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Building Relationships with Other Professionals

On this episode of the #AskMikeReinold show we talk about building relationships with other professionals. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 220: Building Relationships with Other Professionals

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Transcript

Mike Reinold:
Allie asks, “What struggles have you faced or advice you can offer when it comes to building a relationship with other medical professionals. Especially doctors like surgeons who may refer to you and vice versa.” So why don’t we start with that? Let’s talk about some of how we build our professional relationships with doctors. I think we all have some experience with this, Lenny and I kind of grew up this way. I think Dave has done a really good job locally with trying to reach out to the other like niche doctors that kind of share his passion a little bit. So maybe you can kind of talk about that and then maybe after that, we’ll see. Maybe we talk a little bit about who else we should be building relationships with, but Len, you want to start maybe?

Lenny Macrina:
Yeah.

Mike Reinold:
How do you start building relationships with physicians?

Lenny Macrina:
Yeah, I had it way easy when I worked in Birmingham, because the doctors were right upstairs and they wanted us to interact. They encouraged us to interact, so I could go upstairs multiple times a day and visit them. Either because, a patient downstairs was not doing well or give an update or somebody was seeing them upstairs. So I could go upstairs and just see them. Not the case in Boston now. So I am not in a hospital. I am in a remote area, 20 minutes outside of the city where most of the doctors are. So for me, it’s now a little bit more of a challenge. But I think once doctors begin to see that their patients are getting pretty good care and the patients speak highly of their therapist, I think it opens up this world, right? Where they want to send more to you and you got to take advantage of that. Either through going with the patient to their visit, sending an email to the doctor, specifically to the doctor, try to get the doctor’s email. I know they don’t always read these things.

Lenny Macrina:
But you get the doctors that do it and those are the doctors you want to interact with, because they’re the ones that are going to end up giving you their cell and going to communicate that way. So we have a bunch of doctors now. Me moving from Alabama to Boston, I didn’t know many doctors in the area, so I’ve had to work to get a relationship with them. So now I text many doctors at all the hospitals in the area we work with. Because they have like minded thoughts, they want to interact with PT and it’s just going to make the whole process better. Also, trying to speak at conferences or publish papers and if you’re not even speaking at a conference. Go up to the doctor at a conference and just chat with them, small talk. It leads to this world that you would not believe is an amazing world of patient care and sharing thoughts and sharing ideas. It just makes everything better for them. So I think speaking at meetings, interacting with the doctor, either at their facility. Inviting them out to your facility.

Lenny Macrina:
We’ve had doctors visit our facility and want to hang out and see what we had to offer and talk shop for a little. Again, it helps the whole process to go so much better for everybody when you have that relationship. So it’s not easy, the days of bringing donuts to doctors and hoping that, that is the way to get referrals. I just think it’s a bad idea. It’s more of a professional level than just feeding them bagels and donuts at this point. There’s so much competition, you got to really stick out with your services, your personality and I think that’s going to be number one.

Mike Reinold:
Yeah. I think you focus more on joining their care team almost, right?

Lenny Macrina:
Yeah.

Mike Reinold:
Where you’re an extension of them and that you’re there to help, right? So it’s not like kissing up to them or bribing them or anything like that. I mean, those tactics work don’t get me wrong. But it’s not like it used to be. I mean, you literally had people, back probably 80s and 90s, there’d be clinics that would make doctors the medical director. I don’t even know what that means, but I’m pretty sure that meant they got to kick back. Right? So it was all these like weird things that happen and now we’ve evolved from that, we’ve gotten away from that. In our local community, I think we can break down our physicians into three groups. We have the big mega organization, like the big hospital system doctor. They are super pressured by their organization to not refer out, okay? So keep that in mind, that’s one. Two, is then we have the pops. So the physician owned practices, it’s not a ton around here, but there’s some and they are incentivized to not refer out. Right? So that stinks, right?

Mike Reinold:
Then third, is probably just the guys that are the physicians that don’t have their own physical therapy, but are kind of on their own and we have a few of those practices out here. Those are the people that we get most of our referrals from, right? The other people from the pops and the mega organizations that are out there that refers patients, you know who they refer to us? The super specific niche that we’re really good at, the niches that we’re really good at. So Dave, why don’t you jump in from here? Because we even get referrals from the places, you can tell the doctors sometimes are hesitant, they’re like, “Ah, I’m supposed to send this downstairs to my PT department, but I really feel for this kid. He’s trying to get drafted or he’s trying to do this. So, I wanted to work with you guys.” So Dave, like how have you interacted with those barriers with your specific niche?

Dave Tilley:
Yeah, I mean it’s definitely challenging. I think there’s two layers to me that I think are most important and which is one, just be a good human first, right? Just be a good person and be willing to communicate. Realizing it’s about the athlete’s wellbeing and it’s not about you and you making money or you being famous as a good PT. It’s not about that, right? It’s about trying to give the best care, because you care about the person in front of you. Two is, after that you have to be a good therapist. You have to really know your stuff and you have to be willing to go the extra mile and I think for me, learning from you guys, again. One of the best ways I started to really kind of get that foot in the door was, really spending time reading surgical protocols and textbooks and understanding the surgery that happens, so I could deliver better care. I think when the surgeons see that you really understand the difference in surgical technique.

Dave Tilley:
Not that I’m going to say what type they should use for a surgery, but like understanding the nuances of surgeries is important to give better care. From there it’s just about, you have to accept that some doctors don’t want to give you the time of day. They’re maybe not open to emails and communication and it’s unfortunate because it’s a struggle with rehab. But at the same time, you have to kind of get over that and as a new grad, I was a little bit turned off by that. I was like, “Oh man, why are these doctors so uptight?” But then there’s other doctors that we know locally who are amazing and they want to go the extra mile and they really want to help. So you’ve got to kind of take your punches on the chin sometimes at meetings when doctors don’t want to give the time of day. But the more you work at it, the more you just keep doing a good job and communicating well. I mean, a lot of this is word of mouth, obviously it’s doing a good job.

Dave Tilley:
But, you get one patient who does really well in that special niche of something that nobody else could really understand because they didn’t know the sport. Then, two of their teammates come and the doctor’s like, “Wow, you’re doing really well.” Like Lenny said, “Let’s try to get this going.” Now we all have people. You guys have your elbow people for Tom and John, I have a pediatric elbow specialist who I love and is a great guy. I have a girl who’s a little farther away and she’s great with low backs and spine de fractures and stuff. So it just kind of rolls. The more you do good care, the more it kind of feeds back on itself.

Mike Reinold:
Yeah. I think it’s helpful with the physicians. You can’t get upset if you’re trying to get a relationship with a certain physician and it’s not working, right? It always cracks me up, right? I mean, it’s like what could be the reasons why physician doesn’t want to give you the time of day? It’s usually either ego or they just don’t really care. They really don’t care about their outcomes as much as they want or they just don’t want to talk about it. But I will say this, I have seen this happen and I think we’re vulnerable to this right now. Because PTs want to walk in with their lab coats and call themselves doctors, no offense Trey. They want to fluff it up a little bit and they go into the doctors and they try to impress the doctors with how much they know and that they deserve to be there. It is their right to be part of that process and stuff like that. You got to back down completely here and you got to put this in. I am here to help the person, that is it.

Mike Reinold:
I’m here to help the person. Let’s talk about this perfect person specifically. We give physicians too much credit sometimes, that they have this master plan in their head. They have very vague guidelines in their head. We can fill in the specifics of those guidelines and if you could do that in person or call them or email them or talk the PA like Lenny, some of those strategies. You can fill in those gaps and by asking questions and saying like, “Okay. All right. So when can we get the full weight bearing? All right, great. But when can I start this?” Right? You’re asking questions. The physicians love that, they like that way better versus you going in and be like, “Hey, here’s a study that shows I can weight bear at week six.” Right? The doctor’s like… You know what I mean? You go in, “When can I weight bear?” Then we just know some doctors don’t want to weight bear until week 12 and some don’t want to weight bear until week six. I made that up.

Mike Reinold:
But who do you think we’re going to refer people to in the future? The ones that we jibe with a little bit more. So, keep that in mind. It seems frustrating at first that some physicians don’t want to collaborate with you, but just remember you don’t want to collaborate with them either. Right? When you find some that do, man it’s fun. Right? You only need like one or two and man, it’s fun. Because you talk to them about the people, you’re both vested in their best interests, it’s really neat. Look, I think that was pretty cool for the professionals. Mike, Lisa, I mean, do you guys want to comment briefly on anything else? Mike, you came as a new grad too, so maybe you have some advice from that perspective. But the other thing too is, I don’t know if physicians are the only people we should be trying to network in nowadays. But Mike, what do you think?

Mike Scaduto:
I would just add maybe from the patient’s perspective, going back to your last point. The better that we know the surgeon and we know their expectations, especially postoperatively, the better experience that is for the patient. So it’s kind of mutually a good thing for us to work with a surgeon. But anyway, I think if you guys in Alabama, if Lenny and Mike. You guys have the doctors right upstairs, we at Champion, we have the strength coaches right outside. So those are people that we’re kind of working with every day and kind of building that team of strength coach, sport coach, physical therapist and doctor. So we’re really able to collaborate with the strength side of things and we can fine tune a training program to fit for that person’s stage of their rehab or after rehab. Then, we can really try and maximize their performance. So I think that’s a huge relationship that you should be focused on kind of building as a physical therapist.

Mike Scaduto:
Is working with the strength coaches in the area and finding a couple that you really trust and that you have the same philosophy on getting an athlete back to a sport and then improving performance.

Mike Reinold:
Yeah, huge. A lot of times too, as physical therapists, we try to like step on toes too much with strength and conditioning. I’d much rather collaborate with a professional strength and conditioning coach. So that way it takes a lot of stress off me, right? That’s not my wheelhouse so to say. So can we program well? Yeah, sure. But I’d much rather collaborate with somebody else. So keep that in mind. So there’s other people, the strength coaches, the sport coaches, so many other people. But Lisa, have you found any doctors for like rowing by the way? I don’t know if I know the answer to this question.

Lisa Russell:
I mean, one of the like top U.S rowing docs, Kate Ackerman is in Boston.

Mike Reinold:
That helps. That’s pretty sweet.

Lisa Russell:
But I mean, she definitely has a little bit of that conflict that we were talking about before, where she works for Boston Children’s. So, her immediate referral is in network.

Mike Reinold:
Right.

Lisa Russell:
I know the PTs that she refers to and they’re great. So that’s, that kind of shorter term insurance-based timeframe. Right? Then, that’s where I feel like I’m the resource for the, “You ran out of your insurance and let’s keep you getting better and healthy.” But-

Mike Reinold:
That’s a good niche though. That’s a really good point to address some of those things is-

Lisa Russell:
Yeah.

Mike Reinold:
You have to position yourself not to be competitive then with their in house PT.

Lisa Russell:
No.

Mike Reinold:
What can you do better or not better? That’s the wrong word. It’s what can you do in addition to that?

Lisa Russell:
Yeah. I mean, for me the network that I think is most meaningful is more the like rowing community network.

Mike Reinold:
Right.

Lisa Russell:
I’m lucky to be a member of two boat houses on the Charles, so two boat houses in Boston. So to be able to for one, just like be around when I’m going and rowing and people have seen me previously. I volunteer treating with the para national team. So they’ve seen me, know my face, know that I at least massage people or whatever they think I’m doing. Right? So people just like naturally come up and they’re like, “Oh, I have this problem and can you help me?” Then I’m like, “Yeah, here’s my card.” Then otherwise, I’m just part of the network that people know I’m there and I have teammates that if anyone’s like, “Ah, man, I’ve got this going on there.” They know I’m here to help. So being part of the community, I think is my bigger research rather than doctors. Because rowers also don’t need surgery that often, we don’t bust things so much that we have to get a surgical intervention as frequently as like other sports. Right? So doctors aren’t as big of a referral source, no matter what.

Mike Reinold:
That makes sense.

Lisa Russell:
Yeah.

Mike Reinold:
But that’s really cool. Yeah, so we have to focus on our physician referrals and sometimes PTs think that’s all we have. But as Mike said, the fitness crowd, the sport coaches, the communities in there, like Lisa mentioned. All those things are all very valuable too. I guess I’d just leave you with this. If you’re a physical therapist and you have a passion about one thing. So let’s say rowing and gymnastics, right? Trust me, there’s probably an ex gymnast that loves working with gymnastics people that is now a physician. You find them and man, that’s a match made in heaven. Because you guys exactly share the same interest level and they know that, “Oh, you get this right?” So yes, maybe even if they get pressure to send people in house for some things, they know that and we get this all the time. Like, “All right, we’ll do the basic rehab in house.” But then you come for the recheck for the physician they say like, “You know what? You need to go see Dave now, because he’s going to help you get back to gymnastics. He gets gymnastics like nobody else.”

Mike Reinold:
Right? So find those people, they’re out there, trust me. If you love baseball, there’s an ex baseball player that is now a surgeon. There is an ex rower that is now a surgeon. Right? They probably love working with those types of people. The more we can start that relationship, the more that they’re going to also get referrals from us, that’s their ideal client. Right? So now all of a sudden we have this good dynamic and we’re all working with the people that we like working with. So just keep that in mind, I think that’s good and it’s worth saying again. Like Dave said, “If you’re not a good human, it’s probably not going to work anyway.” Be humble, go in there asking questions for the best interest of the patient. Not showing your intelligence and your worth and then I think you’re going to have a much better chance at clicking with that physician. Right? Try to start a team versus trying to say, “This is how I think the rehab should go.” It makes sense? So, awesome. Great question Allie, appreciate it.

Mike Reinold:
As always head to mikereinold.com click on the podcast link and fill out the form to ask us more questions. Please continue to help support the show by heading to iTunes, heading to Spotify, rate and review so we can get the word out and share this. Man, we’d really appreciate that. The more you can share it the better. So thanks for everything as always and we will see you on the next episode.

