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What’s the Difference Between Athletic Training and Physical Therapy?

April 2, 2020/in Ask Mike Reinold Podcast /by Mike Reinold

On this episode of the #AskMikeReinold show we talk about the differences between an athletic trainer and a physical therapist. Sure there are some overlaps, but I also think they are their own unique professions. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 198: What’s the Difference Between Athletic Training and Physical Therapy?

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Show Notes

Transcript

Mike Reinold: Welcome back everybody to the latest episode of The Ask Mike Reinold Show.

Nick: We’ve got Jack from Massachusetts asking: “What are the differences between athletic training and physical therapy?”

Mike Reinold: All right, good. That’s actually a good question. I think this is a good timely question. Am I the only ATC here? Any of you guys ATC’s?

Dave Tilley: Oh. Rub it in.

Mike Reinold: Nothing? Rubbing it in? This is a good question because I think we’re starting to see students ask a lot of questions about what they should do in their career and stuff like that. Your question is what’s “the difference between an athletic trainer and a physical therapist?” I mean, there’s definitely a ton of overlap. I think that’s probably one of the reasons why there’s a little bit of confusion. I am both. I’ve worked as both, which I think is a little bit different. I think a lot of physical therapists think that they can just get an ATC certification and then think that they understand athletic training. But until-

Lenny Macrina: Or an SCS certification.

Mike Reinold: Yeah.

Mike Reinold: But they think that they can do certain things. It’s definitely an interesting kind of change. I guess I’ll start a little bit with what I would say the difference is between the two. Then maybe we can talk a little bit. How many people are SCS’s here? Anybody else have any other S’s? Are you? May have expired?

Lenny Macrina: It expired.

Mike Reinold: Yeah. Exactly. Definitely not renewing that. Definitely. What is it? $1000?

Lenny Macrina: I think it’s close to, if not more than that.

Dave Tilley: And a portfolio.

Mike Reinold: And a test.

Dave Tilley: And a test.

Lenny Macrina: You need 200 hours coverage of on-field coverage.

Mike Reinold: All right. We’ll come back to that.

Lenny Macrina: Whatever. Yeah.

Mike Reinold: We’ll come back to it.

Dave Tilley: Lenny and I will brood on that while you guys talk.

Mike Reinold: Let’s start off a little bit of like what’s the same between athletic training and physical therapy. I think both professions are really good at sport injuries. Or they could be good at sport injuries I should say. It doesn’t mean you have to be. But Understanding the mechanics of a sport injury, how to rehab somebody, how to deal with that a little bit better.

Mike Reinold: I think the biggest difference between the two is more so in the diagnostic focus. Not skills, not knowledge or anything like that. I think we’re going to see these two kind of blend and merge more and more. But I think obviously athletic trainers are really focused on that acute triage. Is it a life threatening injury? Is it a big traumatic thing that we’re worried about? Sinister type response or something? Now we have to be really careful with that. That is that acute traumatic thing. I would say physical therapists are completely unequipped to do that.

Mike Reinold: That initial triage and then what to do. What I think physical therapists are better at is probably merging the medical diagnosis with a functional diagnosis, which is a little bit different than just their acute injury. Not just looking at range of motion stuff. But also trying to rule out some of the medical things.

Mike Reinold: Now you see the difference in that. I think that’s where the education has gone a little bit. The APTA is trying to get DPT’s to be autonomous, and to be able to see people with direct access and stuff like that. We’re trying to be almost like mini doctors in a way where we can rule out some medical red flags and stuff like that. I think that’s the difference between them.

Mike Reinold: The Athletic trainers, I think, can do a great job rehabbing people and doing injuries. But what they’ve done is the way I guess they kind of structured it is to be very underneath the direction of a physician. I think that’s the difference between the two professions right now. That’s how I would probably define them the most.

Mike Reinold: Based on that, I still think they’re different. I think we have to consider them different. But two questions I want to ask. One is now obviously the PT’s in the room with the SCS, a lot of people are thinking in SCS can train you to be an athletic trainer. I’m not sure that’s necessarily the case that you can just take the test and become that. We’ve talked about this on the podcast before so go back and search. Let’s touch on that briefly. But anybody-

Dave Tilley: Lenny rant.

Mike Reinold: Anybody think that’s a good idea with the SCS?

Lenny Macrina: Tis the season. I get called out on Facebook a lot because I think it’s kind of known now that I took my SCS in 2008 and did not renew it in 2018.

Mike Reinold: Who’s calling you out?

Lenny Macrina: In good ways. People know that I have voiced my opinion on the SCS test, or the re-certification process. For the record, I think the test is well done. I think it’s a great test. I think it’s a great learning opportunity that the APTA provides to become a sports certified PT. With that, the certification process for me just didn’t work because you needed a portfolio re-certification, or you took the test again. To do the portfolio, you need to pay a lot of money… I think it was at least $1000… And you needed to have on field coverage because that was the goal of the SCS was to be a PT who could be at an athletic event, like an athletic trainer, and cover the event. You had to take-

Mike Reinold: Let’s focus on that a little bit. Let’s focus on that. Not so much on the re-certification. But the actual coverage of an event.

Lenny Macrina: Right.

Mike Reinold: You’re an SCS?

Lenny Macrina: Yes.

Mike Reinold: I’m an SCS. You guys plan on taking it?

Student: Eventually.

Mike Reinold: I can’t wait to ask why. But I like it. That’s good because I’m still confused. Okay. Len, you’re out on the sideline of a football game.

Lenny Macrina: Yeah.

Mike Reinold: Guy goes down with a head injury. What do you do?

Lenny Macrina: I’m looking for the athletic trainer.

Mike Reinold: Immediately calling the ambulance.

Lenny Macrina: Honestly, I’m calling it an ambulance because, I mean, we took the emergency response course to get… That was one of the requirements, which I thought was tremendous. I learned a lot. Danny Smith taught it. I took that 10 years ago and I haven’t used it since. I know I’m supposed to have 200 hours of on-field coverage to re-certify. But there’s no way taking that test.

Mike Reinold: All right. You took that test yesterday.

Lenny Macrina: Yeah.

Mike Reinold: Kid gets a head injury in a football game. What do you do?

Lenny Macrina: No. Because I have no-

Mike Reinold: Do you know how to stabilize? Have you ever stabilized a head?

Lenny Macrina: If I took the test yesterday, yes. But that was somebody who was healthy, and we created the scenario.

Mike Reinold: Right.

Lenny Macrina: Not working under an athletic trainer who was doing it, and I was assisting, or I was observing, or something. I did not feel ready, or prepared, or even close to prepared to go on field and do anything. I got zero hours of my 200. I believe it was 200. I didn’t re-certify. I just didn’t think me… I feel like when I took the test in 2008 these were not the guidelines to re-certify 10 years later.

Dave Tilley: I did it in 15. That got started the year after I did.

Lenny Macrina: Okay.

Mike Reinold: All right. Let me ask you a question. Somebody fractures their femur right on the field. What do you do?

Mike Reinold: We’re not prepared to do that. We shouldn’t do that. Then here’s the problem I’m starting to see right now. We’ll talk to you three in private. You’re not in trouble yet. But there’s a lot of PT students, and there’s a lot of young PT’s, that actually think that they can be athletic trainers because they have the SCS. Because they took a test. That’s silly, right? That’s a big problem we’re having that there’s these physical therapists that do think they’re better than athletic trainers, and think that way.

Mike Reinold: Now, don’t get me wrong, there’s probably some in the other direction, too. I’m not saying it’s one. But we definitely have this new wave in the APTA, and it depends on who your professors are, your school, and those types of things. But they’re kind of instilling in you that you should have the right to cover these fields.

Mike Reinold: I think there’s a huge difference in athletic training. Yes. You learn it completely different. But two is then you spend years in school under certified athletic trainers learning it, and mastering it, and being a mentee of it. I think that’s the big difference. You are not prepared to cover a sideline because you have a freaking SCS.

Lenny Macrina: The education was very good. I remember taking the test, and studying for the test, and there was a ton of stuff that made me feel like-

Mike Reinold: Like what? That you can deal with a rash?

Lenny Macrina: That was what I was going to say.

Mike Reinold: You feel good about that?

Lenny Macrina: A lot of the tests was me recognizing a scenario of a rash on a wrestler.

Mike Reinold: Are you being polite that the test was well-written? You learned about a rash.

Lenny Macrina: A lot of it was a rash. But a lot of it was also functional PT, meaning ACL progression-

Dave Tilley: Nutrition.

Lenny Macrina: Again, this was 12 years ago.

Mike Reinold: Okay. All right.

Lenny Macrina: But I think you could still learn that stuff without getting the initials.

Mike Reinold: I agree.

Lenny Macrina: It doesn’t really cost you… I think it costs at least $1500 to get the initial test. To get the initial certification. If you want to spend that money and have the initials, apparently Fernando, then-

Mike Reinold: I think they all want it. Your school is making you feel like you want it. You do realize that nobody in the world knows what those initials are.

Lenny Macrina: I was going to say that too. That’s always my stock reply on these Facebook message groups that nobody really knows. I can’t recall anybody. Maybe one person asked me what the SCS meant. “Oh, you’re a sports certified PT. Awesome.” But, in general, it didn’t mean anything.

