3 Things I Have Learned As An Intern

Today's blog post comes from the perspective of one of our interns.  Fresh faces offer new perspectives, so we think it would be interesting to share the insights of a soon-to-be physical therapy student and his perspective on what we do here at Perfect Stride Physical Therapy. 

My name is Joseph Santangelo, and I currently intern at Perfect Stride Physical Therapy. I am a senior at George Washington University studying Exercise Science with a concentration in Pre-Physical Therapy.

The next question you may ask is “Why did you decide on Physical Therapy?” The fundamental reason is; I want to empower people to have healthy, functional and pain-free lives. I’ve always appreciated the stories of people who have bounced back from gruesome or nagging injuries to carry out functional lives. Studying anatomy, therapeutic exercise, and injuries in a classroom setting is a lot different than learning about it in a practical application. I have learned a great deal of information; however, I will share three lessons from my experience.

1) Functional Range Conditioning (FRC)

FRC aims to improve functional mobility, articular resilience (improving threshold of loading muscle/joints), and articular health/longevity. This is done using a number of different modalities including Controlled Articular Rotations (CARs) and PAILs and RAILs contractions to reduce injury and improve performance.

PAILs and RAILs are valuable for acquiring larger ranges of motion (think mobility). Where CAR’s are used to improve awareness and control of our outer limit of our mobility, and serve as a great form of self-assessment.

The main point is that these tools are used to train and bolster the nervous system to not only have flexibility but also have strength and control in different positions. It is equally important to realize that there are many other layers to consider when treating a patient other than FRC (FRC is one part of the total system).

 

2) Individuality

Individuality is a major component in rehabbing an injury and/or developing an exercise program. Since the limitations/injuries stem from multiple areas, a good and concise assessment process should be taken to determine where to start.

Being creative with exercise choice, tissue mobilization, and patient positioning can make a big difference. I’ve seen this first hand whether that was me being challenged to create exercise programs or just noticing how each physical therapist at PSPT tries to target joints, muscles, and movement patterns in different ways.

For example, two patients could walk in with the same injury, but may need different levels of stimuli (depending on current health, level of fitness, genetics, age, etc.) to produce some form of adaptation.

These same two people may also have that injury because of different movement deficiencies and differences in their anatomy. This clearly demonstrates the varying degrees of individuality that have to be taken into consideration. Creative exercise choice and a good assessment tool go a long way towards helping patients succeed.  

 

3) Clinician/Patient Relationship

Because people have stressors and anxieties (aka life), trust and confidence will go a long way towards a holistic recovery. It is a lot more than just the physical injury! Getting to know the person for more than their injury/limitations really helps develop a better clinician-patient relationship. Therefore, being able to understand a person’s desires, goals, and ADL’s can help you become a better healthcare provider while also creating a plan of care that fits each patient.

My internship here at PSPT was full of learning and fun. Rehabilitation, like learning, is never a linear process. However, the ability to meet people where they are and challenge them appropriately will yield positive results. These three things I have learned will help my future career for a long time. I would like to thank Joe, Vikash, Dan, and Austin for the opportunity to become a better future physical therapist to help fulfill what I want in my life.

Why You Shouldn't Stop Asking The Question "How Do You Get Rid Of My Pain"

How do you get rid of "enter your pain here?"  This is the age old question everybody wants answers to.  This question gets funneled to physical therapists all the time through social media, phone calls, family members, friends, and face to face interactions with patients.

It is also a question many of us hate to get.  Not because we are not knowledgeable on how to help get people out of pain, but rather it is an impossible question to answer without a proper movement assessment.

Every patient who steps into our office presents with different movement impairments, have different pain experiences, and responds differently to treatment.  This goes for two people with the exact same injury. Take for instance two people who go to the same provider post ACL surgery; their rehab will look similar, but they will also have their fair share of differences.  

So yes, your PT may hate this question when asked, but I think you should still ask it.  Here's why.

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This question is an entry point into starting a conversation with your physical therapist to figure out if he/she can indeed help you.  If your PT answers this question with fair certainty of what he/she could do before you are evaluated, he/she is full of it. There are too many variables within the human body for anyone to predict the outcomes of your rehab without at least talking to you and watching you move.

Secondly, this can segue into a conversation about the style of PT that they offer.  Are they a manual based clinic, do the focus on athletes or the general population, maybe both, or neither. Ask questions like; what is your style and/or philosophy?  What are the expectations of me under your care? And have you seen others with my condition? The answers to these questions should align with your goals and make you feel more confident in the person’s skill set.  If not - call the next place.