How Do You Diagnose Patellofemoral Pain?

On this episode of the #AskMikeReinold show we talk about how to diagnose patellofemoral pain. Two big areas we like to focus on are ruling other injuries out, and then sub-classifying the different types of patellofemoral pain. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 219: How Do You Diagnose Patellofemoral Pain?

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You can use the player below to listen to the podcast or subscribe. If you are enjoying the podcast, PLEASE click here to leave us a review in iTunes, it will really mean a lot to us. THANKS!


Show Notes



Transcript

Mike Reinold: On this episode of the Ask Mike Reinold Show, we talk about classifying patellofemoral pain syndrome, so that way we can come up with the best treatment approach.

Dave Tilley: Marla from Massachusetts asked how do you identify and diagnose patellofemoral syndrome due to its vagueness and wide variety of cases, maybe causes. We’ll say causes. I think there were some typos in that. That on our end. All right. So Marla, so how do we diagnose patellofemoral pain syndrome? And do we even need to diagnose? What does that mean?

Dave Tilley: For this question, we’re going to give it to Lenny. Start off, Len. What are your thoughts?

Lenny Macrina: First off, if her name is Mahler, that’s great in Boston, right? Mahler.

Mike Reinold: Mala.

Lenny Macrina: Mahler.

Mike Reinold: Yeah. Marla. It’s probably Maria. Marla, Maria, I apologize. I apologize if we typed your name wrong, so sorry.

Lenny Macrina: Anyway. Yeah. This is… I think Scott Dye, doctor out in San Francisco calls it the black hole of orthopedics, right? The patellofemoral joint and patellofemoral pain. It is just this wastebasket term of a gazillion different things that could go wrong. And then you go to the doctor’s office, you get some knee pain and you leave with a diagnosis of basically knee pain. That’s what they told you you have, but they put this fancy term, patellofemoral pain syndrome, on the prescription. So you just go to physical therapy, and then it’s up to us to figure out what’s going on because you weren’t a surgical candidate at that time.

Lenny Macrina: For me, when I get somebody like that, it’s going to be figure out why this has happened, right? You can pinpoint potentially the structures, if that even matters. Sometimes it may, because you may miss a meniscus tear or something like that, or patella tendon pain. But to me it’s why is this happening? And to me it’s often a volume thing, right? Did they increase something dramatically in their life? Meaning did they try to train for a marathon? We see that a ton. Did they start a new workout program? Did they go on a hike and they’re not used to going on a hike? You’re looking for something random where there’s a lot of up and down hill, up and down terrain, or something like that.

Lenny Macrina: Those are the big things. I want to know, what have you done recently that has changed in your life? And then after that, I want to figure out potentially what structures are involved, right? In my head, my differential diagnosis is going to be all over the place. I’m going to start looking at… Because it’s general knee pain. There’s no specific area. So I’m going to look at the tela tendon, I’m going to look at fat pads, I’m going to look at plica, I’m going to look at meniscus. I’m going to look at IT band, I’m going to look at quad tendon, I’m going to look at a superior plica versus medial plica. I’m going to look at back. Hello.

Lenny Macrina: I’m going to look at a bunch of different structures, try to pinpoint. I know palpation people are going to say is lacking, but I feel like on some of these structures, I get a pretty good response from people if I can pinpoint the structures. And that’ll allow me to hone in on what I think is going on. And then obviously I’m looking at strength, I’m looking at how they move, so I use our performance system and see how they move and see if I can correlate that to their symptoms.

Lenny Macrina: If they are increasing their squat or a new workout program, can I somehow hone in on, Oh wow, you got a lot of knee valgus going on on one side. Maybe that’s why you have an issue. Try to load them and see if their squat changes in a loaded position versus unloaded. So, so many different things, long winded answer. That’s my approach. And then I’m going to address some of those impairments and maybe their volume issues and try to figure out a way to decrease the volume on the joint and increase their strength in their hips, quads, et cetera.

Mike Reinold: I’m going to throw this at you. Does diagnosis matter?

Lenny Macrina: The diagnosis of patellofemoral pain? Not that diagnosis, but if I can figure out if it’s a meniscus tear, then maybe. I get to keep that in the back of my head, because maybe it was missed. Maybe you just saw your primary care doctor. And they were like, yeah, you have knee pain, you get patellofemoral pain syndrome. So I would say potentially.

Lenny Macrina: But like labor versus rotating cuff in the shoulder, we’re going to try non op rehab. Us as physical therapists are going to treat the impairments, right? And not necessarily the pathology. And so we’re going to go after motion, strength, function, decrease volume on the joint and then build you back up again like we would do with any other joint. You know what I mean?

Mike Reinold: That makes sense.

Dave Tilley: Sub classification matters but not diagnosis. That’s just the one thing I would say.

Mike Reinold: Len brings up a good point, and it wasn’t the first thing that came to my mind. You diagnose other things out versus diagnosing patellofemoral pain in, right? Patellofemoral pain’s a junk term. It could be for anything, but I like how Lenny makes it a point to diagnose things out, like, Hey, let’s make sure we didn’t miss a meniscus. Or, well you just had this evaluation the other day, a PCL tear probably that had patellofemoral pain for a year with an undiagnosed PCL tear.

Mike Reinold: It’s about ruling other things out, which I think is really cool. And then Dave, you want to touch on that? Because I think that’s good. That’s like the sub classification, because man, patellofemoral pain means a lot of different things. If you have a compressive syndrome versus patellar tendonitis, wow. You’re going to completely treat that differently. Right?

Dave Tilley: Yeah, absolutely. And I think, again, this is something I’ve learned from you, Mike, when you put your PDF out and other stuff was thinking about not so much of what exactly is the reason they have pain, but trying to put them into a category of maybe why they have pain, right? This is kind of comes from like the low back world that they were talking about, instability versus sciatic type stuff or whatever, but they’re doing the same thing, which is helpful because you can treat them based on movement. Is this someone who has, like you said, more of a compressive etiology who is very stiff quads, they have a very stiff nature in general, they’re not very lax. And maybe they’re having some issues with the entire patella is getting pushed into the trochlea and that’s the reason that they’re getting uncomfort.

Dave Tilley: Versus the opposite end of the spectrum, which is something we see a lot, which is more of the excessive lateral movement, which is causing some instability or some subluxation because they’re very shallow in their trochlea and they have a lot of excessive motion. They’re very lax. Both could have the exact same type of pain. It kind of hurts around here. I don’t really know what causes it. I didn’t fall, nothing happened. But completely different types of treatment, right? One versus the other. And I think that’s where people should be thinking is more about okay, what are the factors like Lenny said that are contributing here? How can we cluster this into something for a treatment based algorithm, not so much.

Dave Tilley: And I think really overlooked a lot is what I see as different types of growth play and different types of knee pain that all hurt. You can have inferior pole for [inaudible 00:07:24] versus a tibial tubercle versus more of a superior patella. And you might treat those things very differently, but it matters huge about what exercises you choose is for deeper ranges of motion and stuff like that. So don’t think it’s only the adult PFJ. These things are very much in the youth sports as well.

Mike Reinold: Do you think those docs all sat around arguing?

Dave Tilley: Oh my God, the worst.

Mike Reinold: Whose name was going to be on that diagnosis?

Dave Tilley: Yes. No, I did it. No, I looked at the x-ray. No, it was mine.

Mike Reinold: I bet you Johansson was the worst. He was like, no way. If my name’s not on this, I’m going to be [crosstalk 00:07:57].

Dave Tilley: No, was like, I demand to be first.

Mike Reinold: Yeah, right? I’m number one. Johansson-

Dave Tilley: I’m the first author on this paper. I wrote the abstract.

Mike Reinold: You’re last, Johansson. You barely contributed, Johansson. All right. What are we talking about? All right. Think about it this way. I can make it like a huge, very obvious smack in your face. Inferior pole patellar tendonitis versus an osteochondral defect in your patellofemoral joint versus lateral instability of your patella. My Lord, those are three different things, right? Can I say “My Lord” on there? I shouldn’t have said that. My gosh, my golly.

Lenny Macrina: Jeepers.

Mike Reinold: Those are three completely different things, right? That will change a little bit of that. I love it. Lenny jumps in and says, “Let’s make sure not only are we looking at patellofemoral and looking for stuff, but we rule out some other things. That’s amazing, because sometimes other things cause patellofemoral pain too. I love that.

Mike Reinold: Then Dave is a big fan of sub classifying. I think that’s great. I have a ton of stuff on this on my website. I wrote about this a bunch back in the days and expanded a little bit, but the other big resource for this, and I would say this is pretty much still in play believe it or not. I think we’ve learned more since then, but back in 1998, I know that seems crazy. What’s a new grad PT? What year are they born do you think right now? If you’re graduating college right now, what year were you born?

Mike Scaduto: Something like ’96 if you graduated PT school.

Lenny Macrina: Yeah. Around there.

Mike Reinold: That’s awesome. Anyway, yeah. This came out before you were born, but big article by Kevin Wilk, George Davies, Bob Mangine and Terry Malone. Those are like four of the godfathers of sports physical therapy. These guys, back in 1998, this was mind blowing, their thought process that they came out with this. But in JOSPT they had a really landmark article, Patellofemoral disorders, a classification system and clinical guidelines for non-operative rehabilitation. Kevin definitely wrote that title. That’s a big title. But what they did was they tried to say let’s find out the differences. Right? And they had a few. They had patella compression syndrome, they had instability, biomechanical things meaning is it just coming because of proximal and distal, right? Direct trauma, right? If I bang my knee into my desk, which I do weekly, right? And then I come in with patellofemoral pain, that’s a lot different than that athlete that pivoted and sublux their patella laterally, right?

Mike Reinold: The sub classifications I think really help, so you should check out that article and check out my website, just type in for patellofemoral and I think it’s in the main sidebar. I have so much stuff on these things. Look, I think we nailed the question right there just from Lenny and Dave’s perspectives right there from that. It’s important that you try to do your best to give the right treatments, right? You have to make sure you’re ruling out some other things and then you have to try to subclassify it as best you can. And I think that is a good approach.

Mike Reinold: Once you have that, then it all makes sense. If you’re just getting a diagnosis of patellofemoral pain syndrome, and you’re looking at it and the person just says pain, and you’re not trying to differentiate between the types of that, it seems very daunting. Right? It’s very confusing. Where do I start? Do I just do the same thing for everybody? And that doesn’t seem to make sense.

Lenny Macrina: Plus, trust me, when people come to you with that diagnosis, I think they really appreciate if you can somehow explain what it means and maybe some structures that could be involved. People want to know what’s going on with their bodies, not just we’re going to do these exercises because. They want to know what could be causing their pain and how to avoid it in the future. So if it is a fat pad thing, which I think I see a lot, more than people think, then I think they want to know that and appreciate the explanation of what that structure is, how it contributes, and how they can prevent it in the future. So I think it’s helpful.

Mike Reinold: Yeah. No, I agree. Awesome. Great question as always from Marla, I think. Really appreciate it. If you have a question like that, head to MikeReinold.com, click on the podcast link and fill out the form. And in the meantime, do us a big favor, head to iTunes, head to Spotify, which is an awesome place for podcasts right now, by the way. If you’re not trying to listen to podcasts on Spotify yet, you should check it out. They’re doing a really good job. And rate and review us and we’ll see you on the next episode.

Mike Reinold: Ooh, Mike, you almost missed that one.

Can Physical Therapy be Used for Maintenance and Not Just Injuries?

On this episode of the #AskMikeReinold show we talk about our concept of “performance therapy” rather than traditional “physical therapy” to help with maintenance and prehab, instead of just tradition injury rehabilitation. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 218: Can Physical Therapy be Used for Maintenance and Not Just Injuries?

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Show Notes



Transcript

Mike Reinold: On this episode of the Ask Mike Reinold Show, we talk about the concept of performance therapy for maintenance, and not just using physical therapy for big injuries and surgeries.

Mike Reinold: Let’s get at it, because some people actually dislike that portion, so I hope you fast-forwarded. So, let’s see. We have a question from Greg from Connecticut. Greg says, or asks, “Do you recommend athletes continue some type of maintenance physical therapy once their treatment is complete? If so, how are you able to make this happen in an in-network provider when insurance doesn’t usually cover these types of services?” So Greg, I love this question because this may be the most important question we’ve ever answered for the future of sports, or out-patient, or orthopedic physical therapy.

Mike Reinold: I mean, and we’ve kind of addressed this all the time, but at Champion we have intentionally … We call ourself performance therapy, more than we call ourselves physical therapy. Because we think performance therapy is a better phrase for what we provide. We help people perform, we help people … If you go through our CPSS model or other systems, it’s talking about restoring, optimizing, and enhancing their performance. This is performance therapy. Nowhere in there is it like hey, you had surgery and you need physical therapy. That type of thing. So, I do think there’s a need for our profession to progress, and to get beyond the fact that physical therapy is just for these big traumatic things.

Mike Reinold: So, let’s talk to the crowd and get some of your guys’ thoughts on this, but should we be using physical therapy for maintenance? What are some examples at Champion for people that we do use this on? And I think we could all briefly just touch … We got to keep it 15 minutes, but no pressure. Briefly touch about maybe all of our specialties. Now, we’re sports, so I’m going to give you that for an example, and maybe Dave, you can touch upon gymnastics and … I hate to say crossfit, especially nowadays, but just the fitness athletes. And just somebody that trains, you know what I mean? Somebody that trains. So Dave, why don’t you start? What’s the point of physical therapy? What can you provide somebody like a gymnast, and a fitness athlete that’s not just injuries?