Mike Reinold: Look, if studying for it… Dave always says that, you’ve taught me a lot about this, but if studying for it makes you better in understanding sports injuries then fantastic. That’s great. The problem is when the PT’s with an SCS think they can be an athletic trainer. That’s my only issue with the SCS. I like the SCS. I’m an SCS. I definitely didn’t renew either. But it’s not to become an athletic trainer. If you’re a physical therapist, and you want to cover sideline, and you want to work in pro sports as an athletic trainer, then you need to become an athletic trainer.

Lenny Macrina: Yeah.

Mike Reinold: That’s it.

Lenny Macrina: We’ve had students who’ve come through here, and went back to athletic trainer school. I applaud them because they got their PT license and then they went back to ATC school and learned. Learned the didactics, or the classroom stuff, and then learned from an athletic trainer at the school, and covered events. They got their hours. They did the grind. I applaud them for that.

Mike Reinold: They’re well rounded, and are good at those sorts of things.

Lenny Macrina: Correct.

Mike Reinold: Yeah. I totally agree.

Lenny Macrina: Yeah.

Mike Reinold: Here’s an interesting curveball now. We’ve been talking about this a little bit lately now. My opinion on this has evolved, even in the almost 200 episodes that we have right here. If you’re a PT right now, and you want to work in pro sports right now, what do you think is going to be a better route? Doing a sports residency and getting an SCS, or going back and getting your ETC?

Lenny Macrina: ETC.

Mike Reinold: I will tell you, you’re going to have a much, much easier job getting a job in pro sports as an ETC, and a PT ETC, then a PT with an SCS. Nobody has any idea what that is. If you want to work in pro sports right now, I think that’s kind of my current, as of today in this episode 2020, my current opinion right now. If you’re willing to put in another year and a half to do a residency and prepare for it and all that stuff, you might as well just go back to ETC school and be dual certified. I think that’s the potential next approach because I think you’re more versatile. You can do more for those athletes. You can do more things.

Mike Reinold: What’s the difference? Let’s answer quick. What’s the difference again? I think it goes down to the focus that we talked about with the definition. But I do think we have to understand this. For every physical therapist, hopefully people look up to us and watch this podcast. If you’re a young clinician and you think that you can do those sorts of things, you got to experience it a little bit more before you realize that that’s probably not the case.

Mike Reinold: Just keep that in mind. There’s two different needs, and we should have both of these professions available for us. I don’t think there’s enough overlap to say that only one of us should exist. I think we should both exist.

Mike Reinold: Anyway. Great question. Obviously a good one. We got Lenny a little fired up. I like it. Which is good. He’s definitely not re-certifying.

Lenny Macrina: Well, now I can use this episode to just tag it in Facebook as my stock response.

Mike Reinold: Well, I think we kind of summarized it. Again, there’s a difference between the two. Getting your SCS does not make you an athletic trainer. There’s lots of pro’s to the SCS. Probably not as many as your professors are telling you. But there’s lots of pro’s to it. It just doesn’t make you an athletic trainer. I think that’s the best one.

Mike Reinold: If you have any questions like that, hopefully you don’t get us as riled up as that. Head to mikereinold.com, click on that podcast link, and you can ask away. We’ll see you on the next episode.

Treating Full-Thickness Rotator Cuff Tears Nonoperatively

March 26, 2020/in Ask Mike Reinold Podcast /by Mike Reinold

On this episode of the #AskMikeReinold show we talk about working with patients with full-thickness rotator cuff tears, some of the treatments we would focus on for those trying nonoperative physical therapy, and if they can even avoid surgery at all. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 197: Treating Full-Thickness Rotator Cuff Tears Nonoperatively

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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 treating full- thickness rotator cuff tears non operatively.

(Intro)

Fernando: Brian from New Jersey: “What has been your experience working with individuals, specifically non-athletes, with medium to large size, full thickness rotator cuff tears, non-operatively? I feel some surgeons instill fear in some of the patients that I work with based on MRI findings where they could prolong surgery, or may not need it, once they begin PT based on goals.”

Mike Reinold: All right, so let’s call it a full thickness tear in a non-athlete. I actually liked that because that’s more important in this world, there’s way more. Full thickness tear. How often are we successful at non-operating? Let me ask a question. How common do we think that is? How common do we think full thickness tears, in the general orthopedic population, is?

Dave Tilley: I’ve seen a handful over my young career.

Lenny Macrina: I’d say somewhat common. Whether or not they’re symptomatic or asymptomatic, yeah.

Mike Reinold: Right.

Lenny Macrina: Definitely.

Mike Reinold: So, probably not uncommon as we age, right?

Lenny Macrina: Right.

Mike Reinold: This is probably an attrition type thing, as we get there. So that brings up a whole other question, is there a whole lot of different types of full thickness tears? You can have a small full thickness, a big full thickness. I think that’s actually a big part of this question, but why don’t we start from there? So, who has experience with non-operative full thicknesses that have done well? Probably in college right?

Lenny Macrina: Who’s got a labral tear and bursitis?

Mike Reinold: So what do you think, Len, why don’t you start off? What’s the key, to you, for somebody that has a full thickness and we’re trying the non-operative, what’s the key to you, to make sure this is successful?

Lenny Macrina: Yeah, I mean, obviously they’re coming to you probably because they’re in pain. So I could say if they’re not in pain, leave it alone, but they’re probably having a functional issue. Meaning they have pain, and probably some loss of motion, I’m going to assume. They’re just not going to go into the doctor and get an MRI on their shoulder, they have something going on, limiting themselves. So, if they have pain, we got to try to calm their pain down and if we can calm their pain down, can we get their function back? If they’re coming in with a big shrug, if they have a big shrug, not a good sign, but you can still get people stronger getting the cuff strong or the deltoid is stronger to overtake, overpower what is probably torn, which is a cuff.

Lenny Macrina: So, I would say get their pain to calm down, get them as strong as possible and then make a decision. Some doctors, as the person who sent the question says, they put some fear in there, however they word it. Maybe not all doctors do that, I think there’s some doctors that are very educated in how they talk to their patients, but if that doctor knows the risks involved of that person, their comorbidities… In the research that’s something that does show, people can function with a torn rotator cuff and sends them into rehab. We have to get their pain under control and then work on a general strengthening program and instill confidence in that person that we can get them better. I’ve seen cases that have improved and let’s now take on this challenge and let’s try to get them functional again. So I don’t know, very simplistic form but, Mike?

Mike Scaduto: Yeah, I think the fear aspect coming from the doctors’ is definitely important. It may not be exactly what the doctor says and they may not be purposely trying to instill fear. But if someone tells you, a full thickness tear in your rotator cuff, the patient may just shut off after that, then they automatically think that they need surgery. So, I think… Then they come to us, and they’re very concerned about that, because they think the surgery is going to be really tough recovery. But we may be able to kind of spin what the doctor said or kind of give them hope that they may be able to recover from this and that we’ve seen people make progress with that and I think that goes back to being able to make minor changes in their pain or minor changes in their function, as much as we can, early on. Kind of gives people hope and then also setting expectations for them. It may just be very, very minor progress, but trending in the right direction, will give them kind of hope that this could go better than they think.

Lenny Macrina: I think what Mike said, that the amount of tissue involved is critical. An MRI is going to kind of pick that up, but I mean a smallish tear, you’re definitely going be able to avoid surgery. Right? And this atraumatic… We’re seeing more research that’s showing that atraumatic chronic cuff tear has a chance to heal, if not, maybe has almost the same chance as surgery, because when they have surgery and we fixed the cuff, we do second look ultrasounds or MRIs, in between probably 5% and 90% so the range is huge, because that’s what the research is saying, has a re-tear one to two years after the surgery. So almost everybody re-tears their cuff, after having a surgery to fix the cuff. So, why are we having this 20 plus thousand dollars surgery, when they’re probably just going to re-tear in the long run, anyway?

Mike Reinold: I’m going to throw a curve ball into this discussion then, because if you look at the people with the percentages that don’t do well with surgery, it’s the larger, more chronic, more degenerative over time. So let’s ask a question again now. You have a small tear now, right? That’s non painful-

Lenny Macrina: Does it get worse? Yeah.

Mike Reinold: To me, that’s one of those injuries, rotator cuff tears, that if we’re just saying it’s asymptomatic, ignore the MRI and just let them continue to do things. That is definitely the type of injury that gets worse over time. And then you go to the point where now you have pain, now you have some in there. So, I’m not saying… I’m a big believer in non-operative rehab in this. I’m pretty sure the literature shows that you probably have a greater than 50% chance that you’ll do well with non-operative, if you get it early enough. So it’s an interesting one though. So, what do you guys do? I mean, Dan, if you’ve got something else, jump in too, but what if there’s no pain? What do we do?

Mike Scaduto: I don’t know if they would go to the doctor, right?

Mike Reinold: Yeah, that a maybe, that’s a good point.

Mike Reinold: That’s a good point.

Lenny Macrina: I don’t know and that’s going to be the one reason why they have pain and then how long they… Because they have pain for a day their not going to the doctor. They have pain for months, now they’re going to the doctor. It’s going to be last ditch, “I have a frozen shoulder because…” something.

Mike Reinold: That’s true, yeah.

Dave Tilley: Dad, I love you so much. It’s a perfect example.

Mike Reinold: But do think your dad watches the podcast?

Dave Tilley: Absolutely not. Someone’s going to pass it along to him.

Mike Reinold: I know my mother does. I know Lenny’s mother does. Every now and then Lenny… Good old Janet will give us… What’s up, Janet?

Mike Reinold: They’re always watching but sorry, again. All right, Mr. Tilley?

