the most unsung heroes of NISMAT, who I’d also like to highlight, is Dr. Malachy McHugh, who is the current Director of Research. Considering the relatively small number of clinicians and researchers, it’s quite remarkable how much research the Institute publishes. Mal McHugh is one of the primary reasons for the prolific nature of this group when it comes to pumping out research. If you search MP McHugh on Pubmed, Mal’s contribution to the medical profession will be obvious and jaw dropping. One of the therapists, who also shaped me, was Tim Tyler, who is the current President of the Sports Section of the APTA. Tim had a wealth of experience and was not afraid to challenge me on every possible front irrespective of whether or not he agreed with my statements. As much as Tim used to piss me off, I realize in hindsight that it was ultimately for my benefit.

Any group would benefit modeling their professional endeavors after NISMAT, especially with their core curriculum. The core curriculum took place every Tues over lunch and involved a presentation by one of the staff members followed by a journal club pertaining to the topic just discussed.  The usual cronies sitting around the table were Dr. McHugh, the attending physicians connected with NISMAT, Karl Orishimo (biomechanist), Ian Kremenic (electrical engineer), Beth Glace (nutritionist), Tim Tyler (PT), Michael Mullaney (PT), Carmen Cheng (Managing Therapist) as well as the Sports Fellows and residents. Needless to say, we got into some pretty amazing and sometimes heated discussions and were always at the forefront of the research.

My time at NISMAT also shaped me as a future business owner though not in the way that one might think. Considering the high profile nature of several of the patients seeking our services, it forced to me to become very clear and calculated in my communication while mastering the art of motivational interviewing to elicit behavior change. It also forced me to appreciate my self worth because many of these individuals would seek me out for their rehab, which was flattering. It was always amazing to get calls from people all over the world, who would always make it a point to connect with me in the event that they found themselves in NYC doing business. I see far too many physical therapists undervalue their professional services and nothing upsets me more with regards to our profession.

What were some of the biggest hurdles you had to overcome when you opened your clinic, Chris Johnson PT, in 2010? What did you do to overcome these hurdles?

There are always going to be hurdles anytime one decides to “take the plunge” and start a business. My biggest hurdle, aside from the expensive nature of NYC, was opting to go into a space that was a bit further removed from Lenox Hill Hospital as far as Manhattan goes. This proved to be a deterrent for some though the patients, who ultimately valued my care, always took the time to travel downtown and crosstown to see me. You have to understand that in NYC, if one has to travel outside of a five block radius then it’s out of the way (first world problems ). Although business was initially slower than I would’ve liked, I took this time to develop my online presence.

After reading Gary Vaynerchuk’s book (who is also a friend/acquaintance), Crush It, it became abundantly clear that if one does not have an online presence in this day in age, they are creating a strike against themselves. Additionally, having spent the last eight years at NISMAT, without having much on an online presence, I was finally in a position to start taking everything I learned (right or wrong) and put it out there for the online community when I started my initial website/blog on Tumblr. Initially this was essentially a professional diary for me, though it soon became readily apparent that it was an amazing marketing tool and resource for people as well. Once I started getting positive feedback, I became that much more motivated to constantly write and would sit on the trains of Manhattan cranking out post after post.

Over the course of 12-16 months, I was in a physical therapist’s dream situation. I was operating a cash-based facility without doing any formal marketing while relying on no referral sources outside of patients sharing their positive experiences about working with me. I also always made sure to set aside a three hour window in the middle of the day to either train, write or shoot videos, which was an amazing way to break up my day. The only problem that I encountered, however, was that it was tough to grow a practice of this nature since no one wanted to work with anyone outside of myself. It also did not help that I named the facility after myself. In light of this information, I would therefore discourage anyone who is looking to set up and grow their facility to name it after themselves.

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

Hands down the slow motion marching drills and isometrics (particular the ones featured in the “isometric training essentials” vid). The bottom line is that most folks simply do not have the patience to perform these drills as they are challenging, expose weaknesses, and do not make you sweat. Of the athletes I work with and coach, however, the ones who take the time to master these drills under various conditions become incredibly strong, robust athletes while improving their economy of motion. The reason I put such a huge emphasis on the marching drills is that they demand tolerance to unilateral loading while ensuring the performer can also fully weight bear through the affected extremity while assuming a balanced, upright posture. They also rely on no equipment and therefore are very practical even when folks are traveling. By slowing them down, they also demand a certain level of control and invariably demand the performer to audit the movement.

I should mention, however that once an individual masters the slow motion marching that I will increase the load through either using a weighted vest or performing them to a metronome at faster beat frequencies. As far as the upper body holds/isometrics go, they are a great way to introduce load to people. I’ve been giving isometrics for the past decade and everyone used to tell me that they were not “functional.” However, they also have a pain amelioration effect and are particularly effective in addressing tendinopathies. Cook, Naugle, and several other authors have recently highlighted the importance of training in this manner.

How did you end up with a writing gig for Ironman?

The power of social media! I simply messaged someone on twitter, who was connected with Lava, informing him of my desire to write pieces for their online publication. Within a matter of days, I had my first writing gig. Lava and Ironman eventually became two separate online publications, so I ended up sticking with the woman I had initially established communication with when she headed to Ironman full time. Writing for Ironman was very helpful for gaining even more traction online, especially with the international community, and I’m very grateful for this opportunity. I have not been writing for Ironman much as of late because my pieces are a bit technical in nature and inconsistent with their needs. This may be a bit surprising considering how technically minded and data driven most triathletes are. At day’s end I’m very grateful for having the opportunity to write for Ironman as they have built an incredible brand and still put on the best races in terms of reliability while ensuring a painfully awesome experience.

Who are your heroes? And, what is it that you admire most in them?

One of my heroes who is no longer with us was Scott Mackler (Lynn’s husband), who passed after fighting ALS for several years. He was the epitome of grit and determination. Even when he had lost nearly all of his motor abilities, he still was running a research team at University of Pennsylvania while maintaining a sense of humor. Anytime I feel like life is difficult and things aren’t going my way, I think about the challenges and hardship that he endured and I am quickly brought back to reality.

Read Part 2!

Be sure to connect with Chris on twitter: @ChrisJohnsonPT

Find Me: @Cinema_Air