Dave Tilley: Yeah. And this is definitely something that I’ve learned a lot from you too, especially, because I … I was at an in-network job and I was doing a lot more kind of what you would consider regular PT. And I felt two things. One is that people always felt they wanted sometimes a little bit more. Not in terms of coming three times a week or stuff like that, but they just wanted someone to be in contact with in case hey, this feels weird or is this a normal part of my training? So, I thought that that was lacking sometimes, was just that open communication. And then two is, I feel like, we’re really lucky at Champion where we’re working with people all year round, for performance issues, and then also for physical therapy or rehab issues.

Dave Tilley: And so, we see a lot more of the multifaceted nature of sports, and I think you guys worked in pro baseball, and I think that if you don’t have that perspective seeing someone through a full season, and seeing someone maybe through an off-season, pre-season, and their end goals, I think sometimes you don’t really understand what they’re going through. And so, for us, you guys did it with baseball and for me in gymnastics, we just know competitive sports create unique adaptations that are sometimes great, but if they’re gone too far they sometimes are negative. And the one example I’ll use with gymnasts for example, and this is common in baseball players, common in crossfit, is if you do a lot of lat-based [inaudible 00:04:37], major and peck-based activities, you’re going to continue to get some stiffness in those muscle groups because they get extremely overworked, right?

Dave Tilley: You guys have shown in studies, the eccentric trauma of throwing on a shoulder loses some range of motion overhead, and that is now maybe a risk factor for elbow injuries. And in gymnastics, we don’t have that data yet, but I think we’re seeing a very similar pattern, whereas if you do a lot of bars and your lats get stiff, or you do a lot of crossfit and Olympic lifting and your lats get stiff, and you lose overhead motion, well your back might start to become a problem, or something of that nature. So, it’s not for us about trying to sell somebody into a your life program, we need your time and your money. It’s more about you have goals, you want to get there, and we know that over the course of a season if we let this go unchecked, we see some athletes kind of have problems.

Dave Tilley: So, our services are every other week maybe, in an in-season, for a quick half hour session of soft tissue, some manual strengthening, consulting on their program, and just giving advice that’s really I think what we find it as. It’s not a always need to be here for the rest of time and we’re just here for whatever they need.

Mike Reinold: All right. So, you brought up a really good point that I liked that you brought up, I liked … Dave talked two times during that about being almost like a concierge to the people where is this a big deal? Like hey, check this out real quick. Is this something I should be worried about? And a lot of times, we just pat them on the back, and say, “Nope. Get back out there, man. You’re good.” You know what I mean? That type of thing, right? So, being a concierge, being there for somebody I think that’s super helpful. That doesn’t mean you need to be going every week.

Mike Reinold: But the other big thing I think Dave brought up, that I think is really good, is look, if you’re going to participate in this activity that uses your body to the max, you’re going to have repercussions from that. You’re going to have tightness, weakness, fatigue, maybe some soreness. So, this is funny. When we do an evaluation for somebody that comes in for an injury, it’s almost like we have two components to the exam. But what do we look at? We look at what’s the pain, structural stuff, like the diagnosis. But the whole other thing we do, it’s like what’s tight? What’s weak? What’s this? So, let’s just say it, let’s break it down. It will cause tightness, weakness, and pain. Why is it that people only come to physical therapy when they have pain?

Mike Reinold: Come to physical therapy when you have tightness and weakness, because you’re going to come in for pain and we’re going to work on these two things. So, maybe we should work on those things before you have pain. So, that’s a whole paradigm shift almost, where we have to change the narrative …

Lenny Macrina: Hot topic.

Mike Reinold: Somebody make that a clip for social media. But we got to change the narrative here a little bit here to people that … It’s like the performance aspect of it. So, I love that. So Dave, good stuff. Mike, for golfers, what do you do with … What’s the thought process for your golfers?

Mike Scaduto: Yeah, I think Dave kind of nailed it from a general perspective, that things kind of change over the course of a season. And golf is maybe, for most people, for most amateur golfers, it’s a little bit less structured than gymnastics in that people may play one weekend, and then they take two weeks off, and then they’re playing four rounds next weekend. And they just, they tend to get sore and they tend to get stiff. So, we have to do something consistently to counteract the stress that golf puts on their body.

Mike Scaduto: Also, the stress or lack of stress that they’re getting throughout the week, working in their jobs. We’ll say if they have a sedentary job. So, then these people try and go out, they try and play golf, which is a very extremely repetitive, asymmetrical rotational movement that puts a lot of stress on all areas of the body, and then they end up getting sore. So, our goal is to kind of address that before it becomes an issue for them. But at the same time we have to, over the course of a year, we have to change their program. And so, I think if we’re trying to, in an off-season let’s say, trying to gain a lot of mobility and gain some strength, then when it shifts to them playing a lot of golf our philosophy kind of changes to let’s maintain what we have. Let’s not lose any mobility, let’s not lose any strength.

Mike Scaduto: So, I think yes, they need to definitely come in for maintenance care, and the deep goals kind of shift over time, exactly how Dave said.

Mike Reinold: I thought that was really good, because Dave spoke really well on that we can be here for maintenance and management, I’m going to say management too, because Dave’s like us in baseball. Working with the player year round, you have to manage that. What I think Mike brings to the table with the golfers, Mike actually works with the most sedentary of all of our populations, right? It’s the golfer that works all freaking week-

Mike Scaduto: I’m somewhat offended by that.

Mike Reinold: You know what I mean? Think about it, you’re an attorney by day, and then you try to golf on the weekend. So, Mike brings up a great point where we, as physical therapists in performance therapy, it’s almost also pre-hab. Right? So, it’s preparing them for the task they want to do, and not combating the stress of golf, necessarily, but combating the stress of their life to get them prepared to do the activity they want. That is a cool differentiation.

Mike Scaduto: Yeah, exactly. And I think one of the really big things with golf is we do see injuries that are acute and happen from the stress of the golf swing, but oftentimes it’s nagging aches and pains that then … That come about in everyday life, that then become an issue when they start to play golf. So, it’s kind of maybe a little bit different than gymnastics where they’re literally tearing muscles off of bone in practice.

Mike Reinold: That’s a known fact. Fact. That’s the easiest thing they do. Lisa, you’re probably the best that of all of us, right? I mean, that’s probably a fact.

Lisa Russell: That’s generous.

Mike Reinold: But I mean, from your perspective as an athlete, how has that changed how you now perform performance therapy for your rowers? I mean, you’re an athlete, you know what I mean? So, what did that experience teach you about how to perform performance therapy on them? Terrible question, I’m sorry. But you can answer that better than I just asked.

Lisa Russell: I mean, when I was full-blown training, that’s legitimately when I found Lenny, because I knew I needed someone to help me manage. I was digging myself into a hole all the time. And once I figured out okay, I need some maintenance soft tissue work along the way, my training got much more consistent, and I was in general pain way less frequently because I was managing everything we’re talking about.

Mike Reinold: All right. Keep going on that, I like this. So, as an athlete, you proactively sought out a little bit of this. So, at the time you were also a physical therapist.

Lisa Russell: Right, right, right. Yeah.

Mike Reinold: So, that was super helpful that you appreciated that. So, you had the number one thing that the general public’s missing, awareness. You knew this existed and this would be something for you. Again, if you’re listening APTA, I know you’re not, but if you were, awareness that we do more than just these big injury things. All right. So, keep going on that, tell us how your performance, how rowing improved from that.

Lisa Russell: I mean, I actually felt like I was able to use my body more appropriately. I was not crumbling into a tight ball of whatever. So, I mean, and that’s where taking that experience and trying to teach the rowers that I train with now, and work with, and just rowing friends of mine, the benefits that I had in doing that for myself, and like hi, I’m also here for you and I can help you with this. I try and teach the rowers that I interact with, I’m here for you as a resource. You don’t have to just text me or call me when you’re hurt. You can text me or call me, and say, “Hey, I want to come in and see you”, when things just feel tight, or you had a really heavy training load for the week and you …

Lisa Russell: Wherever I fit into your toolbox, essentially, that’s kind of how I tell people. I’m here as a tool to help you continue to train and continue to perform, and not just for the oh, my ribs are starting to bug me, what do I do about that? And the friends of mine who have actually listened to that, definitely have had more consistent training over the past few years than they previously did. So, it’s pretty powerful-

Mike Reinold: That’s huge.

Lisa Russell: … one you figure out the balance.

Mike Reinold: Right. And I mean, you can share that. So, we have experience with athletes, so we can say, “Yeah, no, we know this helps.” But you can share, you can say, “Look, I’ve been there. I’ve done this. This helped me.” So, that’s pretty powerful to get that message across. So, why don’t we wrap up with a little bit from Len a little bit. So, I don’t think we really need to cover baseball. I think we’ve kind of covered everything. But Len-

Lenny Macrina: I agree.

Mike Reinold: … let’s talk about the business side of this. What is your advice to somebody that is in network, that is an insurance-based thing. How do you deal with this sort of thing? What do you recommend they do?

Lenny Macrina: Yeah, we hear this all the time, we’re speaking at meetings that you guys are cash-based, it’s easier for you guys. But that’s-

Mike Reinold: Why is it easier for us? That makes no sense, by the way.

Lenny Macrina: I don’t know.

Mike Reinold: It’s probably way harder, but anyway.

Lenny Macrina: Yeah. I agree. I think people who, you got to show value, obviously, for the people that come to see you. So, whether or not they had an injury with you, and they use their insurance, and they appreciated your services, well, they need to know that you offer a potentially cash-based option to continue some of those services for a nominal fee. So, maybe you offer a 30 minute session after they get through their eight PT Blue Cross, Blue Shield visits, or you know what I mean? They have an ACL and they have 12 sessions, well, they need more visits. So, you have a 30 minute, or a 60 minute option, or some kind of option where they have some kind of program that they can come and continue to see you.

Lenny Macrina: And obviously if they see value in what you have provided them with their insurance visits, they will probably continue with you. It’s you. They want to work with you. Somehow. They want to feel better, they want to be able to perform better, and it’s you that they want to work with. And they will find a way, especially for their kids, right? Parents will do anything for their children, to get them to be feeling good and to be able to perform at their highest level. So, you got to introduce a program to them, and you obviously have to give them good services, great services. Because they’re using their own cash now, because they perceive cash is king, so if they’re going to use their cash they better be receiving the top services that they perceive.

Lenny Macrina: So, give them that option and I guarantee they will use that option and want to stay with you, and it’s an extra revenue source for your facility.

Mike Reinold: Yeah. I think that makes sense. It’s a lot easier to transition somebody that rehabbed with you to this performance maintenance thing. A couple tips I think I’d give you, based on that would be it’s very clear that nobody wants to buy physical therapy, so keep that in mind. We’re kind of saying that that’s part of the problem right here. So, you just have to change the name, you have to brand this and make it a product. So, say it’s baseball, just sell them a velocity program. Call it a velocity program. Well, what is it? It’s manual therapy, manual strength, you know what I mean? It’s like, it’s the things we would normally do in a treatment.

Mike Reinold: Or maybe it’s like a return to sport ACL program. See what I mean. What you don’t want to say is, “Hey, you’re out of insurance. Do you want to just pay cash for physical therapy?” You’d be like, “No.” You say, “Hey, you’re out of insurance. Now it’s time to transition to our super happy fun, ACL, return to sport program.” You have to come up with a cool name, and sell that to them. And I think they will have a much better appreciation that this is like a different type thing. I think that’s the other thing. And keep this in mind, massages are 100 bucks, personal trainers are 100 bucks for one-on-one. You go get a lesson with a golf coach, or a baseball pitching coach, it’s 100 bucks.

Mike Reinold: Don’t be afraid to charge for the service you’re about to provide, and you’re probably going to way over-deliver it because that’s what we do in our fields, so don’t be afraid to charge, don’t be afraid to come up with that. But come up with it, make it a marketing thing, a rebranding thing where you’re not just saying, “Okay, you’re out of insurance, now just give me cash for the same physical therapy.” No, it has to be like a return to sport program, a velocity program, a performance enhancement, a maintenance program. Come up with a cool name. In baseball, we call it our arm care program. People dig that name, that concept, they get that. So, you have to find what your people are aware of, and we kind of talked about that with Lisa, being aware of it, and then deliver that to them. And I think you’ll be much more successful in that model. Make sense?

Mike Reinold: So, awesome. Great episode, thank you Greg for the question. We appreciate it. If you have more questions like that, again, just head to the website, MikeReinold.com. Click on the podcast link and fill out the form, and be sure to head to iTunes, Spotify, rate and review, and we will see you on … the next episode.

Treating Early Stage Adhesive Capsulitis

On this episode of the #AskMikeReinold show we talk about how to identify and treat early-stage adhesive capsulitis. Maybe we can keep people from freezing, here are some of our thoughts.. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 217: Treating Early Stage Adhesive Capsulitis

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Show Notes



Transcript

Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about some ways that we identify and treat early-stage adhesive capsulitis.

Mike Reinold: We have a great question today from Cecilia, from Brazil. I thought this was a good question and I sent it to you guys a bit little early, I hope you guys took a peek at it so you could think about it. But Cecilia asks, I want to read it well, if diagnosed early enough, can adhesive capsulitis be treated so that way the actual encapsulation process does not develop?

Mike Reinold:
And you know what, why don’t we approach this question as this, if we catch early adhesive capsulitis in a irritable or even a freezing phase, if we want to use the less-scientific terminology, can we prevent them from getting further off, like frozen in that process? So who wants to start? I’m sure we all have some experience with this. Maybe Len, you can talk about some people that you’ve seen that maybe you think that you think you’ve helped.

Lenny Macrina: Yeah, yeah.

Mike Reinold: Why don’t you start off, Len, with your experience and then Dave and Mike, chime in as you get some ideas?