We shouldn’t just be seeing the physical therapist in close approximation to our house/workplace.  We should treat seeing healthcare providers like consumers; checking Yelp/Google reviews, asking questions to those that will be treating us, and getting recommendations from friends and family.  

If you ask the above questions and do your research, you should find yourself with good care during your next trip to a PT.  This will prevent bad experiences that could make you fearful or regretful for seeing us.

Strength Training's Place In Sensory Processing Disorders

As a former strength and conditioning coach the ability to help people develop strength is near and dear to my heart.  However, in the world of rehabilitation we sometimes can lose sight of how resilient the human body is.

It may not be apparent, but the same principles used in strength and conditioning can be applied to those in rehabilitation to yield remarkable results.

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Because of this I try to connect with other strength coaches and trainers to expand our profession, and have a greater impact on the clients we see.

This networking led me to a success story from a good friend, and strength coach, P.J Strebel. It was about how strength training helped a young boy with a sensory processing disorder - I had to reach out and learn more.

It is typical for Occupational and Physical Therapists to treat these patients using a handful of modalities, but the progressive overload from strength training is rarely one of them.  

This story further reinforces that strength and conditioning principles have their rightful place in physical therapy treatment plans.  Let this be a reminder to not let an individual’s diagnosis or our misconceptions guide our treatment, but rather use sound scientific principles to help our patients.

Hopefully this post will help us start exploring some of the (unconventional) benefits of strength training in the treatment of those with this type of condition.

Today's guest post is by P.J Strebel.

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This is a story all about how (no, not that show, keep reading) strength training changed the life of a middle school boy with sensory processing difficulties.   Let’s call this boy: Wesley (changed for his privacy). Wesley is a good athlete and is one of the hardest working kids that has come through our gym doors.

However, it hasn’t always been rainbows and unicorns for Wesley within our program.  Wes started out in our elementary school program which is more play based and free-flowing.  It is essentially organized chaos. For someone who deals with sensory processing issues, this can become very overwhelming.  There are 15-20 kids hooting and hollering, running and jumping, throwing and kicking balls. It’s a blast.

A lot of really great things can occur during this time frame: kids can learn boundaries, they can learn how to play tag and not tackle someone, they can learn how to tackle someone, they can learn how to play as a group and discover and explore physical movement.  All good things. But for someone who has issues inputting all of these things in an environment, it can be disruptive and cause outbreaks and breakdowns.

Here is how the Occupational Therapist that Wesley is working with defines sensory processing and body awareness in his evaluation:

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You can see how the play-based group could be a difficult spot for someone who has trouble processing so much information at one time.  However, I do think that the younger play based groups, coupled with less screen time and more outdoor activity might actually help to decrease some of the sensory issues, but that’s left for another time.

After numerous conversations with Wesley’s parents we needed to figure out a new game plan to help get Wes where he would be successful. We started him in our middle school strength training program last summer in a smaller group setting as a trial basis.  He was a completely different kid.

Now, before we get into why the strength training helped, let’s take a look at the recommendations for Wesley from his OT:

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Take a look at the top section and other ideas:

  • Isometrics

  • Push ups

  • Pull ups

  • Deep breathing

  • Weighted carries

  • Tension

  • Laugh

*Aside:  we changed read a funny book, to get a funny strength coach.  It’s way better.

These are all beautiful things that should be implemented into a sound middle school strength training program.  But if we break this down even further and look back into the OT eval, it says that Wesley continues to seek out deep pressure.  In the younger groups this can be done through tag games, wrestling, tumbling, jumping off of things, etc. So put a kid who is searching for deep pressure and who has trouble processing and put him in a chaotic environment and it can lead to disaster.  It can cause too much rough housing, tagging too hard, throwing too hard, etc.

So let’s fix it…. But how?

Remove what’s harmful:  Big group, chaotic setting

Manipulate the environment: smaller group, organized setting

Add in what’s needed:  deep pressure

We can think of strength training of just adding more resistance. By adding weight to things like  squats, deadlifts, bench press and weighted carries we can create the deep pressure that Wesley was seeking out and do it in a way that he can also get the loaded benefits that come along with strength training.  

Fast forward a full school year and Wesley has been lifting 2 x week before school as well as a Friday afternoon and/or Saturday AM. He, his parents and his teachers have seen marked improvements in his ability to sit still, pay attention in class, he is getting less demerits for acting out.  We all feel it is because he is getting the input his body is craving before school, so he doesn’t need to seek it out.