Dave Tilley: My dad’s story is exactly what we’re talking about, where these people don’t go to PT sometimes. My dad is a great guy, he played softball 10 years ago on slow pitch league. And he was, “Oh, I’m going to get back out there and play.” So my dad has zero background for this and he goes out and he goes super hard for three hours, in the outfield and then pitching, which is not fast pitch. He texted me and he’s like, “Hey, I think my shoulder is a little bummed. Can you help me out? I just need some exercises.” And I ask him to move. He’s like, “No, it’s fine, I got a little motion.” Had a huge shrug sign. He can’t move his arm at all. He’s like, “Yeah, it’ll work itself out.” So many people don’t have a problem until something flares up for a day or two, or they can’t raise their arm, they’re like “This is probably a problem.” But then three weeks go by and they’re like, “Okay, I’m better.”

Lenny Macrina: Did he have surgery?

Dave Tilley: No.

Mike Reinold: Right. Wow.

Dave Tilley: He didn’t go to PT.

Dave Tilley: The reason I bring it up, is I told my dad, I’m like, “Okay, this is a warning sign. You probably had symptoms before or had issues before.” And I wasn’t going to let him blindly not do anything. I was like, “You should do these exercises. At least warm your arm a little bit. Maybe try to add a couple of exercises in.” But like you said, you can’t leave these people like, “Nothing is hurting or nothing is lost motion.” So it’s just like, “You’ll be fine. Keep going.” There’s a reason behind why the cuff is probably irritated, whether that’s a structural thoracic kyphosis or something like that. Or they just get super excited and go play three hours of softball.

Mike Reinold: That’s probably what happens with most people, they have chronic postural adaptations, chronic degenerative changes of their tissue. And then they go pretend that they’re 10 years younger than they really are and they do an activity they haven’t done it a while. And that starts to kind of cascade a little bit. So, I think that right there, gives you the answer that we shouldn’t just ignore these and we shouldn’t be content with the fact that they have an asymptomatic MRI and that’s normal. That’s not normal. If it wasn’t torn when they were born… Did that just rhyme? Wait a little, let’s come up with something. If it wasn’t torn, when you were born…

Dan Pope: It’s not the norm.

Mike Reinold: You must..

Dave Tilley: Grab the bull by the horns.

Mike Reinold: You must grab the bull by the horns. It’s t-shirt time.

Dave Tilley: This little bull with a cuff tear.

Mike Reinold: I mean, if it wasn’t that big of a deal, then we wouldn’t have a rotator cuff. So it’s not supposed to be torn. So I think that’s kind of the point right here. So if somebody has this or somebody has a small tear, there’s definitely some things we can do. Let’s shift gears for a little bit here and try to conclude with this. What is our rehab strategy on this person? What is the key to their success? Who wants to jump in?

Mike Scaduto: Yeah, I think you got to look at their function and obviously do a full assessment of them, but I think it’s going back to the basics of restoring as much passive range of motion as you can, restore active range of motion, isolated strengthening of the rotator cuff and the scapular muscles and then go back into some more functional type training. If they are doing any training now, that gives them symptoms, you modify in the short term and then gradually progress them back to what they want to be able to do.

Mike Reinold: And we’d probably see this more and more with people in younger generations, probably now. Was fifties now, probably forties, maybe even late thirties, in the aggressive fitness athletes, Dan. Because they’re having these rotator cuff tears. Again, they’re hopping on Instagram and saying that, “I should work through this.” What do you tell those people?

Dave Tilley: It’s tough. It’s two different populations and I think we get flamed sometimes for trying to pull athletes back, because it’s supposed to be this hopeful message that everyone can heal and adapt and get better. It’s challenging because I think it’s similar, probably, and we don’t have the research to support this yet, but to… Let’s say, a baseball player, where they’re going to have asymptomatic cuff tears and labor pathology, sooner than the general population. So, it’s a tough thing to answer. Because I’ve definitely worked some people in their twenties that have pretty bad cuff tearing and the thought is, “Can I continue? Should I stop?” And then, here’s the thing, most rotator cuffs, over the course of time, will tend to worsen. You have this whole idea of adaptation, “Is my tissue adapting because my pain is going away?”

Dave Tilley: Well, I’ll tell you what, your pains go down and you can get stronger but your tissue can also be getting a little bit worse. So that’s pretty challenging. I think that looking at symptoms is going to be important, but doesn’t give you the whole answer. I will tell people to go in every few years to maybe get it checked by the doctor again and see if the MRI is not worsening. The only reason for that is because there is a potential that you could get a retracted tear, potentially get more arthritis and not be able to get the surgery that was better. So reverse total shoulder versus shoulder replacement. I see people that are in their sixties that are doing high level CrossFit to have a good amount of arthritic changes in their shoulder. And at that point it’s kind of like, “What do I do? What do I not do? Is pain a guide? Is it not a guide?” And I don’t think we have all the answers.

Mike Reinold: Yeah, we’re definitely getting there. And then I would just share one last thing with my experience with some of this. Back in the early part of my career, we used to do a ton of elderly people with massive rotator cuff tears that were irreparable. And that’s the one thing that people don’t get about people like Dr. Andrews down in… Well, he was Alabama. He still did surgery on… He treated everybody in the community too, not just the pro athlete guy, so he had a ton of people just massive chronic rotator cuff tears that were irreparable and we had great success. We actually… I mean, it depends on how you define success with them, but we got them lifting their arms again, we got them pain-free, we got them doing really well. We always went back down to this whole suspension bridge concept that we always talk about. Who came up with that, by the way, is that Rockwood? I don’t even remember now.

Lenny Macrina: The Rockwood and Mattson book?

Mike Reinold: I don’t even remember. So the suspension bridge concept is, you think about, you get your shoulder and you’re looking at it from above, if you think of a suspension bridge. As long as your anterior and your posterior rotator cuff are really, really strong, it’s okay if you have a tear on the superior aspect or supraspinatus because those two can kind of steer the ship. The anterior posterior cuff can allow them to elevate their arms still. And we got a lot of people super functional by just getting their anterior posterior cuff as strong as we can. So, obviously, again, the more massive of a tear you have, that’s a problem. It starts extending into the infraspinatus.

Mike Reinold: But then man, you better focus on the teres minors. So you better know different exercises. Better read the article that we’ve published in JOSBT that talks about these different EMGs, because you have to be able to hit that teres minor a little bit more, for example. So, there’s definitely things you can do. So I guess to answer, yeah, you can definitely be successful. I don’t think you want to be that guy riding your high horse right now, saying that, “Nobody should get surgery!” “MRIs and being asymptomatic are normal.” I don’t think we want to go that far down the road. That’s a little too far with that. But yes, we can be successful. Mike, what’ve you got?

Mike Scaduto: Just got to throw a wrinkle in there. This is a question that I kind of have. Where do you guys think biologics… Gene injectables like PRPs, and even anti-inflammatories, corticosteroids and cortisone, kind of fit into the rehab process for someone who has a medium to large cuff tear?

Mike Reinold: Good question. So, I’ve actually… At the meetings I’ve been speaking at recently, there’s been a lot of good physicians that are big on the biologics. The guys out in Chicago at Rush are doing a really good job. Brian Cole, is kind of one of the leaders in that and I’ve heard him speak now a few times on biologics. And then obviously, anyone jump in if you had experience. But I think right now like the results are getting there and I think the idea and the concept of biologics on these people, are there. I don’t know if it’s there yet. But, another thing to consider here, if you have a full thickness retracted tear, I don’t think biologics are going to help with that. So, I don’t know how much biologics are going to help with a big full thickness retracted tear. Maybe if you have a partial thickness undersurface, I think, is what we’re going to look at. So, good question. I don’t know if it’s going to necessarily help that. It might help with the reconstruction or repair.

Lenny Macrina: That’s what I was going to say, is to augment it with the repair. So if they can do some kind of PRP or STEM cell, which I don’t think that I’ve seen it’s working, yet. Maybe we need…

Mike Reinold: I don’t know if we know yet.

Lenny Macrina: We don’t know yet.

Mike Reinold: The concept’s there and biologics are getting better. I think that’s the other thing to do. As FDA regulation stuff changes, that we’ll get there.

Lenny Macrina: And then even also, almost like an internal brace that we use for ankles and elbows and we’re starting to use non-human tissue. Collagen scaffolding for these tissue types that failed, in the nineties and early two thousands, trying to use different materials. And I think we’re revisiting an old concept and seeing promise. So I think there’s something to keep an eye on. Superior capsular reconstructions, things of that nature. We have tears in areas that were never repairable before and function was lost. We can now use some of these newer materials, and there’s newer promise, so we’re definitely making gains.

Mike Reinold: Awesome. Great question. Thanks so much for asking that. If you have a question, head to mikereinold.com, click on that podcast link and you can fill out the form to ask us questions. Ask us anything you want, we’ll be happy to try to get it on a future episode. Thanks!

How to Help Athletes with the Psychological Aspect of Injury

March 19, 2020/in Ask Mike Reinold Podcast /by Mike Reinold

On this episode of the #AskMikeReinold show we talk about some of the psychological struggles of being an athlete dealing with an injury. There are a lot of things that can feed into the mental health of an athlete after an injury. Here are some of our tips on helping as best we can as physical therapists. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 196: How to Help Athletes with the Psychological Aspect of Injury

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Transcript

Mike Reinold: On this episode of the Ask Mike Reinold Show, we talk about how you can help athletes dealing with the psychological aspect of being injured.