Lenny Macrina: Yeah. And no doubt, I’ve treated a bunch of people with this. And a lot of times when they come to me, it’s well… I think of it two different ways. They come to me and it’s way too late and the are way beyond this because they thought it was just a rotator cuff or they just thought they had shoulder pain or rotator cuff tendonitis. And they come to me and they just can’t raise their shoulder up. I think that’s more deep into the freezing or frozen phase.

Lenny Macrina: But I get a lot of people that come in that are in that early phase, and I think if you can recognize it early, meaning they’re having this pain that, without a specific onset, a very benign kind of reaching back, I hear a lot. Pulling luggage, reaching to my back seat, my shoulder started to ache. It’s been a few weeks as throbbing now. And I have good motion, but just doesn’t feel right. And it’s not that true rotator cuff pain that you get down. Another clue that I get from people, and I think I got this from Kevin Wilke in Birmingham, is that they had this horizontal pain, this band of pain, that goes along the shoulder that tends to be more synovitis, which we think is the precursor to frozen shoulder, versus the pain coming down, which is rotated cuff. Not the pain going all the way down, that’s going to be more neck, but the pain coming down rotator cuff horizontal band, more synovitis.

Lenny Macrina: So for those people, I’ll go cortisone injection. I’ll try to get them in to see a doctor and get a cortisone injection. So that’s where the relationship with a doctor is critical because they need to trust your judgment and try to recommend, hopefully, that the patient can get one, because I think that’ll help them in the long run to avoid, I think, the full blown, I think I’ve definitely seen people where I’ve gotten them a cortisone shot early and we were able to manage their symptoms, manage their loss of motion. They still got a little loss of motion, but not the full blown months and months and months of that freezing, frozen, thawing phase. And I’m pretty convinced that we were able to recognize early. Could be biased, maybe I want to pat myself on the back, but I don’t know. I’m pretty convinced that their symptoms really matched what was going to be a bad episode or could have been a bad episode, and we were able to help him with early cortisone. And research has shown that really cortisone is definitely beneficial to people.

Mike Reinold: It’s interesting. It’s a biased question a little bit, because if you address it early enough, you never really know if it was adhesive capsulitisis.

Lenny Macrina: Right, I know. I know exactly. Yeah.

Mike Reinold: You only know until it’s too late. I thought that was pretty cool though. A good way to differentiate some differences in whether or not it’s rotator cuff. Like Lenny said, rotator cuff kind of radiates down almost, whereas the other one, sometimes they almost do this, like what we say about the hip.

Lenny Macrina: Yeah.

Mike Reinold: They almost kind of grabbed that.

Lenny Macrina: [inaudible 00:04:30]. Yeah.

Mike Reinold: It’s almost like more joint-y, versus rotator cuff-y. You brought up a good point that you brought up somebody that reaching in the back seat, stuff like that. Sometimes it takes an incident and then it trips this cascade of inflammation they can’t get out of.

Lenny Macrina: Yeah, yeah.

Mike Reinold: I don’t think we completely understand that, but you just brought up a really good example. So that person would almost look like a rotator cuff impingement type person because they strain their rotator cuff, or whatever, picking up something, and then that could turn into it. But yeah, I think you kind of alluded this too, sometimes people just come in and they just have some goofy pain and we’re not a hundred percent sure why, and it doesn’t add up to impingement signs either.

Lenny Macrina: Yeah.

Mike Reinold: And you’re like, “Man, I don’t know. You’re too young. I don’t know why. You don’t have OA, you don’t have osteoarthritis.”

Lenny Macrina: Another thing is the medical history too. Make sure you [tease out 00:05:27] a couple… Do they have diabetes? Do have thyroid issues? Those two have been linked to a higher incidence of frozen shoulder as well. So maybe their medical history could give you a clue, along with their symptoms and maybe an onset. So those are my go-to questions.

Mike Reinold: Dave, Mike, anything you guys want to add?

Dave Tilley: My 2 cents, I think Lenny hit it really well, is often these things are multifactorial and I think we get kind of stuck in the research of looking at the shoulder capsule itself. And I think, as Lenny as you pointed out, there’s a lot of issues that could possibly mitigate the longterm progression of it. But at the same time, I think we don’t really know a lot about exactly what’s going on and exactly the time courses people have, so I think to some degree, you may be able to reduce the intensity or severity of that onset.

Dave Tilley: But I think a lot of times these people have a lot of other low hanging fruit that we can help them with, that they don’t realize is linked to maybe why they have shoulder issues. So looking at thoracic spine motion, looking at neck motion, looking at soft tissue stuff, you’re not going to maybe prevent the capsule itself from becoming really irritable, but you can give that person 10% motion from their upper back and from their soft tissue. That’s probably going to be a big deal for them because they can move a little bit more with less pain. So I think we often look at the pathology, and I’m guilty of this when I was a kind of a newer clinician and just hyper focusing on the capsule, but there’s a lot of other things that we can do for these people, I think in the short-term, to help them, and I think it’s not only about looking at the capsule, but many other things as well.

Mike Reinold: Yeah. I mean, we don’t know a lot about this. We don’t know who turns into this and who doesn’t. And in a lot of times it’s chicken or the egg. And I think that you kind of alluded to that, Dave, a little bit of it’s chicken or the egg a little bit, like where is it the capsule that is getting a little tight and irritable for whatever reason, maybe something systemic that we don’t understand, like linked to their diabetes or something like that. But maybe it’s the capital getting irritated and then they’re causing a little bit more impingement and it’s causing a little bit more pain, and then you start to get that cascade.

Mike Reinold: Or maybe it’s the opposite. Maybe you get a traumatic incident or you get some rotator cuff impingement, and then for whatever reason, the capsule becomes inflamed. Because we see this both. We see the idiopathic, and then we see the post-injury type adhesive capsulitis. They both seem to happen. So that’s pretty interesting.

Dave Tilley: Yeah.

Mike Reinold: Mike, anything on your end?

Mike Scaduto: Well, I think from a treatment perspective, if someone’s presenting with loss of motion that could be painful, especially into external rotation, I’m going to make that a focus of my treatment, especially early on. So we’re going to do a lot of active assisted range of motion, some soft tissue, maybe some joint moves. And that’s going to be our monitor of progress, is how well are they maintaining motion? Are they losing motion? If so, maybe we reassess where we’re at. Maybe then we’re sending off to doctors doctor to get a cortisone injection if you haven’t done that already. But definitely want to try to maintain and gain motion, especially into external rotation, which seems to be the capsular pattern for something like adhesive capsulitis.

Mike Scaduto: And then probably just not… With joint mobs, I tend to go not super aggressive with my joint mobs. So I guess there would be great for joint mobqs, but maybe I’m not doing a lot of them. The thought in my mind is we don’t want to stimulate that inflammation or that inflammatory process, but we want to do it until we get a little bit of motion, and then have them passively move their shoulder or active assisted range of motion from there to maintain motion.

Mike Reinold: I like it. So if we kind of put it all together, I think we talked a lot about what’s going on, or as much as we know what’s going on, which is pretty good. So it sounds like maybe an early cortisone is pretty helpful, which is great. I’m on board with that and I think that helps quite a bit. But otherwise I think the concept of this is you got an irritable shoulder that maybe has a little bit of loss of motion. It’s about getting after that a little bit early. And I think if you take some of what Mike said there, we focus more on the frequency of the mobility, because again, maybe self-immobilization is part of why they got into this mess, because they said, “Oh, it kind of hurts. I’m going to just not use my arm for a few weeks.” And maybe that kind of got into it. So it’s a lot of frequent motion. So yeah.

Mike Reinold: So I guess to summarize for Cecilia, how do we treat it? Well, I think we treat it just like anything else, but I think the number one key to treatment is identifying that this may be what’s happening. And I think I would just add this to the discussion here, is that I think a lot of times what we think is impingement or even early rotator cuff-like issues, inflammation type things, may in fact be early adhesive capsulitis, that if we address right away, I think we save them from going down that road. I think it happens almost every day in your clinic, I bet, and you don’t even know it’s happening. That’s my guess, just because I’ve seen people noncompliant or people not take care of themselves, spiral down out of control and you can’t stop that. So I actually think we’re doing more helpful things to them by trying to get them to break that cycle before the cycle even begins. So I think that’s kind of the key.

Mike Reinold: So Cecilia, I think you’re right. I think there’s some things we can do. Now you talked about before the actual encapsulation, I mean I don’t know. I don’t know about that. That’s like late-phase type of adhesive capsulitis. I think just even focusing on it earlier. You got to notice, hey, somebody’s got just a loss of like 10% of their very end-range of range of motion. That’s weird, right? That’s weird. Makes sure they can get that motion back and make sure they’re frequently moving it. So we can do a ton of good for these types of patients if we are thinking that way. Because if you’re thinking rotator cuff impingement and that’s it, you might not focus on assuring that the capsule stays mobile and their range of motion stays mobile, you just might focus on strength, for example. So kind of keep that in mind as well.

Mike Reinold: Anytime you see an irritable shoulder, we’ll call it that, I want you to think that going forward, that this may be like a phase one freezing kind of adhesive capsulitis. It might even be pre-freezing. I just made up a new stage. That’s a thing, that’s a thing. Pre-freezing. What would pre-freezing be? It would be wet. It’s wet. It’s the wet phase. All right. Not funny. Okay. It’s early, we’re doing this early in the day, but anyway. Awesome.

Mike Reinold: Well great question Cecilia, we appreciate it. Thanks for listening and watching from Brazil. That’s awesome. If you have a question like that, head to mikereinold.com and click on the podcast link and you can fill out the form to keep asking us some amazing questions. So keep them coming. Anything you can do to help support the show we’d appreciate it. Head iTunes, Spotify, rate, review, and we will see you on the next episode.

Restoring Muscle Function with Biofeedback

On this episode of the #AskMikeReinold show, I’m joined by Russ Paine to talk about the use of biofeedback in rehabilitation to restore volitional muscle contraction. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 216: Restoring Muscle Function with Biofeedback

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Show Notes



Transcript

Mike Reinold: Welcome back, everybody to the latest episode of the Ask Mike Reinold Show. I am here today, we’re going to flip the script again, and we’ve been doing this a bunch lately with obviously the COVID pandemic going on and us staying at home. Instead of us all being at Champion and answering your questions with my team there, what I’ve actually gotten to do is to team up with some of my friends and colleagues around the nation and ask them some questions. So instead of you guys listening to my garbage all the time and all my stupid answers, it’s time for me to ask some questions to some of the smart people that I know too.

Mike Reinold: So, today we have a very special guest, my good friend Russ Paine from Houston, Texas. Russ is the Director of Sports Medicine at UT Physicians Sports Medicine Group. I hope I said that well. You guys have probably heard me talk about Russ in a lot of my presentations because a lot of the things that I’ve learned and I’ve done on the scapula and, heck, lots of things on the knee and neuromuscular control rehabilitation, all these things I’ve learned from Russ and people all the time. But Russ, to me, is one of those groups of like godfathers in sports’ physical therapy that have been very influential to me. So if it wasn’t for the pandemic, I feel like we wouldn’t be doing these things, right Russ? But it’s great to have you on the show, so welcome.

Russ Paine: Thanks, Mike. Happy to be here.

Mike Reinold: Yeah, it was awesome. So a few years ago now… It’s been, what? How many years since the mTrigger came out?

Russ Paine: I think we hit the market two years ago.

Mike Reinold: Two years?

Russ Paine: We’ve been developing it for five years, so it’s been on the market for a year and a half, two years.

Mike Reinold: Nice. So, Russ has teamed up with another friend of ours, Brian Prior, that has done some good work with the light care laser and stuff like that. But they’ve teamed up together to come up with a new biofeedback unit called the mTrigger. And if you’ve followed me for some time, I’ve been talking about this now for years with Russ and been trying to help get the word out because what a lot of people don’t know is that people like Russ and I, and a lot of our friends, we use biofeedback a ton, even though it’s not readily available on the market. But we love biofeedback for postop patients, even some of our injured people that didn’t have surgery. But Russ, why don’t we start with that? Tell us a little bit about biofeedback. What happened to biofeedback and why did this fade away? Why is biofeedback not as common as it used to be?

Russ Paine: Well, I’d disagree with you a little bit that it never was a big thing.

Mike Reinold: Right, that’s a good point.

Russ Paine: It was over shadowed by muscle stim. So it didn’t come and fade away, it’s just been gradually building over a period of time. And I was one of the few people that used it. I use a little handheld biofeedback because I just didn’t feel like I was getting results with muscle stim, and I’ve had 13 knee surgeries. So I’ve tried all this stuff to get your quad back and all I put muscle stim on, I said, “Oh, that looks good, but I can’t make my own muscle.”

Mike Reinold: Right.

Russ Paine: So I started using biofeedback and I realized that my patients were getting better so much faster. I’ve seen all pro athletes and I see athletes that have had an ACL reconstruction in the NFL and they’re a year and a half postop and they come to me and they can’t do… They’ve got an extensor lag.

Mike Reinold: Crazy.

Russ Paine: They can’t even do a straight leg raise. And my patients don’t have that problem because we address that in the beginning. Part of the reason is that the devices were expensive too.

Mike Reinold: Right.

Russ Paine: They were two or $3,000 for a device and it really wasn’t that very user friendly. And the muscle stim market was so big. The reason the muscle stim market was so big, it was because it was a rental, reimbursable product and made millions and probably billions of dollars. So tons of money was issued to help support that as a rental product for research. There’s only a few articles on biofeedback because biofeedback got cut loose as a code. The actually code is still there, but most people, most insurance companies don’t reimburse because the psychology and psychiatric group abused that code for relaxation and that type of thing. So insurance company said, “We’re not paying for that.”

Mike Reinold: That’s crazy.