Not only have we decreased his undesirable behaviors but we have also packed some muscle mass on him, we’ve increased his injury resiliency, we’ve improved his sports performance, he has also become more disciplined, he has become more confident, and his mental toughness is through the roof!  

If more elementary schools allowed for more free play and recess, and more middle and high schools implemented strength and conditioning into their PE programs kids would be able to sit and pay attention, test scores would go up, detentions would decrease and all around everybody would enjoy school a little bit more.  

Strength training for the win.

About the author:

P. J. Strebel is the Youth Program Director at Seacoast Sport Clubs in Portsmouth, New Hampshire, where he runs a youth program for athletes from grades 1 through 12                  Website https://strengthbystrebel.com/

 

 

 

How To Warm-Up For A Run

Running in any form is a serious undertaking for the body.  Each step sends forces through your ankles, knees, hips, and spine that equate to roughly 3x your body weight (1). Due to the high levels of forces it is important that you properly warm-up before you go for a run.

Warm-ups should be considered active, not passive. They should include movements that prime the nervous system and promote active mobility. In general, the intensity should increase as the warm-up progresses, and take roughly 10 minutes.

Following the warm-up, ease into your run with a light jog or a 5-10 minute walk.  This will help further prime the muscles used while running.


MOBILITY

There’s many ways to carve a turkey, just as there’s many ways to gain mobility in a joint. The major-key is having a reason for each movement. Below are some selected mobility drills for ankle, hip, and thoracic mobility.

______________________________________________________
HOW MANY: Do
2 sets of 10 repetitions for each movement.
______________________________________________________

Ankle Mobility:

  • Starting PositionStand with toes 6” from a wall. Foot pointed straight ahead.
  • Movement: Try and get your knee as close to the wall as possible without lifting your heel. 

Hip Mobility:

  • Starting PositionOn the hands and feet in the quadruped position.
  • Movement: Example - Left Hip
    • Bring left leg to outside of left hand
    • Rock the body 5x front/back, and then 5x left/right
    • Switch legs

Thoracic Spine Mobility:

  • Starting PositionIn side lying with your top leg crossed over the body and rested on a foam roller (leg height should be at waist height). 
  • Movement: Start with your one hand on top of the other.  Rotate your shoulder towards the ground.  Make sure your focus is on rotating from the shoulder, not the arm. 
  • Tip: Don’t forget to breathe! Inhale when arms come together, exhale while arms are spreading apart and thoracic spine is rotating.

Leg Swings:

  • Starting Position: 
    • Side-side swings: Facing a wall/fence with enough room between you and the wall to swing your legs.
    • Front-back swings: If swinging left leg, stand so the wall/fence is to your left.
  • Movement: side-side and front-back 
    • Side-side swings: Drive your leg towards the mid-line of the body, let the elastic energy at the end help you drive your leg back out.  Repeat in a dynamic fashion.
    • Front-back swings: Drive your leg backwards, let the elastic energy at the back help you drive your leg forward.  Repeat in a dynamic fashion.
  • Tip: This movement uses momentum to open up the hip, as well as mobilize the ankles.  Work within your given range, don’t compensate, and don’t overdo it.

Running Drills

Your neuromuscular system plays a huge role in running. The nervous and musculoskeletal systems work together to create stability, mobility, elasticity, and regulatory roles. “Priming” this system prior to your workout helps get blood flow to the muscles and ramps up the neural drive.

______________________________________________________
HOW MANY:
2 sets
DISTANCE: about 50 feet, or half a basketball court distance
______________________________________________________

Walking Lunge:

  • Alternating lead legs, with twist over lunging leg
  • Knee shouldn't lurch over the foot, lead heel should stay on ground
  • Backpedal back to start 

Horizontal Skips:

  • Like regular skips, except you're really trying to cover a large amount of horizontal distance with each skip
  • TIP: Land softly, be cautious on uneven terrain
  • Backpedal back to start 

Karaoke:

  • Instructions: Direction going to the RIGHT >>
    • Cross left leg in front of the right leg
    • Step open with the right foot (to start position)
    • Cross left leg behind the right leg
    • Step open with the right foot (to start position)
    • Repeat (in front, open, behind, open > in front, open, behind, open, etc.)
  • Back to StartFacing the same direction! The opposite leg will be crossing over/behind on the way back
PSPT Running Warm-up (1).png

Wait - what about stretching?