(Intro)

Joe: Jennifer from Massachusetts says, “Hey guys, I was curious on how you handle the psychological aspect of injury at Champion. I see many physical therapists who are great at physically helping athletes return to their sport, but lack the knowledge when it comes to mentally preparing them as well. I see so many athletes come through the doors who are upset, regretful, have fears of reinjury and become really burnt out in the rehab process. So how do you guys handle these situations?”

Dave Tilley: Great question.

Mike Reinold: Yeah, it’s a good question. We actually haven’t tackled this much on the show. We’ve talked a little bit about some professional burnout, a little bit, with some of the podcasts and we had some good guest posts in the past on my website. But from the athlete perspective, I think this is a pretty cool topic. So heck, I don’t know, I don’t want to just throw it at somebody, but what do you think Dave? You feel like you… I guess I’m throwing it at you.

Lenny Macrina: Boom.

Mike Reinold: I mean so Dave works…

Dave Tilley: It’s the closest I’ll ever be to baseball so…

Mike Reinold: …Dave works with younger female athletes. So you have a different kind of perspective a little bit. I know that probably a lot of our athletes probably hide their feelings on our end a little bit more, kind of more the collegiate or pro level male athlete. So maybe we start with that because I think obviously you have some interesting perspectives. But I actually think learning from you for example, may actually help us work with some of our other people that are probably just putting on a fake smile sometimes. So what do you think, Dave? Where do you want to start with this?

Dave Tilley: Yeah, I think that I’ve learned from my experiences, again working in this population, that you have to remember that, what matters to them, you have kind of get from their point of view. It takes a lot of empathy I think to have a really good understanding of this. And I think that on the younger athlete side for sure, you always have to get back to… A big thing for them is social acceptance. And it’s being part of a community and their team. And half their life, if not more, is part of their team and their community. And so that’s a big part of who they are when they’re younger especially.

Dave Tilley: So I think always recognizing that that’s a big driver of why they may be nervous or have something like that. I think that the fear of social judgment from their peers or their coach or their parent about why they’re injured or they’re kind of the outcast a little bit, they’re kind of usually off to the side in training, they’re not involved. I think that’s a huge barrier to making sure that someone doesn’t spiral into a negative thought process.

Dave Tilley: So I always think about that but also allude to the question, fears are always at the root of a lot of these things. Like fear of reinjury, the fear of, again, social judgment, the fear of “will I get back, is this going to derail me a lot?” And so I think that obviously on the physical side we have a lot of tools to pick those things up. But you always have to be thinking about from their point of view, what are they most scared about or what are they most nervous about? And it’s usually a conversation about fear, insecurity or social judgment. One of those three things has pretty much always been involved in… A younger athlete that I’ve worked with especially… In a high pressure sport like gymnastics where it feels very cut throat. It is. But sometimes when you can intercept some of those things about… Don’t catastrophize, this isn’t the end of the world. You heal, you’ll get better. This doesn’t mean all of your life is falling apart. Just like this area of gymnastics is maybe struggling a little bit.

Dave Tilley: And then educating coaches and parents about how can you keep them involved in training. Can you give them a program where they can go for an hour and kind of still be involved? The rehab process itself is sometimes a little bit more isolating. So that’s kind of my advice.

Mike Reinold: Yeah, no, I like where you went with that here because there’s a lot of different things that can be going on in the head of an athlete. So, you brought up a couple of points. I’m just going to try to get it out of my head a little bit from hearing you. But I heard a couple of things. One was obviously, there’s that fear of reinjury. And man I actually wonder, the more I learn about this and the more I work with it, I wonder if that’s the least effective one. The fear of reinjury, that’s probably the one we go to the most. Sometimes there’s lack of confidence in their limb or their injured body part or whatever, or there’s a fear of getting reinjured again. Those are the ones that I think we do a better job in our environment, like the service base industry of fitness and wellness and rehab, those types of things. I think we do well with that because we can do things like graduated exercises and slowly increasing the demands to get them to have some more confidence in their limb and their extremities.

Mike Reinold: So we see those sorts of things. But yeah, I think some of the other ones that you started hitting on, and maybe this is what you guys can think about if anybody else has any more feedback, but the other stuff. So now it’s, man I’m letting my team down.

Dave Tilley: Yeah.

Mike Reinold: Cause that actually happens quite a bit, especially…

Dave Tilley: College setting for sure.

Mike Reinold: Oh man. And then imagine getting up to the pro level where I’m letting my team down, I’m letting my coach down, I’m letting the owner down, I’m letting the city of Boston down. People feel this way when they get a big professional injury. I’m getting paid $75,000 to play tonight and I’m not in the lineup. There’s a lot of guilt. You just signed a big contract, something like that. So it’s fear of being out of it a little bit too that I think some people miss, but I don’t know, who wants to jump in? Anybody else got anything?

Dan Pope:I don’t know, you already alluded to this. But for the people we see, athletes, especially for you Mike, all the professional guys, their entire sense of self is completely wrapped up in the sport or their activity that they have. And once you get hurt, that’s an enormous threat to that. And you start to have all sorts of crazy emotions that pop up as a result of that. So there’s so much you can do, I think, as a physical therapist. But I think the first and most important thing to do is just to realize that it’s probably going on, more or less depending on the athletes in front of you, and just accept that and let them know that it’s okay and we’ll work with them. I think where physical therapists go awry a little bit is belittling that.

Mike Reinold: Right.

Dan Pope: And I think it’s a fine line because one thing is, I think we do really well at Champion, is having this really fun environment where people are kind of hurt, they’re getting better, it’s not a big deal. And we create that environment. We’re not actively telling people “dude, your problems aren’t that bad. You’ll get better.” In some ways we are, but it’s a fine line. Again, it depends on the athlete. You don’t want to belittle what they’re going through, but at the same time you want to make sure that they understand that it will be okay.

Mike Reinold: Yeah, I’ve actually seen that backfire too. And that’s kind of interesting where, if you take the approach—and maybe you’re doing this intentionally—that hey it seems like they’re overreacting to the threat, the environment that they have, they’re overreacting to that. Sometimes what we do is we make a mistake of that and we actually try to go the other thing, and you said belittle and I think that’s actually a good word.

Mike Reinold: Sometimes it’s unintentional but sometimes we try to minimize it. I think we do it accidentally. We’re not trying to minimize their injury, but we’re saying, man they seem really freaked out for… This is just a grade one ankle sprain. This shouldn’t be that bad so you try to minimize it. Sometimes I have actually seen that backfire. And then the person has to say, well, I don’t feel good, I don’t feel like I have a place. And now I almost have to pretend it’s worse. And then that delays them getting back because they’re worried about the social anxiety of… Oh especially, you get to the pro level, what’s the media think? The media is going to rip me apart or all these things. So these are all the things on the big stage with pros, but I think they’re happening more at the high school, middle school level than we probably get. So I don’t know. What do you guys have, anything on your guys’ end?

Lenny Macrina: I don’t know. When I have somebody in front of me, whether it’s a kid, a college athlete or a professional, I just try to put myself in their shoes. What would I want to know? What information would help me to figure out a game plan and give me guidance? So I try to just reverse the seat and pretend like I’m the athlete and what information would help me the best. Am I progressing? Am I normal? Where am I going wrong? What can help me? Just little things like that I think would be…

Lenny Macrina: If you just kind of flip the roles, what would you want to know? You know what I mean? What would help them better understand their situation? I kind of keep that in that simple frame. I try to just kind of figure out what information would help them better make a decision on how they feel like they’re failing. Because you’re trying to interpret their generalisms that they’ve given you and not all the time they’re giving you information. But I think if you can weave through some of the complexity, especially some of the guys that we see that really don’t want to talk about it, I think it kind of helps as well.

Mike Reinold: Another strategy I’ve kind of tried sometimes with this. So it sounds like empathy is number one, right? Dave kind of brought that up a little bit. Belittling them is number two. Oh wait, no, sorry, not belittling them.

Mike Scaduto: Don’t do that.

Mike Reinold: But empathizing then just be careful with how you articulate things. Sometimes we unintentionally try to minimize it because we think we’re trying to help. We’re trying to decrease their stress, when sometimes that’s not necessarily what they want to hear. So the other thing that I think I would add to this is, how do we keep them, especially as an athlete, how do we keep them part of their team somehow? And I’ve seen some people really succeed with this and some people really fail with this and make it worse. Some people love staying part of it. So in baseball, just for an example, I don’t know, I’m sure we can think of other sports. But in baseball, like the catchers, if a catcher gets hurt… I’ve seen most catchers they do double the work. They’re doing double analysis of the upcoming pitchers. They’re getting in on the meetings. They still want to provide value to their team. So I’ve seen that a little bit.

Mike Reinold: Then I’ve seen other ones where people, they isolate themselves because they’re anxious and I think that sometimes makes it worse. So things we can do I think just on that note, is how do we incorporate them with the team? So we did this in spring training this year with some of our baseball players, but the beginning of spring trainings, we’re crazy busy, there’s tons of people around, but you still have some guys that are rehabbing. Even some high level guys that are rehabbing. It’s very easy to try to push them off to the side and have the pitchers go play catch over there that are injured and then the healthy guys go over here. But then they start feeling like, well, I’m by myself, nobody’s here with me, the coaches aren’t even there. You got to make them part of the team.