Russ Paine: So now we use the neural muscular code when we use biofeedback. So instead we do therapeutic exercise, manual therapy, and then neuromuscular code is what we use for biofeedback. So that makes senses, there’s really not a code for biofeedback that really works. Even though there is a code, most people don’t reimburse for it. But I think this is a… Since I’ve learned more about it, it’s a new wave concept that’s spreading through to understand the science behind why biofeedback works maybe even better than muscle stim.

Mike Reinold: Right.

Russ Paine: So when you have my device, which is very sophisticated, user friendly people can come in and download the app on their phone and get to work with it. They see the results and people that are really in tune with. Our patients love this device. And it’s up to your creativity, what you can do with it. So it’s all about starting to diminish the atrophy and inhibition that occurs day two postop. I’ll use the biofeedback for day two postop up to three months postop. Every time they come in, they get 10 minutes of quad setting. And our goal is to recruit more motor units.

Mike Reinold: Right.

Russ Paine: And that’s why my patients all do well. That’s one reason.

Mike Reinold: Right. And we all know that people, especially the complicated procedures, the big pain and the swelling in the knees and other joints, we all know that they have a terrible time with volitional control. So it’s funny, you hear other people struggling, or they say like, “Hey, contract that quad. “You’re like, “Yeah, no, I know I’m supposed to contract quad, I can’t. I haven’t been trained to do that well.” So we’ve been big fans of biofeedback just along the way, because I think it’s great that it works for volitional control, but a device like yours, like the mTrigger, it gives you feedback immediately of how much muscle contraction you’re performing. It’s biofeedback, that’s the whole point of it. It’s not just let’s turn on a neuromuscular stem and crank it up as high as we can, but let’s see how much you can press and you can contract.

Mike Reinold: And we know through all the research, that effort goes up when you have an immediate feedback and you see that and you know the outcomes comes back. So it’s great for volitional control. For me, I think a lot of the new grads and students in physical therapy just haven’t been exposed to it a little bit. So we know there’s neuromuscular stem. Why don’t you tell people that maybe haven’t worked with biofeedback much, what’s the difference on the inside between biofeedback and neuromuscular electrical stem, that NMES? What’s happening to the body differently on these two?

Russ Paine: Well, another point to make, just to finish it with one of your point was that patients like to grade themselves too.

Mike Reinold: That’s true.

Russ Paine: They come in and they’re like, “Oh my God, I can’t even make this leg go up hardly at all. I’m only at 300 microvolts.” And then they’d come in the next week, they’re at 1200 microvolts. So that’s another motivational thing.

Mike Reinold: Yeah.

Russ Paine: So the difference, I think, between the two devices is a scientific thing. And we’ve done a little… I did a little lecture that Mike’ll share with you that goes into detail on this, but it’s all about volitional contraction versus electrical muscle stim distally contracting.

Mike Reinold: Right.

Russ Paine: So when you have a volitional contraction, you use your brain. And we now know that there’s a decrease in cortical input in an ACL injured patient or anybody that has a swollen knee. So when you start with the cortex and go through the cortical pathways down to the femoral nerve, you’re involving the entire system. So that’s one thing that’s different. When you put electrodes on your muscle, it’s a distal brain. It’s on your quad. So that’s why you can’t put muscle stim on and wake up with a big muscle or big abs or whatever.

Mike Reinold: Right.

Russ Paine: And so the other thing it does is when you put electrical muscle stim on, this stimulates the largest diameter axons. Okay. So Mike, what is got the largest diameter axon the fast twitch or the slow twitch?

Mike Reinold: That’s type two. Right?

Russ Paine: Right.

Mike Reinold: That’s good…

Russ Paine: Good job.

Mike Reinold: That was pretty good. You got me nervous there, but type two.

Russ Paine: Type two. Okay. So what is the most inhibited muscle fiber type? Is type one or the slow twitch muscle fiber types are the ones that are inhibited the most. And that has been proven several times. So if you just stimulate the fast twitch and don’t get to the slow twitch, you never really start with this volitional order of recruitment. And when you make a volitional contraction, the first muscle fiber top that fires is the slow twitch. So an isometric contraction starts with slow twitch. And if you’re bench pressing or are doing a big squat, you bring in the fast twitch. And that’s a good thing to do because it develops muscle fiber size. But if you don’t start with the proper order of recruitment between slow twitch, to medium fast twitch, to high end fast twitch, then you never establish that hierarchy. And you never really reverse the inhibition.

Mike Reinold: Right.

Russ Paine: So over a period of time, patients start to get a volitional contraction. But have you ever tried to have a volitional contraction with the muscle stim? It’s hard.

Mike Reinold: Right.

Russ Paine: It’s hard to do. And that’s what we tell our people to do. I want you to work with the muscle stim, but they’re like, “Well, I think I’m doing it, but I’m not really sure.” But when you use biofeedback, you get immediate feedback and you start this order of recruitment to go from slow twitch, building up really strong contraction eventually to fast twitch. So that’s the science behind it in a nutshell.

Mike Reinold: Now, what do you do with somebody that is super acute? So they’re just days within surgery and they have zero volitional contraction. Do you ever use some NMES for a little bit to help them get over that hump? Or do you still go right into biofeedback?

Russ Paine: It’s not because I’m prejudice, its because it works. So I haven’t put a muscle stim on a patient in probably, I don’t know, maybe five years.

Mike Reinold: That’s awesome.

Russ Paine: So what I will do in that case is, we’re having them with their knee in full extension, the quadriceps in the shortened position, and they can’t make a muscle. It’s hard to do.

Mike Reinold: Right.

Russ Paine: If you’ve got a swollen, painful knee. Maybe they can do a leg rise. When you do a leg raise, the EMG goes way up. So I’ll shoot them over the edge of the table because they typically don’t have really any range of motion restrictions. In the video, you’ll see, in my presentation, we set a two day postop patients that couldn’t do a raise, couldn’t do a quad set over the edge of the table. And we had one of the top Texans quarterback that you know of that was having difficulty after his ACL. And I said, “Doctor Lowe, man, we’re having a difficulty ….” Sit him over the edge and have him do an active knee extension. So that’s what I do.

Mike Reinold: Yeah.

Russ Paine: Sit them over the edge, and if they can bend to 70 degrees or so, the peak EMG activity of your quad during an active knew extension is between 90 and 30 degrees on an active knee extension is out near full extension, but it’s at 30 degrees. So we do 90 to 40 and they can fire their muscle in that position.

Mike Reinold: That makes sense.

Russ Paine: Another trick you can do is have them in the gravity eliminated position. So just bring their knee up and full extension to a 90 degree position, just like we do with a rotator cuff repair, have them in gravity eliminated and try to hold their limb in that position and have them try to pick their heel up off your hand.

Mike Reinold: That’s great.

Russ Paine: That’s another tool. But the easiest thing to do is sit them over the edge of the table. You’re not going to blow the graft out.

Mike Reinold: No. They can’t even control the quad.

Russ Paine: With no resistance. And you’re not even getting their full extension. Now, if you had them do a 50 pound knee extension machine, maybe.

Mike Reinold: Yeah.

Russ Paine: But with this… That’s why people don’t do because you got so ingrained to orthopedic surgeons brain that knee extensions are bad for ACLs, but it’s not a problem in the acute stage.

Mike Reinold: Right. Yeah, no, I agree. So obvious implications for the knee. Especially ACL. We’re having patients that have quad strength deficits for months down the road. Who knows if we had just layered this on earlier to get volitional control earlier, would strengthen conditioning at the two, three, four, five month mark been much more effective? It’s mind blowing to think what we may have missed.

Russ Paine: It’s a variable that we have not looked at in the past.

Mike Reinold: Right.

Russ Paine: Now, there are EMG devices that were five to $8,000 where you could do a true EMG test, but there’s never been anything that is quick and dirty, that you can look at the neural muscular deficits. And that’s what we’re doing right now. And our goal is to compare our strength deficits that we see when we test them at six months postop in our followup program, and compare those strength test is to the EMG deficits.

Mike Reinold: Right.

Russ Paine: In my patient population, typically around two to three months we’ve gotten rid of the neuromuscular deficits.

Mike Reinold: That’s great.

Russ Paine: But as I said before, people jump the gun, they don’t restore strength and they jumped into functional movements and functional exercise and these swells, they had no e center control, they can’t decelerate and I’m putting them on the biofeedback and they’re fricking 50% deficit in their neural muscular control.

Mike Reinold: Right.

Russ Paine: That’s a variable that I think this is a wave of a mentality that I think people will adopt once they see it and once we publish things that this is one variable that we need to take off the shelf.

Mike Reinold: Right. And you know what it makes sense too, because if you look at how a quad functions, if you can barely do a quad set and a straight leg raise, and then you immediately jump into the gym and start doing some exercise, just because it’s week X, then you’ve missed the boat. But that’s the really neat thing about biofeedback in general though, is it’s not just an exercise tool, but you can quantify, you can quantify the contraction. You can compare side to side, you can look for a neuromuscular deficit. So this isn’t just a tool to rehab with, this is a tool to almost use as part of your evaluation process, too.

Russ Paine: Right. And we spent a little extra money to put in that neuromuscular deficit test because I thought it was important…

Mike Reinold: There you go.

Russ Paine: … To do a two channel biofeedback instead of one channel so we can do that comparison. So the other thing we’re doing in the next year is we’re partnering with a company called BlueJay, and they do home networking with patients, it’s HIPAA compliant. So eventually the patient will be able to download the app on their phone and they’ll have a folder of their EMG data that we can share, and we can pull it up and look at it together. The physician can see that. And this is one thing that if you guys have a mTrigger out there that are listening to this, I’ll put these numbers down in my notes objectively.

Mike Reinold: Right. Sure.

Russ Paine: So instead of saying, “Quads a little bit better, better muscle tone.” I’ll put, “They started at 700 microvolts, now they’re are 1200 microvolts EMG.” So this is an objective criteria that allows us to document a patient’s progress. And the patients love it. They like to see the numbers that they’re getting better.

Mike Reinold: Yeah, no, that’s really neat. And we’ve talked a lot about using it on a muscle group to get a muscle groups volitional control back and to get it stronger down the road. Another neat thing that I do with biofeedback, I wanted to throw at you and then see if you have any other creative things. But the fact that it’s two channel, I like to do certain exercises with two different muscle groups on two different channels. So making it up off the top of my head, but maybe say a hip extension and we have some of the pads on the low back and some of the glutes. And I say like, “Look, I want you to do this bird dog for a hip extension. I want to see glutes and less back.” I want to make sure that we’re doing it right. Or the right core is firing or heck even upper trap, the lower trap ratios. What other neat ways do you use it? Because I’m sure you’re even more creative than I am.

Russ Paine: Well that’s for sure.

Mike Reinold: Good answer. That was good.

Russ Paine: No, you’re Mr. Creativity. So I’ll learn a lot from you. One thing that’s really helpful is to use it with prone planks, for teaching people to do a lumbar stabilization program. So you want to fire your abdominals and your erector spinae together to brace with that.

Mike Reinold: Right.

Russ Paine: And so you teach people neutral spine positioning, you teach them to brace, but they don’t really know whether they’re firing or not. But with the mTrigger you use two channels, you can see exactly what’s going on and you say, “Well, you’re not really firing your abs.” “Well, I think I am.” But I said, “You need to get that… Oh your erector spinae is going down.” So you can use it for that. That’s a really good, I don’t see that many spine patients, I see a few, but the spine therapists are crazy with it.

Russ Paine: Now strength and conditioning is a whole nother ball game. And it’s a really good tool for performance individuals that are strength coaches and also personal trainers. It’s a great tool for them. With regard to the shoulder, posterior cuff and the lower trap are two great sister muscles that work together with different activities. I’ve got a bunch of videos that I think you’ve seen so that we can fire the posterior cuff and at the same time, try to get a posterior sculpting of the scapula. Now Phil Page has used it for limiting upper trap activity along with lower trap, so some people believe that the upper trap maybe like an antagonist of what you’re trying to achieve. So you can use one channel for inhibition, the other channel for contraction.

Russ Paine: Now, another thing we’ve been doing reasonably well, if you have bilateral knee patient, you can use two channels. And the patient can do both of those knees simultaneously during the rest period of one, do the other one. You know me, I’m brutal. The other thing you can do is you can do quadriceps and hamstring contractions, but I don’t do a co contraction. I do 15, 10 seconds of quad, and when the quad relaxes, do a hamstring isometric. We never do hamstring isometrics.

Mike Reinold: Right.

Russ Paine: But hamstrings are a really important muscle group, we forget about that. But it’s really up to your creativity. That’s the beauty of this device is you can think of things to do. And the other fun thing to do is put it on the serratus anterior and try to prove some of these research articles that you’ve seen that this climbing of the wall with your elbows against the wall, what do you call that? I can’t remember. Does that increase your serratus activity? And sure enough, it does.

Mike Reinold: Right.

Russ Paine: What about the dynamic …? Which one’s a better exercise? What about rowing or what about manual resisted external rotation? So you can prove it to yourself. So it’s a fun tool.

Mike Reinold: Right. And everybody’s different. When we look at those studies and we look at a mean of a group of subjects. You may find that one exercise is better than another for a certain person. So the more individualized the better. So awesome. So this is my favorite episode right here, because one, I don’t have to talk the whole time, it’s fantastic to actually ask smarter people questions. But Russ is the man on biofeedback. And this mTrigger device is really amazing and ridiculously affordable. There’s no reason why everybody shouldn’t be using this. I just think people don’t know about it. So hopefully we can get some awareness to this because it’s something that some of the best sports physical therapist I know are using. So the best are using it, I think it’s something everybody should use it.

Mike Reinold: So we learned about the science behind it. We learned about why it’s better than neural muscular stim and some creative ways to use it for a bunch of different things. Thank you, Russ. I appreciate you taking the time out of your schedule and the freaking pandemic that we’re having to do that. So thank you very much.