In general, holding a static stretch increases flexibility in both the short term and long term, however several recent reviews have agreed that static stretching for greater then 45 seconds immediately before performance either; 1) negatively influences maximal strength, power, muscular explosive performance (e.g. jumping or sprinting), balance and agility, or 2) has no effect on performance.

Shorter duration static stretches are also hard to justify immediately before participation given the potential for decreased performance and lack of clear benefits(2). Stretching certainly has its place, however it should be purposeful. To quote our blog on stretching, “Remember, the why in what you do is everything.  Random assortments of mobility drills, with random time periods because Joe Schmoe told you to do so is not good enough.”

Wrap-up

Give the above warm-up routine a shot before your next running workout. It focuses on mobility deficits commonly seen with runners, and ramps up in intensity leaving you feeling fit and ready to roll.


References:

  1. Nilsson, J., and A. Thorstensson. “Ground Reaction Forces at Different Speeds of Human Walking and Running.” Acta Physiologica Scandinavica, vol. 136, no. 2, 1989, pp. 217–227., doi:10.1111/j.1748-1716.1989.tb08655.x.
  2. O'Sullivan, Kieran, et al. “Injury Prevention and Management Among Athletic Populations To Stretch Or Not To Stretch?” Aspetar Sports Medicine Journal, pp. 624–628.

Strength and Conditioning in the Rehabilitation Setting

When you think Physical Therapy, what do you think?  If you imagine it is a place where you get a massage, do the same exercises as everyone else (on a table) for an hour, or simply a place where you are told what you cannot do/should stop doing, you are thinking of an older model of care.  

It seems more and more that the gap between the rehabilitative field and the strength and conditioning field is becoming narrower by the day, and for good reason.  Rehab IS strength and conditioning, just on the opposite side of the continuum.  

 This graph does an excellent job demonstrating the idea of a TEAM approach to a patient's care.  Worth noting is just how long we as healthcare professionals and strength and conditioning specialists can have in the rehabilitation of the strength and conditioning athlete. 

This graph does an excellent job demonstrating the idea of a TEAM approach to a patient's care.  Worth noting is just how long we as healthcare professionals and strength and conditioning specialists can have in the rehabilitation of the strength and conditioning athlete. 

When tissue gets injured it is our job to influence the healing process while maintaining progressive overload to create resiliency.  Better known as the act of accepting the demands of weight training, running and sports without being re-injured or suffering set backs.  In order to do this we must use the appropriate load, intensity and volume that challenges the injured tissue without irritating their symptoms.  

  • LOAD >> CAPACITY = INJURY
  • LOAD = CAPACITY = REHAB
  • LOAD << CAPACITY = PREVENTION

This sounds a lot like what I used to do as a strength and conditioning coach.  Create an exercise program that uses the appropriate loads, intensities and volumes that will help create positive adaptations without hurting my clients.  

The goal of rehab after all is to get the person in front of us back to their prior level of function. This can be anything from being a desk jockey to the All-American Jockey. 

When healthcare professionals do not understand strength and conditioning protocols, it will be hard to help that patient to continue to train around injury.

This is an e-mail that I received this morning from a trainer that I work closely with:

"Hey Joe. I have a question.  I have a client that is seeing a PT for some shoulder issues.  The client introduced us through email so we could work together to figure out an alternate plan of training that would allow her to get the treatment she needs for her shoulder while continuing her training. The PT responded that he wants the client to abstain from any and all exercise, like do nothing at all."

No one should ever have to hear that have to abstain from all exercise unless it is 100% warranted.  If I person can go into the gym and perform pain free movements, they should, not just to keep their body some-what conditioned, but to help keep them sane.  There are plenty of activities one can perform while still "protecting" healing tissues.  

This is where a healthcare professional who also has experience as a strength coach can really help.  It becomes very easy to understand regressions and lateralizations of exercises that will allow them to still have some training effect while recovering from their injury.

For these reasons, it becomes highly important for rehabilitation providers to understand performance, and on the flip side strength coaches and trainers to understand more of the rehabilitation world.  This will allow for better communication, and make for a much better transition from being hurt to getting back to your previous self. 

It is okay to not know everything, actually it is perfectly normal.  However, identifying areas of opportunity in our practice and linking them with patient's needs should force us to build a reliable network of providers in order to ensure that each and every patient receives optimal care and has the greatest chance for success.