Mike Reinold: And that was one big thing we did is everybody’s out on the line and stretch at the same time, including the injured guys, because you got to be part of the team. And then what happens is they get around, they fool around with their friends again, they start doing the same old things that they were doing and they feel part of the team and then they can tell that their teammates I should say, not their athletes, their teammates are still accepting them, they’re not mad at them. Those things like that. So have some empathy. Try to put yourself in their shoes a little bit. Watch your words. Don’t accidentally minimize or maximize their symptoms. And then I think this is really important is, somehow figure out a way to keep them part of the team. I think that’s a big one all the time.

Dan Pope: I don’t want to speak too much because we already talked about this. But I think the other thing that really helps people with the fear is that… The question had kind of two major parts. The fear of reinjury. I think as physical therapists, we have to do a really good job getting people prepared for whatever they want to try to get back to. So if you’re an athlete in say like a field sport, I don’t know, let’s say you keep on straining your hamstring as a soccer player. If you never do really advanced drills, never pushed them to their peak and then give them some sort of plan after they’ve rehabbed to stay healthy, over the course of time, then of course they’re going to be fearful because they’ve never actually experienced that stress. They don’t feel like they have a good plan or a good process.

Dan Pope: So actually going through with a good plan of care and showing people they can do it, is not only you believing as a physical therapist they can get better, but the athletes starting to see that they can make that progress and starting to change in their own head.

Mike Reinold: Absolutely. Absolutely. I think that’s good advice. And then don’t forget, we oftentimes need to get them some help. They probably don’t want to talk to us. We’re probably actually okay. But if you’re in an environment like this, there’s lots of people around, sometimes that’s awkward. They probably don’t want to talk to their coach. They probably don’t want to talk to their teammates or their parents. So they need these outside people. So I always tell a story. Bob Mangine, a friend of ours, he’s the head athletic trainer at Cincinnati, but he told us a story. He was telling how they changed the name to mental skills and all of a sudden people would go to it, but they weren’t going to the…

Mike Scaduto: Mental health.

Mike Reinold: … mental Health, that’s what it said. They said they started this mental health wing for their athletes and nobody took advantage of it. But then they changed it to mental skills coaching and now all of a sudden everybody took advantage of it and then they started talking about it. So again, there’s a stigma, there’s a negative stigma there. That’s our fault as a society. But how do we get them to a mental skills coach to kind of help them in there? So awesome. Anybody else? Pretty good? Solid? No? Awesome. All right, well good.

Mike Reinold: I think that’s some good advice. That’s a start and I think that’s a good place right there because sometimes we’re not equipped. We didn’t learn this. So sometimes it’s just identifying some of these things. I’ll say the more injured athletes I work with, the more I can see these things. I remember… You start getting fringe players, minor leagues, NFL Europe back in the day, which is like the minor leagues, the NFL, those guys were always nervous of all time that their dream was going to be over. So we got to keep this in mind. This is a big deal. Like Dave said, this is a big deal to them. You have to keep that in mind. So hopefully that helps. From there I think sometimes just outsourcing and just like we always say it’s good to have good strength coaches, massage therapists, physicians, skills coaches, maybe you also need a good mental skills coach or somebody that they can talk to in your network as well. So, awesome.

Mike Reinold: Great question. We haven’t really tackled anything like that at all, I don’t think really. So maybe we probably should more. But great question. Hopefully that gave you a little bit of guidance and I get the apprehension with that because that’s not probably something we all learned in school. So good one. If you have a question like that, head to Mike Reinold.com, click on that podcast link and you can fill out the form to ask us anything related to PT, fitness, business, sports medicine type stuff. Anything you want to talk about it. And hopefully we’ll get to your question in a future episode. Thank you so much.

When to Use Joint Manipulations

March 12, 2020/in Ask Mike Reinold Podcast /by Mike Reinold

On this episode of the #AskMikeReinold show we talk about the use of joint manipulations versus mobilizations. As physical therapists, I’d say we have been manipulating less and less as we continue to learn more, but we discuss it a bit more on this episode. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 195: Using Joint Manipulations

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Transcript

Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about joint manipulations, when we use them, if we use them, why we use them, everything you want to know.

(Intro)

Joe: All right. Nick from New York asks, “What are your opinions on manipulations? Do you use them and how do you incorporate them into your treatments?”

Mike Reinold: Awesome. Lenny, I feel like you’re very manipulative.

Lenny Macrina: I like manipulating people.

Mike Reinold: So joint, we’ll say joint manipulations, not mental manipulations.

Mike Reinold: So what’s our opinions on joint manips, and do we use them? When do we use them? Stuff like that. So all right, who does manipulations? Okay. Happens, right? Yeah, it’s probably less than we had at one point. Okay, so for those that do manipulations, let’s start with that. What do you manipulate and why, and is there anything you won’t manipulate? I don’t know where to start with that, but Mike do you want to start, what are your big joint manips that you perform?

Mike Scaduto: Very often times, say 90% of the time, it’s the thoracic spine, probably a PA manipulation. I’m relying on my assessment techniques to decide if I feel like it’s a hypo mobile segment that is limiting their range of motion grossly to either thoracic extension or thoracic rotation or something like that. I think I try and get a global picture of the patient. Are they more hypo mobile in general, or are they a hyper mobile person with excess motion? Typically, I would steer away from a manipulation in that type of person.

Mike Reinold: Nice, good thought process. I like how you make that decision so it’s not just manip everything. It’s, make sure it’s the right person. And to comment on your thoracic spine manipulation. I mean if there is an area that shows some efficacy in the research, I think thoracic spine manipulations are probably one of the bigger ones. Right? Lots of good manips. Dan, you probably have some references off the top of your head, but doing a thoracic spine manip to increase overhead mobility and to decrease shoulder pain and stuff, it has been shown. So I think that’s a great one right there. Anything else Mike? Other than thoracic?

Mike Scaduto: I don’t think so. So I said 90% of time it’s probably thoracic spine, but I don’t do it 100% of the time.

Mike Reinold: Yeah. Yeah. That makes perfect sense. How about you Dan? Do you manipulate anything else?

Dan Pope: Every so often I’ll manipulate a cervical spine. A couple of thoughts here. I mean it is, I don’t think it’s risky necessarily. The risk of causing more serious effect is very low, although it can happen. The one thing I will say is that I looked into this myself to figure out just how dangerous this is. And again, it’s, it’s not very risky, but you can also cause problems by doing a mobilization of the neck. Right? So I would say that you just have to think about the patient in front of you to figure out whether or not you think you should be doing mobilizations or manipulations of the cervical spine in general.

Mike Reinold: Right.

Dan Pope: A lot of times for me, the cervical spine is more patient buy-in. There’s someone who really wants it, I think it’d be beneficial.

Dan Pope: Certain conditions where it might be helpful and things like TMJ can be a good one.

Dan Pope: Those can be decent areas, but generally if there’s someone who really wants it and I feel is a healthy candidate for it. And then again it has to fall into like critical reasoning process of whether or not, I think there is a joint restriction that can be utilized. You know, it could benefit from that.

Mike Reinold: I like that there’s actually a study that showed that there’s, I don’t know, I’m forgetting off the top of my head, but I think I wrote a blog post about this a while back that one of the primary factors on whether or not a manipulation was something you should include and would have a successful outcome is the person’s perceived benefit of the procedure.

Mike Reinold: So meaning if they didn’t think it was going to work, it didn’t work. And if they did think it was going to work, it did work. So I don’t even know what that says. We can hack that out a lot, but you said that, yeah.

Dan Pope: One of the things I will say really quick is that oftentimes we’re thinking, okay, I have to mobilize a stiff segment. That’s why I’m using manipulation. What we’re probably doing is a short term effect. So again, I don’t know if that would manipulate a hyper mobile joint, especially if I may cause some sort of injury. But what I’m thinking about when I’m doing a manipulation is that I’m probably having a neuro physiologic effect. Right. And I’m guessing this is one of the reasons why people have less pain reaching overhead, less pain-free grip after manipulation.

Dan Pope: If it goes globally, we cause a change in probably sensitivity. Right. And these studies are done in pressure pain threshold. That was my research project that I did for my graduate degree. Is that if you manipulate someone’s spine, right? Let’s say it’s lumbar spine, thoracic spine, or cervical spine, you cause global changes and pressure pain, excuse me, pressure, pain threshold. In other words, you have less pain, your pain threshold goes up, your sensitivity goes down. So if I have somebody who has a pain problem and I’m trying to decrease that pain, albeit maybe temporarily. I don’t think about manipulating and not just because I have a stiff segment per se.

Mike Reinold: Right. And you see here how there’s so many levels of clinical reasoning that we’re kind of talking about here. That was awesome. Any preference? You know, upper versus lower cervical sounds like you’re not scared of manips.

Mike Reinold: Are you afraid of upper cervical or have you already kind of answered that by saying no.

Dan Pope: I guess not. But it’s always in the back of my mind, and I’m doing it very rarely and I’m doing young, healthy people generally. I’m definitely not doing somebody who has cardiovascular disease or you know, obviously any red flags in general, I’m not going to do that.

Mike Reinold: Yeah.

Dan Pope: Yeah.

Mike Reinold: I feel like in my experience with cervical, you know that person that wakes up and they like can’t move their head to the right or whatever, whatever direction they just can’t move their head. A lot of them want to run to a chiropractor or anybody really and try to get that manipulated. But I find that if I try to do that too early in the sequence, that sometimes it helps for a second, right, for a couple of hours, or something like that.