Russ Paine: Thanks, Mike.

Mike Reinold: Yeah.

Russ Paine: Thanks for having me.

Mike Reinold: Awesome. Yeah. And if you have any more questions like this, even though I asked all the questions, but if you have questions too, you know what to do, go to mikereinold.com, click on that podcast link, and you can fill out the form to ask us questions. Be sure to rate and review this on iTunes and Spotify. And we will see you on the next episode. Thanks so much.

Restoring Knee Hyperextension Range of Motion

On this episode of the #AskMikeReinold show, we talk about our current thoughts on restoring knee hyperextension range of motion after surgery. We’ll cover how much we try to restore and what may influence our thought process. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 215: Restoring Knee Hyperextension Range of Motion

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Show Notes



Transcript

Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about restoring hyperextension after knee surgery.

Mike Reinold: Let’s see. Lynn from Arkansas said, or asks, “What should the goal be for knee extension post knee surgery, when the contralateral knee has excessive hyper extension?”

Lenny Macrina: Whoa!

Mike Reinold: It’s a good question. I feel like Lenny and I’s opinions, I don’t want to say change, because that seems wrong. I think they’ve evolved slightly over the years from where we’ve done, but Len, why don’t you answer this from your perspective as what you currently recommend and maybe some of the past thoughts on that too? Because I think a lot of people have learned something in the past and then just go right back to what they were doing 10 years ago, without thinking about some new stuff. So what’s your current thought process on this?

Lenny Macrina: Without knowing what excessive hyperextension means in the question, I’m going to assume it’s that excessive like 10, 15 degrees of hyperextension, which is a lot for some people. But hyperextension is normal. If you measure people’s knees, they’re going to probably have four to six degrees easily of hyperextension.

Lenny Macrina: So the excessive person, 10 to 15 degrees, I would say maybe 10, 15, 20 years ago, we would say, “Maybe that’s why you tore your ACL. Let’s just get to zero and you’ll be fine.” Then we got some research that had come out that showed that those people, longterm, don’t do as well. So they have anterior knee pain. They may get some arthritis in the front of their knee, like the patellofemoral joint. They just never get back to their sport, because they always have irritation in the knee. So a couple of studies that I always go back to by Don Shelbourne out of Indianapolis, showed that the ligament has no extra laxity on it if you gain hyperextension back, meaning, similar to the other side to that person and their function improves, they feel better about their knee and people report that all the time.

Lenny Macrina: So for me, my goal in PT is to get hyperextension immediately. So again, depending on the person, if they are really loose-jointed, I’m not going to go at it as fast as somebody who only has three or four degrees and they are known to be somewhat tight, that’s just their persona. So for somebody who’s really loose-jointed, like the question asked, I’d probably say, get maybe half of it, something like that. If they had 10 to 15 degrees, I’d probably get five to seven degrees relatively quickly. I’m going to try to crank on their knee, but I want the patient to comfortably get it and feel comfortable getting it at home. Then the rest of it usually comes with just functional activities, because they have the underlying tissue laxity.

Lenny Macrina: There are some studies out there that show people who have hypermobile tissue have more elastin than collagen in their makeup. So they are going to get their motion back easier than somebody who doesn’t. But we don’t know that, we aren’t going to biopsy everybody’s legs, or perhaps everybody’s tissue, but I think you know pretty quickly by some kind of Beighton score or something like that and just getting information that will help guide how quickly you want to progress some people.

Lenny Macrina: But to answer the question, symmetry is important. Numerous studies have shown that it’s important for functional outcomes and won’t put stress on the ligament. That’s my goal, is pretty quickly try to get most of the motion back, but let the rest come back through function.

Mike Reinold: Going historically through that, I think this speaks to both our experience, but I think this is the general experience too. At first, I agree, we were definitely like, “Let’s get it all back. Let’s get hyperextension back right away.” Then I think we evolved a little bit like, “Let’s try to keep them at neutral.” A lot of people said, “Let’s keep it neutral. It’s going to put too much stress.” Then we’ve evolved to be a little bit more individualized, but tend to lean on restoring, but not forcing maybe. So let’s go through a couple of specifics and then anyone jump in, based on opinion.

Mike Reinold: Somebody on the contrel leg has zero to five degrees hyperextension, how much do you get back and how fast? Len, you want to start? And then if anybody disagrees or agrees.

Lenny Macrina: So they have five degrees of hyperextension, is that what you said?
Mike Reinold: Zero to five degrees. Somebody in that zone on the contralateral side, are you getting it all back and how fast?

Lenny Macrina: I’m going to probably get them to at least zero, at least… We measure, we’re probably going to have three to five degrees of error, but I’m going to get it back somewhat quickly, zero to twoish, I want to see a little hyperextension when they come in. I’m not going to try to get them to five right away, but I want to see a little hyperextension those first couple of weeks and we keep it. Because if we don’t keep it, if they start coming in and they start lacking extension, you start worrying about a Cyclops lesion. So the people that… Oh sorry, go ahead.

Mike Reinold: I see. No, no, no, I was going to say, so they have five degrees on the other side, you get them to two forever? Or do you ever get them to five?

Lenny Macrina: No, I’m going to get them to five eventually, but I’m going to monitor it. Every time somebody comes in to see me after an ACL, I don’t care if they’re nine months out of surgery, that’s the first thing I look on at somebody is their extension. I want to measure their extension. So for them, I’m not going to get it immediately, but I’m going to get them to five degrees eventually. How quickly that comes back, I don’t know, we’ll see. We’ll monitor it. If they are kind of hovering it two and they’re stuck there at eight months out of surgery, well, yeah, hopefully I didn’t mess that up and I need to be more aggressive, but I think they’re eventually… I’m going to get them to five degrees by the time that they are doing functional activities and feeling good.

Mike Reinold: Anybody else?

Dan Pope: It was too beautiful. I don’t want to mess it up as heck.

Mike Reinold: I feel like somebody in the zero to five range, I’d be a little bit more prone to get them to five sooner, to be honest. Because I think what we’re trying to do is I’m trying to chunk people in terms of their hyperlaxity.

Lenny Macrina: Correct. So instead of getting…

Mike Reinold: I feel like you would too.

Lenny Macrina: Maybe I didn’t say well, but if that person has 10 to 15 degrees of hyperextension, I’m not going to push on them. I’m going to let that come naturally because that’s going to come. But that person who’s probably a little tighter and only has that zero to five, somewhere in that range, I’m going to get twoish, threeish, something like that. Then just let the rest kind of hopefully come. But I’m probably going to be a little more aggressive, probably do a little bit low load, long duration stretching with them, because I know that they are just not that tissue lax person.

Mike Reinold: If they’re two months out and they’re two degrees versus five degrees, I know that doesn’t sound like a lot, I’m doing low load, I’m working on that, I’m concerned about that. I’d feel like the zero to five, I’d be a little bit more prone to get them closer to five sooner than later. Not week one, but probably within the first month. Now somebody with 15, 20 degrees on the other side, what do we do? How does that change the equation?

Lenny Macrina: There’s big arguments out there. So I’m always, as you guys know, hovering in social media world and there’s some docs are like…

Mike Reinold: The blogosphere.

Lenny Macrina: The blogosphere on the interweb. I have conversations on Twitter and stuff like that with docs who are like, “No, if they have 10 to 15 degrees of hyperextension, you keep them at zero, I don’t want them to tear their ACL.”

Mike Reinold: Zero?

Lenny Macrina: Yeah, zero or barely getting get hyper extension.

Dave Tilley: What’s the percentage of that difference though, when you think, that’s a 20% difference?

Lenny Macrina: Can you imagine being that person who has a 15, 20 degree difference in their amount of motion in their knee compared to the other side and how differently that feels. But the doc is concerned structurally, right? The doctor is concerned with re-tearing that ligament, we’re concerned with function. It comes down to this, oftentimes, especially with rotator cuff repairs. We’re concerned with function, can the person go and do their life? The doctor’s concerned with re-tearing that rotator cuff. Same thing with the ACL thing. For me, if there’s somebody has 15 degrees, I’m going to get them seven degrees or so, seven or eight degrees, about half and then-

Mike Reinold: Not nine. Nine would be bad.

Lenny Macrina: Not nine.

Dave Tilley: Pull that ligament out, nine. Mm-mm (negative).

Lenny Macrina: Roughly half.

Mike Reinold: No, I like that.

Lenny Macrina: Usually the rest will come back. I’ll prop them up. I’m not going to put a 10 pound ankle weight on their knee. I don’t need to do that, but I’m going to prop them up and just let gravity push their knee straight and I’m going to monitor them. I’m going to maybe give him a little over pressure. If they’re feeling pain in the front of their knee when I start doing over pressure or if I start assessing them, that’s usually more indicative of a Cyclops lesion, than if they feel pressure in the back of their knee, that’s going to be more indicative of capsule and/or hamstring. So that’s another nice little test that you can do, is that over pressure test. If you start seeing somebody losing motion or they’re kind of plateauing or getting irritable in the anterior knee, look for a Cyclops lesion, because it’s in five to 10% of cases typically, but I think it’s underdiagnosed and it’s a reason why people don’t get their motion back.

Lenny Macrina: It’s a lot of what I see in my practice, because of a blog post and a video that I did, people are finding me from all over the place, because of missing Cyclops lesions and just assuming getting zero is good enough.

Mike Reinold: So think about it. If you have 15 degrees of hyperextension and you only get zero to five, which a lot of people would say, that person is not getting to their terminal knee extension, they’re not getting their full screw home mechanism. They’re probably have their quadriceps isometrically engaged all freaking day. They’re all just like walking around. I can’t wait to see that transcribed below, all freaking day too, by the way.

Mike Reinold: Can I say, don’t transcribe those last two sentences, before this sentence, now three sentence…. I don’t know what to do, anyway. Think about it, if you’re used to having a hyperextension and you don’t, you feel like that thing is bent 90 degrees. It’s going to be a functional thing. We tend to see people with hyperextension that don’t get their extension back, have a really hard time getting their quad back. They’re going to have a ton of problems down the road with that. So it’s something to keep in mind. I guess just to summarize, I guess I would say again, that zero to five range, I feel like where you could argue, they’re not super lax, that’s the person that’s coming in, maybe we’re putting a little ankle weight over their distal thigh to give some over pressure into the extension, let them get that motion over time.

Mike Reinold: But somebody that’s 15 degrees, that’s somebody we get halfway and you just prop them up with a heel wedge and probably gravity’s enough to give them a little bit of an over stretching, we don’t have to be as aggressive with that. But I think the general concept is this, there is no one answer. There’s really no one answer to anything. It depends on the person, the tissue type in their amount of motion on their other side. So I guess the answer as always, it depends. But I think, if you think strategies like this, I think that’s a good way of doing it.

Mike Reinold: I will say that if you’re on either end of, let’s just jam it into hyperextension as far as we can, that could have some bad things. But I would say, you probably are more likely to have bad things if you’re on the other end and you let them get tight. So makes sense?

Lenny Macrina: Yeah.

Mike Reinold: Awesome. Good episode. Thanks Len. Always good to hear. Len’s the guy for these types of questions. I didn’t think that was a good rant. I mean, that was education, nothing to rant about. Should we ask about meniscal repairs and we have in the ’90s…

Lenny Macrina: Why are we stuck in the ’90s?

Dave Tilley: What about prone hangs? What about prone hangs?

Mike Reinold: How about prone hangs, yeah.

Lenny Macrina: That’s another episode

Mike Reinold: No, no. Great question, Lynn. Thanks so much. If you have a question like that, there’s a website, mikereinold.com, click on the podcast link and you can fill out that form. Keep asking away. Head to iTunes, Spotify, rate, review, subscribe, whatever you guys do on podcasts things and we will continue. We’ll see you on the next episode. Thank you.

Medical Screens in the Physical Therapy Setting

On this episode of the #AskMikeReinold show, we talk about the use of general medical screens in the outpatient orthopedic and sports physical therapy settings. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 214: Medical Screens in the Physical Therapy Setting

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Show Notes



Transcript

Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about using general medical screens in the orthopedic physical therapy setting.

Mike Reinold: We got another awesome… I think this is a pretty cool question. We haven’t talked about this yet, I don’t think on the podcast, which is kind of crazy, over 200 episodes. But Brendan from Florida says, “Hey guys, love the show and everything you guys do for the profession. As a new grad therapist, I’m working in outpatient orthopedics in a predominantly underserved population area. I find myself performing a lot of medical screens of other systems to rule out more sinister pathology like GI, cardiac, et cetera, more frequently than I thought I would be doing. Do you guys do this in your setting, and can you speak about any past and previous experiences of missing something that turned out to be non-musculoskeletal?”

Dave Tilley: Got one.

Mike Reinold: So yeah. I know, I definitely have some stories too, and I think we have some decent advice, but I don’t know, what are we starting with this, right? So we’re outpatient orthopedic, you could argue we’re probably high end orthopedic/sports. Most physical therapy clinics in the world have sports in their name. You drive by and there’s no athletes anywhere near them, right? So most people aren’t sports. We’re probably what? What would you guys say, 80% sports? Meaning an actual athlete that plays on a sport with a team, you know? So we’re like 80% sports, so I don’t know. I feel like most of our people come to us with very specific things, that doesn’t mean that they have some underlying things we have, but who wants to start? Anybody have stories? Maybe we’ll start by sharing some stories so that way we can do that experience, talk about the experience. So Dave, you said you had one.