Mike Reinold: But then there’s this reflexive kind of spasm and tone that happens from it and it almost gets worse a little bit here. So I would say, I probably, I don’t manipulate that often. I don’t manipulate as much as I used to. For cervical manipulations, I actually find that I avoided a little bit initially and then if once they’re down and now, okay, the pain and the spasm and the guarding is down, but they still have some hypo mobility, then that’s when I would probably apply it. And that’s very few and far between. Maybe with my patient population too, but I definitely feel like I do it last. Let’s shift gears a little bit. How about lumbar spine? Anybody do lumbar? Dan does. Yeah, you do. Dan does everything, I like it.

Dave Tilley: I’m super unique in this because the people that I treat are hyper mobile gymnasts or dancers and things like that. And you know, so I’ve heard of circumstances where they fit the clinical prediction rule or they had this acute low back pain that wasn’t below their knee and all this kind of stuff, and they got manipped and it’s the worst possible thing that they can do.

Mike Reinold: Right?

Dave Tilley: And I have a lot of people who are hyper mobile, but when they get taken in you’d get a lumbar manip. Either gymnasts or different people or whatever, they’re like, I feel like, like you said with the neck, I feel better for an hour and then I actually feel much, much worse after. So you have to kind of use your critical thinking skills about why is this person having, it’s probably relative hyper mobility at their lumbar spine. Making up for a lack of hip mobility or their core is not stiff enough during their activities whether they’re, so I would say you can’t use them.

Dave Tilley: I think if I have a general popping type patient who has more of a classic disc issue or something like that, it’s more my options. For most people, I’m kind of thinking about some other things first.

Mike Reinold: Yeah, I don’t want to say I ever had strict contraindications. There’s only very few rare things that I kind of feel that way about. But I kind of think in my head I just, I don’t want to do lumbar manips anymore. And just me personally, I just feel like the majority of times somebody has some pain is there’s either some hyper mobility, right? And/or soft tissue restrictions. But it’s not really joint as much in the lumbar spine. So I just feel like, and maybe again, maybe it’s my patient population, but I just feel that’s barking up the wrong tree lot of time. So I’ve stopped. I don’t do lumbar that much. Yeah?

Dan Pope: I was going to say is, if you start looking through the Chocrane reviews about manipulations, they’re not that powerful for the average person in front of you for low back pain. So it’s not, to get rid of that I don’t think is a bad decision. Right?

Mike Reinold: Yeah, sure.

Dan Pope: Yeah.

Mike Reinold: Yeah. I mean, extremity wise, probably not far off, right? I think a lot of times our joints are hyper mobile, right? Not hypo mobile. So you know, a lot of times I think we focus on soft tissue a little bit more here is what I’d say. Anybody else? Anything to add?

Lenny Macrina: I think Dan nailed it. I don’t think I could have said it better. I don’t really think. I used to be in the world of, “Oh, I see a lot of hyper mobile people. Why would I manip?” Are we really making a segment or hyper mobile by a quick manipulation? You’re dealing with bone and collagen and everything else there. When we talk about the knee, we talk about having to load it low-low long-duration for hours at a time and all of a sudden we can do a quick thrust to a lumbar spine and we’ll get, or thoracic spine and we’re creating more mobility. Are we creating more mobility by stretching tissue? Or by what you said, kind of a neurophysiological response where maybe a sensitivity goes down, pain goes down, or the relative, the ability to detect pain goes down so you can do more.

Lenny Macrina: I still, I’m in the world of, and maybe it’s my patients that it’s a soft tissue issue, meaning muscular tightness. So to me doing a manip, yeah, it might feel good. I do thoracic manips a little, and it’s usually by accidentally doing something and their joint pops. I’m like, Oh sweet. You know, and I treat a lot of hypermobile people. Yeah. I mean that’s my joke, I just saved you $35 going to another practice. I don’t know. I think we think about it incorrectly, but the perception that somebody is going to benefit from it, like anything else, if they think it, it’s probably going to be more likely to occur. Like a positive effect. I think, anything else? There’s a reason why people come in here after going somewhere else and we don’t do anything differently than anybody else, but I feel like our results may be a little bit better or at least I perceive that because the person thinks they’re going to get better. So you got to play those mind games.

Mike Reinold: It’s all perception. I think I saw you say no, that you don’t manip.

Lisa Russell: No.

Dave Tilley: What about rowers and stress fractures in the ribs, is that a thing, right?

Lisa Russell: Yeah, I don’t.

Mike Reinold: Well why? Why don’t you manip?

Lisa Russell: I have way more success in getting people to feel better with soft tissue and teaching them self mobility, breathing, any of that kind of stuff. Rowers get low back pain. They’ll come to me and say, “Oh man, can you just crack my back? It’s just, I’m so stiff. Well it’s like, well you’re stiff because your muscles are all tight cause you’re really tired and it’s not… I get way more success in hitting the soft tissue and doing mobility work than manipulating anything. So I haven’t spent the time to get good at it. So I don’t really do it.

Mike Reinold: Yeah, I think a lot of people have that barrier. It’s a little bit harder technically to manip because a lot of people have that barrier. So I guess I’d end it like this. A lot of people don’t manip and they seem to be doing fine. Right? So clearly you don’t need to manip, right? A lot of people think manipulations help them achieve their goals faster too. That’s great too. I guess I would just end with, what I’ve been doing lately a little bit more, is I think I will put people at end range of motion. So whether it be cervical, lumbar, even a joint. End range of motion, and then work a little bit in that position, whether it’s soft tissue, whether it’s deep breath, whatever it may be, and that end range position and maybe even do like a grade three, four kind of like joint mode.

Mike Reinold: In my mind, if they cavitate at that point, so they have a pop that they have from there, then I don’t need to do a thrust, which is I think the question. I don’t need to do a thrust there. They cavitated with a grade three, four manip cause I put them at end range. In my mind, I think that means they got it, right? Versus me. I can just go, “Well, bam,” and just crack everything. I feel like the majority of the time we end up manipulating the hypermobile joints the hypo mobile one doesn’t actually pop.

Dave Tilley: I think there’s research out to that grade four and like they controlled half and half and some got high-grade through grade four. Some got manips and they’re both fine.

Mike Reinold: Right. There’s only one thing though. That if you think you needed the manip, the grade four, it doesn’t work.

Dave Tilley: Right.

Mike Reinold: It’s kind of interesting. So I like to, if it goes, it goes, and in my mind then you got that one segment that needed to go because you put it in the right position and you gently worked on it and manipulated. So I think that’s kind of how we do it here. We’re not against it, but I don’t think it’s a big part of our practice here. And again, I think we’re doing fine. I know a lot of other people that’s kind of their bread and butter and they do great with it too. So it’s definitely a skill set you should look into, but you know, I think it depends a lot on your patient population. Right? So, great. So another good question. Appreciate it. Head to MikeReinold.com, click on that podcast link and you fill out the form to ask us questions and we’ll keep doing this right? Mike?

Mike Scaduto: See you on the next episode.

Correcting the Shrug Sign After Shoulder Surgery

March 5, 2020/in Ask Mike Reinold Podcast /by Mike Reinold

On this episode of the #AskMikeReinold show we talk about why people may have a shoulder shrug sign after surgery, and what to do about it in physical therapy. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 194: Correcting the Shrug Sign After Shoulder Surgery

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Show Notes

4 Ways to Improve Overhead Shoulder Mobility

Execution Plans from my Inner Circle:

Transcript

Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about should or shouldn’t we worry about shoulder shrug signs after shoulder surgery.

Andrew King: So we have a Theo from Pittsburgh: “When dealing with a post op shoulder patient, how do you correct increased shoulder shrug when they began active flexion or abduction.”

Dave Tilley: You put on Thriller and you teach them.

Mike Reinold: I know what our thumbnail is going to be.

Mike Reinold: All right, so for a post op patient? Post-op shoulder, how do we… Was it avoid, or how do we treat?

Andrew King: How do we correct?

Mike Reinold: How do we correct a shoulder shrug sign post op patient. So pretty common, right to have a shoulder shrug sign shou… [Crosstalk 00:01:41]

Mike Reinold: The shoulder shrug sign, that was still hard. That happens a lot post op, right? Any type of injury tends to cause some sort of pain, inflammation and anything that may happen from an injury post op type thing, it tends to shut down the cuff.

Mike Reinold: Lots of potential things that we can have here to have a shoulder shrug sign that happens post op. So before we talk about how do we fix it, I think the number one thing we should talk about is what are the potential reasons why they may have that right? Cause there’s a handful and I know we’ve talked about this in past episodes, but I think at this point we’ve talked about everything, but I like how you said specifically post op. So anyone want to jump in and say what are some of the causes of shoulder shrug sign?

Dan Pope: All right, so I think the main reason why people get a shoulder shrug sign is because they’re compensating through the shoulder blade, right? So if you have some sort of pain, weakness, or stiffness in the shoulder, which you’re going to have after a shoulder surgery then you’re going to compensate through the shoulder blade to make up for the issue at the shoulder joint itself.

Mike Reinold: Okay and sometimes this is the path of least resistance. You’re afraid or it’s painful to move the limb so it’s easier to just try to do that right?

Mike Reinold: So I think there is number one right there and let’s call that a neuromuscular patterning issue that the person has meaning they can do it, they just aren’t doing it, right?

Mike Reinold: So maybe some education on how to help them do that so usually that’s a progression of passive, active assisted and then active range of motion type things. But I think it’s more about showing them that A) they can do it and then maybe facilitating them to do it either by using some of your hands, doing some active assisted type things but I think, that’s a good one.

Mike Reinold: Nice. One. What’s next? Who wants to jump in with number two?

Lenny Macrina: Soft tissue, either muscle or capsule is going to probably guess if, usually if it’s a cuff repair. It’s shoulder right?

Lenny Macrina: For cuff repair, then they’re probably 40 plus. So they have a tendency to just get capsular stiffness more so and probably some tightness in their muscles around the joint so you got to be able to address that through a range of motion and maybe some mobz, soft tissue work to soften all the muscles around the area try to loosen it up.

Lenny Macrina: Cause if it’s the capsule’s not moving well, the Humeral head is going to get stuck and what’s going to happen is, you’re going to try to fight through that sticking and just try to raise it up any way you can and you’re not getting normal arthrokinematics in the joints. The Humeral head can’t roll, glide and slide where it needs to cause it’s physically limited. So you got to work on that as well.

Mike Reinold: All right, so I like it.

Mike Reinold: So mobility restriction, so you just had surgery, either you were immobilized by the physician, like you’re in a sling or an abduction pillow or whatever it may be. Maybe you self immobilized because it didn’t feel very well, right? So you mobilize for a little bit and then you had some adaptations to the rotator cuff… The muscles I should say or the capsular tissue that started to get a little tight. Good one, nice.

Mike Reinold: So what would we do for treatment for that one? Well, easy, soft tissue, joint mobility type things. Trying to get them to actually increase their mobility through some of our manual therapy. And probably again the exercises we give them, so good. And I think these all play together, that’s a good one, good.

Mike Reinold: What else? Who wants to jump in? Little more, little more, yeah there we go, right.

Dave Tilley: I’d say, weakness is probably one, a little bit farther down the road that maybe you’re doing exercise, like you’re trying a standing full can variation or even when with weight but that itself is a long lever arm so it’s too much on the cuff to maybe do comfortably or do with the proper mechanics.

Dave Tilley: And so maybe laying someone on their side and starting with a bent elbow on their side eliminates gravity and then progressing them to a straight arm and then putting some dumbbells in their hands on their side. That will help the smoother transition to get strong over a couple of weeks.

Mike Reinold: Perfect. So weakness, specifically in the rotator cuff, so it’s probably not stabilized in the Humeral head so you’re getting superior migration when you’re shrugging right?

Mike Reinold: So I like that, so gravity assisted or eliminated position, very helpful, right? I think that’s a good one.

Mike Reinold: And then the other thing is just get super strong down here, right? That’s the no brainer part right there. So those are good ones, right? Cause sometimes you’ll have somebody that doesn’t have any mobility restrictions but they’re still shrugging right?

Mike Reinold:
Or you have somebody that doesn’t have any weakness issues and they’re still shrugging. So those are the two big ones that kind of go into play. One more I’m thinking of, which kind of isn’t much different, but anybody else want to try? I think we nailed the 98% of the time.

Mike Scaduto: Say narrow, like nerve involvement somewhere.

Mike Reinold: That’s a good point, right?

Mike Scaduto: Surgical trauma.

Mike Reinold: You could have some surgical nerve related stuff too, which then would probably feed into Dave’s weakness type thing. But I think the difference with that is, instead of trying to get weight and get stronger, if it’s a neurological, neurogenic weakness type thing, you probably doing more reps and lighter load, right. Kind of get some of that.

Dave Tilley: Stem trigger would also maybe be more appropriate for that.

Mike Reinold: Yeah, neuromuscular stem would be great to get that, I like that.

Mike Reinold: I think the other thing I would add and I think it maybe it just piggybacks on Len, it’s like a subset of what Lenny just said was that maybe you actually had a capsule repair and not only now is your capsule tight, but perhaps your capsule is surgically tightened or over tightened a little bit.

Mike Reinold: So I guess it’s pretty similar that your capsules tight like Lenny said, but it’s not just that you got, you are immobilized and you got stiff. I think it’s sometimes, especially with the capsule repair for Hypermobility or whatever it may be you actually get some surgical tightness.

Mike Reinold: And the reason why I bring that up is I think the treatment’s a little bit different with that, right? Because you have to be careful with what we’re doing if we’re early within those phases. So you do the best you can with your mobility, but you can’t be super aggressive with it because you can’t disrupt the repair. So that’s probably the one time that we’re actually saying, hey pump the brakes a little bit on that.

Mike Reinold: Hopefully as the capsular tissue gets a little bit looser, then over time that shrug will go away. Especially if you are subsequently working on the strength and the stability down below, right?

Lenny Macrina: I will say it’s a good point and I think we take some of that for granted because I’ve had a bunch of people recently, now that I’m in a cash based setting, people find us, especially me, I can speak for me, that I find people are a year or two years plus out of surgery.

Lenny Macrina: They’re still not happy with their outcomes and even though people seem to be functional, there’s a subset of people that the capsule just never gets this mobility back the way it was before the surgery and people struggle.

Lenny Macrina: And especially if they’re going at a high level of something, whether it’s CrossFit or, I have a female right now dancer and she has what everybody would say is full range of motion in her shoulder and the doc was probably happy and her PT was probably happy, but she’s still not satisfied over a year out of surgery because her shoulder just doesn’t feel right. She still gets this little pinch. So I think that something we can’t take for granted is we got to protect the area, but we have to get back that normal capsular mobility the way it was before the surgery.

Lenny Macrina: And how do we know it? People will tell you they feel a pain in the back, they feel a pain in the front, just doesn’t feel right. But this is months down the road so you got to figure out a way to protect the area but still get that mobility back in the glenohumeral joint because it will affect subtle arthrokinematics and the joint that still bothered a good group of people down the road after these types of surgeries and she had a subscap repair and an anterior labor repair, do you know what I mean? So bigger deal, a lot going on, younger person and she still doesn’t feel right. We’ve had to..

Mike Reinold: Open?

Lenny Macrina: No scope.

Mike Reinold: Scope, that’s got to be hard to do.

Lenny Macrina: So a dancer, good tissue quality, very flexible but her capsule is still not the way she wants it and we’ve made some good gains by some of the stuff I’ve done. That’s a different story.

Mike Reinold: Capsules, exactly how the surgeon wanted it though.

Lenny Macrina: Probably, yeah right.

Mike Reinold: Success, they did it right.

Lenny Macrina: She doesn’t feel right.

Mike Reinold: That’s a big part. We used to see this a lot more with open procedures, you had the incision and you had to take down the subscap to get in there. It got pretty tight after those things, whereas we’re seeing it less with scopes. But there is certain physicians that just over-tighten it, they like to make it tight because in their mind they’re trying to weigh the consequences of them having instability again down the road versus not.

Mike Reinold: So sometimes you’re kind of limited with what you can do, but hopefully even if it’s over-tightened surgically, that’ll affect them more at end range, right. Initially over here, but at end range. So meaning we shouldn’t really have a shrug in there so something to keep in mind.

Mike Reinold: So I think we nailed that. I think we covered like a bunch of reasons why you could potentially have that shoulder shrug. Pretty common, but definitely something that you want to try to get rid of right away.

Mike Reinold: So appreciate the question. Head to MikeReinold.com, click on the podcast link and you can fill out the form to ask us more questions and…

Mike Scaduto: See you on the next episode.

How to Periodize Strength Training After ACL Surgery

February 27, 2020/in Ask Mike Reinold Podcast /by Mike Reinold

On this episode of the #AskMikeReinold show we talk about how to periodize strength training after ACL surgery. We all know that it takes a long time for the strength to come back after an ACL, here’s how we tackle that with a more advanced periodization progression. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 193: How to Periodize Strength Training After ACL Surgery

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Show Notes

Transcript

Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about how we periodize strength training after surgeries such as ACL reconstruction.

(Intro)

Mike Reinold: Austin, what do we have for a question today?

Student: All right, we got Dan from Minnesota.

Student: “You’ve talked several times on your podcast about certifications to learn about weight training and becoming proficient at learning those movements. What about periodization principles for a post-op ACL? How do you periodize a strength program to get a quad back to 90%?”

Mike Reinold: We have talked a lot about physical therapists getting into weight training and how to do that, right? And there’s tons of ways to do it. Probably the best way is the fitness pain-free certification.

Dan Pope: Wow.

Lenny Macrina: Whoa.

Mike Reinold: No, but in full sincerity, yes, absolutely. But I like how you asked your question; it’s not about learning the lifts, it’s not about learning how to do them, how to coach them, how to fix them, how to optimize them, right? But it’s also about how to periodize them, which is more programming. So great question.

Mike Reinold: So how do we periodize, and I actually used ACL as an example, it’s good. How do we periodize a rehab strength training program?

Lenny Macrina: First I want to say, it was Dan from Minnesota, right? 90% quad return is not good enough, so rephrase the question or rethink your thoughts.

Mike Reinold: Wow.

Mike Scaduto: Wow.

Lenny Macrina: Because 90% – I don’t know where this is coming from in the world of PT, but 90% return to quads is-

Mike Reinold: It’s a good point. 10% stinks, and your other leg is weaker because we had a really bad year, right? So yeah, that’s a good one.

Lenny Macrina: That would be my initial, if we’re going to periodize, let’s get to-

Mike Reinold: I like it.