Dave Tilley: Yeah. I’ll say one, answering point too is that I think that there is still obviously not medical, in terms of different systems, but there’s still a lot of red flags that we have to look out for as sports like ruling out a stress fracture, or ruling out something that’s a little bit more serious in nature, and I think that is important to remember if you work in sports. That it’s not all casual. But yeah, the best experience that I had was I evaluated somebody for neck pain, and just the story was not making great sense of how they got rushed through… I think they were either in the ER or the got a consult and it’s very quick, they got rushed by somebody who looked at them and say, “Oh yeah, general neck pain. Here’s some muscle relaxers and I’ll see you back in six weeks after your 500 .. of PT.”

Dave Tilley: The person was a little bit older and had some symptoms that were overlapping with dizziness, so it was hard and I was with a student and she was just doing her evaluation, she turned her head to one said and she was like, “Oh, that kind of makes it hard to see.” I was like, “What?” She was like, “When I turn my head like this, things get really fuzzy on this side. I get dizzy and it gets fuzzy.” I was like, “Wait a minute.” It turned out she was having some VBA occlusion, so we sent her back and the same doctor was a little dumbfounded. He was like, “I don’t know how I missed this.” I was like, “I can think of a few ways, maybe it was just a little rushed.”

Mike Reinold: Yeah.

Dave Tilley: Probably time. Yeah, it was snap of a finger as it went from very musculoskeletal like okay, looking and turning some ear stuff, or whatever, dizziness, but when she started to say her vision was going, it was like, “Stop everything and we’re all set with this.” We didn’t even bill her. It was a half hour we were like, “We’re not going to bill you and we’re going to get you back to see somebody.” She went directly to the ER with her sister maybe and they got it cleared up.

Mike Reinold: Nice. Anybody else? Come on, I know you guys have some good stories.

Lenny Macrina: Yeah. I mean, I’ve had stuff where you found a AAA, low back pain that’s an aneurysm, something like that. I know when I was in North Carolina, that I practiced, we had a client that had that and saved that person’s live. But I think a paper just came out in JOSPT, I think it’s this month, looking at some red flags you have to keep in mind when somebody who presents with low back pain. So I thought it was a really good paper to throw in your back pocket and just have it in your head, because it talks about some questions you should probably ask the person about their recent history that they probably wouldn’t think is significant for their back pain, and then when you start asking them and they start answering positively, you really need to set some bells and whistles off in your head. Like having some kind of fever, or sweats, or some of the typical things that we kind of ignore as PT sometimes, and we just focus on the musculoskeletal system, because we just think everybody has low back strain, or herniated disc in their back and you just dive into that.

Lenny Macrina: If you don’t ask the question, they don’t know to share that. That’s one of the things that really evolved in my career is really dive into the subject and the history, because I think that’s going to be the most important thing is asking the right question. People don’t know what to tell you. They just think they’re there for back pain. They’ve been told they have back pain, X-ray was negative and so here we go. So I think that paper in JOSPT was a nice little paper to summarize some of the red flags that we often see, but DVTs, finding DVTs in people, especially postop people where it looks like calf pain and you start questioning stuff. I’m trying to think of anything else.

Lenny Macrina: We had a baseball player that had thoracic pain. We treated for a should issue in the back, the thoracic pain just didn’t make sense and we were treating it. We’re like, “Your pain is getting worse. This doesn’t seem musculoskeletal. It turned out he had a benign tumor in his spine.” I think if it doesn’t fit your typical presentation, it really makes you think and you’re really wracking your brain to try to figure out what is going on. Refer out, just refer back and get imaging, or get something, get another set of eyes it, because if it doesn’t make sense, it usually is something more severe.

Mike Reinold: Lots of good information. I wanted to add a little piece to what Lenny said, just because he said the aneurysm thing, the AAA. Do we say AAA or triple A, what do we say? Can’t say triple A, is it triple A?

Lenny Macrina: I think I have a flat tire on the highway, but whatever.

Mike Reinold: Yeah. So somebody on Twitter posted this a while ago and I took a picture of it. I’m going to… I’ve been meaning to write one of my weekly newsletters about this, but here’s the exact tweet or Instagram, whatever this was, but had a case recently in which I evaluated an 85 year old female with lower thoracic pain. She has a history of compression fractures. All the time with her previous physical therapists, they worked on general range of motion and pain science, trying to get her to cope with her pain, okay? Without much help. After digging in, I referred out and she had an aneurysm. So she had the triple A, so abdominal aortic aneurysm, right? We’re doing pain science with this person because she has chronic low pain? Well chronic back pain, holey smokes, right?

Mike Reinold: That tells me right there, that their therapist wasn’t… A, probably wasn’t asking the right questions. B, wasn’t thinking enough and C, being a little righteous thinking like, “Well chronic low back pain, it’s all pain science.” Yeah no, apparently aneurysms hurt. I didn’t know that. Aneurysms are frowned upon, but you can see where I think more… not just to dig on the whole concept of pain science with that, but more of the concept of being stuck in one treatment paradigm, right? If that is… if you only have one thought process and everybody is chronic pain, you’re going to miss somethings. And we can say that about anything. How about you guys? Lisa, Dan, you guys have any experience with this stuff?

Dan Pope: I think it’s super important. To be honest, I moved from a population that was less healthy to a population that’s more healthy, so I probably do a little less screening than I used to. But yeah, I’ve referred a few people to the emergency room. One person was having dizziness and diplopia and they said they were having drop attacks, and they got faint when I was needling one time like, “You need to go to the emergency room.” It was actually fine, and I had another gentleman who had a hip scope, labor repair and sent him to the emergency room because he was having some symptoms that I potentially thought were DVT and it turns out it was. I’ve sent a few other people where there was nothing in general, but I really agree with what you guys have to say.

Dan Pope: First and foremost, you kind of have to know what the red flags are and it does change a little bit based on the area, but I mean red flags still exist for a shoulder problem, right? I mean, I think we also think of low back pain, that could be a whole bunch of problems that are sinister, but you can say the same thing for the knee, or the same thing for the shoulder, so you always have to have your eye open for that. If it’s not just progressing the way it normally does then refer out, because I think right now in the blog… I keep calling the blogosphere, which is probably about 10 years ago, the social term.

Mike Reinold: Yeah. That’s pretty good. I mean, that’s your niche.

Dan Pope: That’s my niche. I like quiche.

Lenny Macrina: Blogosphere.

Dan Pope: Yeah.

Lenny Macrina: Or the interweb.

Dan Pope: I think for good reason, we’re kind of anti-imaging right now. But the other part is we don’t want to miss things, right? You got to make sure you do what’s appropriate for the person that’s in front of you, right? I don’t know if you’re going to…

Mike Reinold: Can I just jump in to say we’re not all anti-imaging.

Dan Pope: Yeah.

Mike Reinold: Right?

Dan Pope: The Blogosphere is though.

Mike Reinold: Depends on which niche you’re in.

Dan Pope: Yeah.

Mike Reinold: If you’re a niche person or a niche person, depends on what your-

Dan Pope: Depends on the quiche that you’re cooking.

Mike Reinold: Yeah.

Mike Reinold: Yeah, but I think it goes back to my story. If your personal beliefs are that you’re anti-imagining, then you’re going to probably dig your heels in a little bit in delay, and that could be a problem in somebody’s life. So I don’t know. Anything else Dan?

Dave Tilley: Lisa go first and then I have one more thing to chime in that’s important.

Mike Reinold: Yeah. Take turns Tilley, let’s go.

Dave Tilley: I’m allowing her.

Mike Reinold: I’m just kidding. Dan, I didn’t mean to cut you off, sorry.

Dan Pope: That’s all right.

Dan Pope: I’m good. No, I just… do your due diligence, right? We have guidelines for even meniscus tears. If you think it’s a meniscus it might be something else. You get an X-ray first and then you treat it, right? You don’t just assume blindly.

Mike Reinold: Yeah. I think that’s great. Lisa, have you been lucky or have you had to have any of these experiences yet?

Lisa Russell: Luckily, I haven’t had to send someone to the ER straight from PT.

Mike Reinold: That’s good. That’s good.

Lisa Russell: But I mean, I definitely… I’ve worked in settings where there are not as healthy population, and I think I was on my guard a lot more to… and I guess what it taught me was that I needed to ask a lot of questions and not just assume that I was immediately going to musculoskeletal something, you know? To really confirm that everything felt good and it seemed to fit the picture, and to encourage someone to at least ask questions of their doctor, or find some more information, or that kind of a thing before we press on into anything really significant.

Mike Reinold: Right.

Lisa Russell: I mean, yeah, I’ve been lucky that I haven’t had to send someone out.

Mike Reinold: That’s good. Now you’re prepared, because we’ve given you some amazing advice. Dave, what else? You said you had something?

Dave Tilley: Yeah. I probably should have started with this story, but I remember in a previous patient that I worked with that she had a labral tear, very hyper mobile. She was doing crossfit, things like that, she had a hip scope and got it repaired. It’s good, but then the other side, also started to have issues too and the surgeon I was working with is super high level, really good doc and we both were just like, “Man, this doesn’t make sense.” She started having weird, generalized multi-joint pain and so one time, she got a fever or something of that nature and went to the hospital and got… I forgot what lab test she got done, but I remember calling my friend, who’s an emergency room physician’s assistant. I was like, “Man, this doesn’t make sense. What would you say if you saw these numbers?” He was like, “Oh, high risk of bone cancer.” I was like, “What?” He was like, “Oh yeah for sure.” Clinical patterns.

Dave Tilley: I never followed up with her because she continued on her own way with that medical path, but it just really struck me as two different perspectives of the same… I was looking at only ortho, hip scope, crossfit, squatting, whatever and he was like, “Yeah, that’s a really high risk bone cancer”

Mike Reinold: I like it. So you know, the general theme that everybody said here and this is how I educate our students with this. I say this, I go “When you have a scratch your head moment.” Right? So when you’re trying to put the pieces of the puzzle together and you end up concluding that the puzzle doesn’t fit nicely together, then we’re missing something, right? That doesn’t mean we’re missing something sinister like we’ve talked through here, or just general medical. You could be missing something orthopedically like musculoskeletal, but often times, it’s a sign that we’re missing something. So we either need to dig in deeper like our subjective, digging deeper with our objective, right? To try to get this out, or refer them away, better safe than sorry. Right?

Mike Reinold: I think that’s the general consensus, especially now as our profession gets more and more direct access. You better be ready for this, right? You certainly don’t do that. So I would say the big summary is don’t have a closed mindset about some of your beliefs here. When people come in with certain symptoms and pains and complaints, right? You’re going to have tunnel vision and put them in one basket, so having an open mind about when things don’t start adding up, ask more questions. Figure out where we are and see if we need to refer out. That was a good one.

Mike Reinold: I think that’s going to be real helpful for people. No one’s an expert at this, right? You just have to be an expert at having a good hunch, right? Dave gave some experience and some things like early on in his career that I think a lot of young therapists could probably benefit from. If you don’t have 20 years of experience that you can go back into your head with, then ask. Ask some friends, reach out, be like, “Hey, this doesn’t add up to me. Does this add up to you? Am I missing something?” And see what they say too, because remember, it’s for the benefit of the person in front of you.

Mike Reinold: So awesome, great question. Thank you so much. Another great episode. Head to mikereinold.com, click on that podcast link and fill the form to ask more questions and please head to iTunes, Spotify. I want to see more reviews. We haven’t got a review in a while I think. I don’t know. I actually haven’t looked, but I want to see more reviews. Reread the reviews, we jump in there every now and then for feedback because we want to make this better. So hopefully you guys are enjoying this and staying from home just like us, and we will see you on the next episode.

Building Your Own Brand as a Physical Therapist

On this episode of the #AskMikeReinold show we talk about some of the ways that a physical therapist (or fitness specialist) can build their own personal brand the right way, and without your employer being annoyed. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 213: Building Your Own Brand as a Physical Therapist

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You can use the player below to listen to the podcast or subscribe. If you are enjoying the podcast, PLEASE click here to leave us a review in iTunes, it will really mean a lot to us. THANKS!


Show Notes



Transcript

Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about building your own personal brand as a physical therapist.

Mike Reinold: We got a good question here. This is a good one that I think is going to be good for this crew. I wanted to kind of talk to you guys about this, but Brian, from Los Angeles, asked, “Mike, you have a team of physical therapists that all have their own brands and side businesses educating in their field of expertise. Unfortunately, you don’t see that often with other employers. How do we push our profession forward to see this type of model and PT practices as beneficial instead of employers viewing their employees having brands as negatives.” Honestly, it’s a lot. While you guys gather your thoughts, let me think a little bit here and I think it’s kind of funny.

Mike Reinold: Let me hit the end of that while you guys think about it because I want to hear it from your perspectives as the employees with the brands. And maybe Lenny can talk a little bit too as an employer, but I want to talk about that last part, about this being a negative. I have no idea why an employer would consider this a negative. I mean, what are they worried about? You going around the corner and open up your own shop? I mean, that’s the only negative, right? Is that you’ll leave and do your own thing. But whether you have a brand or you don’t, if you have an entrepreneurial spirit, if you’re a business type of person, that type of thing, and you’re dying to open up your PT practice, then you’re probably going to do it anyway, right? I don’t know, we never fear our employees leaving to do other things because it probably means it’s a better opportunity for them and we’re supportive of that decision, right?

Mike Reinold: So it’s funny, we’ve had, I don’t know even, over the years, people tend to come and go a little bit, right? We’ve had a few employees give their notice-

Mike Reinold: And they’re that, yeah. We have a few employees give their notice and they’re always like, I don’t want to say scared, that’s the wrong word, there’s like a level of anxiety when they give their notice. And I don’t know if it’s just because they don’t know what to expect from the employer side, but I’m always ecstatic for them because they found something better for them. I mean, who am I to judge what’s good for them, right? So congrats. I’m happy for you. I’ll reflect on what we could do better to make it a place where people want to stay forever, but you can’t think of it as a negative that your employees are gaining expertise. It’s funny when you can just say that sentence, it’s comical, right? You kind of laugh like, “Who would…”

Mike Reinold: But I’m going to take a step back and just say there’re probably employers out there that either have some egotistical issues or maybe some self-confidence issues, and they’re just super worried about their employees getting too powerful. And I don’t even know what that means. But that, obviously that’s ridiculous and hopefully, if you’re in a situation like that, you see there’s other opportunities out there. So based on that, I want to hear from you guys a little bit, as the employee. I mean, what do you guys like about your ability to have your own brands?

Dave Tilley: Dan, you want to go?

Dan Pope: Yeah, sure. And I’ve said this a lot of times before, but I think it helps me on a lot of different levels. First and foremost, I love to learn, I love to share things, and that’s kind of what having my own blog and brand is. But it kind of comes full circle because I’m out there doing more learning, working with a specific niche, niche, whatever you want to call it, getting my craft, better posting about it, continuing to refine my craft, and then making products about that, and then trying to make some income in ways that helps me, helps everyone else, and supports me eventually buying a house and a car kind of thing. So I think it’s very fulfilling for me in a variety of different ways.

Mike Reinold: You know what I like about everything you just said there, Dan? That’s also beneficial for your patients and your employer. And again, I think everything you guys are about to say, we’re going to conclude with that again, right? So, Dan obviously approaches his brand as an extension of him, him learning and growing and getting better. All wins for both the employee, the employer, and the clientele that you have. Dave, how about you, man?

Dave Tilley: Yeah, well, the first thing I think is important to say is I think we’re really fortunate that you and Lenny, as leaders, have always kind of been what’s best for the team, what’s best for the employees. So we’re really lucky. I think people who are listening maybe on your side of the fence have to realize that it’s a selfless thing. I think you guys are always like what’s best for all the team and so that allows us to have some freedom to kind of do our brand stuff well. I think in previous situations I’ve been in, sometimes that’s not as supported and it’s hard to kind of get your feet off the ground.

Dave Tilley: So, with that being said, I would definitely agree with Dan that a big part of why I started my brand was because I felt like I wanted to have a way to continuously learn. And, I mean, content’s expensive, man. Getting high quality information, books, courses, is expensive. And I ended up finding that I was spending a lot of money on books and courses and so I wanted to use a brand to kind of leverage the ability to support that.

Dave Tilley: That was a big initiative for me because I enjoy constantly learning as well, but the second piece to mine is I just feel like I was really lucky, in a unique point of view, where I had a lot of different experiences as a coach and as an athlete, and as someone who’s able to work with you guys, that I had a unique perspective that I wanted to share with people. And so that was a big reason why I started mine too, as well, because I felt like there was a lot of information that could help people with their training or with PT side of things and I wanted to make sure I used that opportunity and the platform to do that.

Dave Tilley: So I started building more on top of it and it just became a company because it just happened to grow more, and I needed to like travel and kind of get expenses and stuff. But I found mine is more a combination of what allows me to learn, but then also what allows me to help people who I think really could use the information. I think you guys did that with baseball and I kind of followed in your footsteps with gymnastics.

Mike Reinold: I like that. And when I think about what you said, is like we talked about… So Champion’s like a small footprint right here, but you’re educating the world. Why would we ever want you to hold that back?You’re helping other therapists around the country do what you’re doing and sharing what you’re learning, right? That’s another great thing, and what you didn’t mention is your you’re working on, probably, an underserved population a little bit, right? The gymnastics community didn’t really have these resources, so you’re really going out there and giving back to the community like love and you’re passionate about, and build up a little prominence there. So that’s awesome. I think that’s fantastic.

Dave Tilley: But I’ll also say to you that a lot of the brand benefits have actually been directly helpful for Champion. A lot of patients of mine have found me through blogs and through different stuff, and they come and get an evaluation and they work in our sports performance in the summer and stuff. So you have to make sure you look at that right angle.

Mike Reinold: Yeah. I mean, yeah, think about it, the more popularity you get, you start generating, and this from an employer perspective, you start generating your own leads. Right? If you think of it that way. So, again, why would we be upset? Again, I think it just comes back to a lack of self-confidence in, probably, the private practice owner. I think that’s interesting. Lisa, how about yourself? I mean, you’re kind of starting off a little bit in your journey here with your brand and your passion with working with the rowers, and your background, and stuff like that. I mean, maybe from your perspective, you’ve worked elsewhere as well, have you ever dealt with anything like that and where’s your head now?

Lisa Russell: Yes, I 100% have. I’ve had a couple of different jobs where the employer is not welcoming to someone becoming sort of their own independent brand within… Either completely independently or in the umbrella, or whatever, I’ve been shut down a good number of times before in that way. And ended up where-

Mike Reinold: And how did that make you feel?

Lisa Russell: I mean, I don’t work for them anymore.

Mike Reinold: Yeah. I mean, that’s a valid point, right? If you’re an employer and you want to just have a bunch of crappy people that you can put under your thumb all the time, then, yeah, that’s a great strategy.

Lisa Russell: Yeah, I mean, what is amazing about the culture that you and Lenny have created at Champion is that you encourage everyone to continue to learn and to find their passion, and do what we all want to and follow what we want to do in our careers. And you support that in ways that, I mean, I have not come across other employers who do. So you guys have set up a very, in my experience, unique setup, where you really encourage your employees to do this. To spend time on bettering ourselves and educating ourselves, and consider that a value for the company as a whole. I’ve 100% worked for employers who… If you say like, “Hey, I don’t have anything to do, so I want to just take this continuing ed course.” They’re like, “Well, you need to do that on your own time. You can’t do that during work hours.” And it’s like, “But that would make me better at my job. Doesn’t make sense.” So-

Mike Reinold: I’m just sitting here, I don’t I have anything else to do right now.

Lisa Russell: Yeah. You really just want me to sit here and check my email, and like what? So, I mean, it’s definitely something. I mean, I’ve worked in a lot of different settings, other outpatient settings, inpatient settings, home care, it doesn’t matter, and no… The benefit, I suppose, of the setup of Champion and even just maybe cash-based, generally, is that you have that flexibility. You have that ability to allow your employee to go and spend the time to educate themselves, and not always be worrying about how much money they’re bringing in and because I find that’s most employers’ primary focus, right? Is what your-

Mike Reinold: Sure. Yeah. Get different numbers in.

Lisa Russell: Your value is in that way and spending time learning doesn’t bring money in at that particular moment.

Mike Reinold: Yeah. It goes back to, I mean, a lot of the ways we do things is just based on what’s best and what’s best will work itself out, right? Not what’s most profitable or how do we squeeze things. So, Len, any negatives from the employer side that you can think of?

Lenny Macrina: Not really, I mean.

Mike Reinold: I have some.

Lenny Macrina: Yeah, there’s-

Mike Reinold: There are some, but I wanted to hear your perspective.

Lenny Macrina: I mean, I think everybody has kind of spoken to the… I don’t think I have much to add on from their perspective that… Engage that it-

Mike Reinold: I want to hear from your perspective.

Lenny Macrina: Right. From my perspective, if these guys can better themselves and become more educated in what they’re passionate about, and then that helps to generate leads and potential clients for the business, then why would we ever stop that? And if these guys, if we somehow cannot put an environment together where they are 100% satisfied and they have to begin to look, which I know people are going to leave us, but if it’s something that we could’ve controlled and we held them back, and they left because of that, then that’s on us.

Lenny Macrina: So we’ve always tried to do something to put the employee first, where it’s learning, it’s letting them spread their wings and do whatever they feel is most comfortable for them, and I think that everybody benefits from it. So why would I want to stifle that? So to hear Lisa say that, I know Dave has had that in the past, it just blows my mind because I kind of lived it. You’ve got employers or previous companies I’ve worked for where they have a philosophy where you have to take the courses that they want you to take. Whether or not everybody has to be McKenzie certified, not to throw McKenzie, or some kind of manual therapy certification. And it just doesn’t fit what the person is trying to do in their own professional niche, niche, whatever. And so it’s just, to me, I would love to have our PTs really expand in what they are passionate about, not necessarily what the employer is passionate about.

Mike Reinold: Can we just settle on is it niche or niche? Because I feel like we’re all hedging our bats on a bonsai.

Lenny Macrina: I know. I don’t know, that’s why I repeated it twice.

Mike Reinold: It looked like you were going to anyone if you say one or the other. You know what I mean? Well, so I’m going to give the employers a little credit here and let’s talk about some potential negatives maybe, right? So the first one I think was… I think we all answered that because we’re all good humans, right? We answered that assuming all good things were happening. So, obviously, there’s a ton of benefits. But if you’re developing a personal brand and you want to be that confrontational brand or the person that’s the contrarian or the real negative person, or if you want to be throwing political stuff on there, then, yeah, a lot of employers do not want to associate themselves with someone they don’t align their core values with.

Mike Reinold: So I would say, I would throw that out at you first, right there. It’s just made sure that that isn’t the issue, right? If you want to be the contrarian guy, a lot of people are going to be like, “Whoa, I don’t…” I get that, right? And then, you can certainly have like your own personal account and try to give some disclaimer stuff, but I still think a lot of employers aren’t going to really back you up for being the bonehead online, right? Did that make sense? I think that’s one thing we didn’t talk about.

Mike Reinold: Two is, we talked about it a little bit here, but none of us are going rogue in the clinic with some crazy stuff that we do. At Champion, we share some clinical values and we share some common systems that we’ve developed and educated, and brought in as the group. I mean, if you’re a therapist here and you are completely on one side of a spectrum, away from us, it’s probably not going to be a good fit.

Mike Reinold: So, again, same thing. We talk about like having your own brand and thought process, but we have to share, again, core values and then we’ll call them the clinical values, right? So core personal values and then maybe clinical values, it has to be close. And then, I guess the last thing would just be a conflict of interest. We all educate other professionals as to what we do online. It’s a mild conflict of interest. Say, Dave was doing social media posts. He’s like, “Hey, anybody wants physical therapy in my garage? DM me and we’ll get it going.” And we’re putting a lot of time into building up Dave and Dave brand equity, and stuff like that too because we support that.

Mike Reinold: But he’s educating other people on what he does. And that’s even myself and Lenny, and so we educate Dan, we educate people on what we do versus selling physical therapy. I don’t see it as a conflict of interest, but I could see maybe your employer doing that. But if you’re trying to build your brand to charge people in your basement, then, yeah, your boss is probably not going to be happy about that. He’s doing a lot to drive people into the clinic to put on your schedule so you make more money. Right? So if you’re putting all your efforts into driving people into your basement, then, yeah, it’s going to get awkward. That makes sense?

Dave Tilley: Why don’t we just stay away from that?

Lenny Macrina: Dave’s correct.

Dave Tilley: Yeah, another well-established facility.

Mike Reinold: Did I make it more dramatic by saying a basement because it seems to turn-

Dave Tilley: I know, it sounds like a horror film now.

Mike Reinold: Yeah, it seems. Yeah, ready. Seems negative, right? So I actually, just quickly before we end, as the employees, that makes sense right? Was that off base in any way?

Dave Tilley: Yeah. I would agree, I think you hit the nail on the head, wrapping up saying it’s all about your intent of leveraging your brand. If your end goal with the company and with your financial, or not if you’re just doing it because you like it, is just to educate and you’re speaking or you’re traveling, you’re selling services with courses. That’s a very different end goal than if I’m building my brand to leverage getting physical therapy clients. If I’m going to start my own gymnastics-specific, cash-based practice, and I just pull 50% of the clients away from Champion, that’s a very different intent, and I think that’s really what it comes down to, is what’s the end goal of your nonfinancial or financial kind of.

Lenny Macrina: My end goal is I’m selfish and I want to just be a better PT. It’s honestly that. I’m afraid of falling behind in the research and not keeping up, and not being the best that I can be. So my selfishness is I want to be the best PT. It’s that simple for me. You know what I mean? I don’t want to lose track of what’s going on in the research. I need to stay on top of that stuff so I am not that outdated therapist that’s doing crazy stuff and everybody’s looking at me like, “What are you doing?” I want to be a good PT. And it’s just that simple. And then it carries over into social media and then you have other stuff.

Mike Reinold: Yeah.

Dave Tilley: There’s a massive benefit at Champion because we all have different niches that study different topics. Nobody else at the clinic studies hip microinstability like I do. I don’t study inguinal hernias like Dan does, right? So we get that ongoing kind of melting pot of new information.

Lenny Macrina: And then, we talk about it during work and we chat, and we have fun, and then it’s just a great environment. So I think it works well.

Mike Reinold: Love it. Yeah. All pros, right? I mean, very few cons. If you have an employer that’s probably hitting the negative things that we talked… Or no, if you have an employee that is hitting some of the negatives that we talked about, then, yeah, it’s probably just not a good fit anyway. Right? You’re probably butting heads a little bit anyway, you’re probably not at your best. I mean, there are some people, we talked about this, there are some people we deem unemployable. Right? I think there’s a book about that. There are unemployable people out there that just need to do their own thing and that’s fine, and I encourage that. I’m unemployable in my mind, right? That’s part of why I started Champion because I was like, “Hey, I can’t go work for a hospital right now and wear a lab coat, and stuff.” Yeah. Right?

Mike Reinold: So it was kind of like how we kind of think about it. But anyway, great question. I wanted to spend a little extra time. I’m glad we went a little longer on this one because I think it’s an important topic. A lot of people want to start their own brand now. Again, this is almost like a little mini course on the right way and the wrong way to do it, for so many reasons. So great question, Brian, thanks so much. And again, if you have a question like that, head to the website, mikereinold.com, click on that podcast link and you can fill out the form, and keep them coming. We’ll see you guys on the next episode and continue doing this as long as we’re getting good questions like that. So thank you very much.