Mike Reinold: All right, so why don’t we start with Dan, and get you in here. Periodizing; how do we periodize? The more you say it, it gets harder every time. How do you do that for a post-op rehab patient? What’s your strategies? What do you do?

Dan Pope: Yeah, I thought about this question a little bit. In terms of the word periodization, I think periodization has to do with having a sport that you’re preparing for, right? So part of periodization is basically, what are you trying to achieve? What’s your end goal? What are you trying to get to, right? So I think the simple way to explain, or at least the way it works in my head, is that you have an end goal. So probably playing a sport, I’m guessing, right? And then you’re starting at a very low level. How do we connect those two, right?

Mike Reinold: Right.

Dan Pope: At least in my mind, and I know you asked specifically about the quad, but let’s say it a field sport, you say ACL, I usually think field sport, we have to be able to accelerate, we have to be able to do top-end sprinting, we have to be able to change direction, and we have to layer in endurance on top of that, right? So maybe you’re not starting on some of those things until about three months or so, because you’re working on trying to get inflammation down, or get swelling down, getting pain to go away, getting all those initial stages of rehab down. But as soon as we can start working on those things, we’re going to start at a very low level and then just progress those over the course of time so we meet that person where they need to be at the end stage.

Mike Reinold: All right, so good first dip into periodizing is the qualities, right? Because it’s not just about sets and reps, you know? That is a big part of periodizing, but usually we tweak sets and reps because we were working on different qualities, right? But I like what Dan kind of said here, is like you have to start again with the end in mind. We talk about that a lot; about what qualities you need to get back to the activity you want to get to, and make sure you’re building a program that sequentially adds in those qualities. That is one form of periodizing, right?

Mike Reinold: So I think the other big one in rehab that we always talk about being guilty of is rehab tends to do three sets of 10 on everything for forever. And they tend to stay with low weights, because we’re oftentimes afraid to load because we’re worried about people, right? So who wants to comment on that? Maybe Len? Oh Dave, you can start too, but maybe you guys, because you guys do a lot of athletes coming back from injuries, and Len, you do a lot of knees and ACLs. Like yes, we start with two or three sets of 10, right? How do you progress that, and where do you go, and why? How do you know when to progress that?

Lenny Macrina: Yeah, I mean, in my head, I’m thinking about movement. So where do I want them to get to is some form of heavy front squat, back squat, you know, single leg stuff, so I need to get them there. So I am teaching how to hinge at the beginning, I’m teaching them just an air squat, to a goblet squat, to some form of heavier loaded front squat, to a back squat. So in my head, I know where I want to get them, I just need to know that they can move correctly to get there, and I slowly add resistance. So weight training, so extra weights. So for me, yeah, I may start off two to three sets of 10, but then they start going into sets of six to eight when I get feedback from them. What was the amount of effort that was needed to get through that set, you know? And then I get feedback from them with the weight, and then I slowly add more weight and take away reps. Because now I want to work on more strength and heavier loads.

Mike Reinold: So after an injury they’ve transitioned from that neuromuscular deficit, and they’re starting to get strength gains. So if we continue to just do three sets of 10 then you could argue we’re potentially not challenging them enough; we need to increase the intensity. What do you think Dave?

Dave Tilley: Yeah. Kind of marrying what you guys both said is, I think a problem that physical therapists have in general is they don’t really understand what’s a normal, expected response to adaptation, or just soreness, or a healthy kind of discomfort versus what’s pathological, or what’s maybe limited by the tissue itself that’s still healing. I think if you don’t really understand what a normal versus an abnormal response to a training effect is, or a training session, that’s where you start to get into hot water. Right?

Dave Tilley: So say, for example, someone who is getting back to doing some front squats, or they’re doing some low-level plyometrics before they start a running program; if they have very much patellar tendon or something in their joint that’s sore the next day, you should be aware of that, and be concerned, and you have to modify the program. Versus if you just trained a really good program, and your quads are sore, and you feel tired, and you’re little drained, that’s a good thing, we want that. And I think sometimes as physical therapists we don’t really know what’s the response we want and vice versa. We don’t know how to program or give people the right dosage of exercise to cause a positive adaptation.

Mike Reinold: So I counted, you took two breaths during all that.

Dave Tilley: No coffee.

Mike Reinold: Right? That was impressive.

Mike Reinold: So obviously an amazing response, right? So that’s a whole other thing. Dan talked about qualities, Lenny talked about movements a little bit, Dave now talked about adaptations, and how do you achieve those adaptations, which I think that’s the thing that some of the physical therapists kind of do. So for the sake of time I think… Anything? That’s all right.

Mike Reinold: For the sake of time, I think I would summarize a typical scenario for what I do. So I always start with linear periodization. Always linear. Why? Because they’re really weak, right? They’re neuromuscularly inhibited, right, they have these issues. So what we do is we keep very similar set rep schemes, like two or three sets of 10, and we go up in weight once each week, or whatever it may be, each session, whatever it may be. That’s classic physical therapy; that’s why we have all these millions of ankle weights and dumbbells, right, from one, two, three, four, five, six, seven, eight, nine, ten, you know, all these different weights.

Mike Reinold: So we linear load that over time until they’ve started to have a good response. And once they start to need to actually get stronger, and you need to go up in weight, then you have to decrease the volume, the sets and the reps. So that’s the first step that I do when I periodize somebody coming back from injury, is we linear load until we’ve kind of maximized as far as we can go with that. And that can take months, theoretically, right? That doesn’t mean you have to, but most people aren’t trained well enough that we have to get fancy periodization schemes, right? We don’t have to get fancy, because their challenge to their system to adapt is relatively easy to accomplish.

Mike Reinold: So we linear load for a decent amount of time, and then what we do over time is, once we run out of weight, what we start to do is go up in weight and to go down in reps. And you could argue that’s still a bit of linear periodization, but now we’re going in the other direction, right? We kind of do that before we even talk about anything else. So don’t be afraid to linear load, but build it up over time. Yeah?

Mike Scaduto: Do you continue… At that point, would you continue isolated, maybe open-chain strengthening of the quad, or does that kind of go away as you get into more of a gym based program?

Mike Reinold: So once they’re getting super advanced, my progression from linear, then, is to then do conjugated, where we’re actually now putting multiple qualities at the same time. So at the beginning, there is no point on doing low-set rep schemes, like five sets of five, three sets of five, because they’re only doing a very small percentage of what they can probably handle because their body’s not ready for that stress, right? So that’s kind of how I start with it there.

Mike Reinold: But once they’re starting to put some maximum effort into it, I think it’s very short-sighted with somebody coming back from rehab that needs to be working on multiple qualities, and working on multiple movements, and working on the correct adaptations; we need to put those together in our program. So we have certain exercises, like our main lifts, that might be three sets of five, right? And then we may have accessory lifts that are two sets of 15, or 20, even; maybe we’re trying to build some endurance, and some single leg stability-based things, and we’re trying to get really strong on some of the main lifts, right? So I think that’s how I would put it together. I mean anybody else want-

Lenny Macrina: To answer your question, I would still do both, if that was-

Mike Reinold: Right.

Lenny Macrina: Which is I think what you said, Mike, is yeah, you have your main lift in mind. So for me, I usually like to have a squat and a hinge in there, or something of that nature, in somebody’s program, and so at the end, I’ll also incorporate some blood flow restriction stuff as far out as possible. I don’t mind doing that forever with somebody after an ACL rehab, because I want the main lift to be there at their strongest. But then I want to get some isolation-type activities, specifically of the quads, because we know the quads are going to drive the athlete when they’re getting back to their sports. So if they need a strong quad, not just 90% quad, I still do isolated knee extensions, even with BFR, or not. We don’t have a knee extension machine yet, so I have to use BFR to get the fatigue factor with the lower amount of ankle weights that we have here.

Lenny Macrina: So I can load them with maybe a 20-pound ankle weight and have them do it with the cuff on them, and they’re going to get a good isolation of their quads after they’ve done their lift. And so that’s, to me, how I think is the best way right now to get the quads engaged, because we know that’s the issue coming back after an ACL. But I think, hopefully some of this periodization talk is good for you, because I think it is a point. I think as PT, traditionally the insurance-based model fails these athletes, because we get them three, four months out, where we’re doing three sets of 10, because that’s still a challenge for them, and then after three or four months, their insurance runs out, and now where do they go?

Lenny Macrina: They go to fitness training, they go to personal trainers, they go on their own, and the failure rates are so high. So I think it’s a great question to educate the audience, because we fail miserably as PTs at this, to understand how to progress people from four months, to nine, to 12 months out of surgery, because it’s that lost area where people go to rehab.

Mike Reinold: We probably fail at loading them enough to get adaptation.

Lenny Macrina: Correct, yeah.

Mike Reinold: Right? Awesome. Great question. If you have anything like that, head to mikereinold.com, click on that “Podcast” link, and you can fill out the form to ask us more questions like that. And, you want to say it? You say it.

Mike Scaduto: We’ll see you on the next episode.

Lenny Macrina: Hopefully in the future.

Using Vibrating Massage Guns in Physical Therapy

February 20, 2020/in Ask Mike Reinold Podcast /by Mike Reinold

On this episode of the #AskMikeReinold show we talk about the popular vibrating massage guns, if we use them at Champion, and if we consider this a form of “skilled” therapy that a physical therapist should be performing. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 192: Using Vibrating Massage Guns in Physical Therapy

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Show Notes

The Best Self Myofascial Release Tools

Transcript

Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about using vibrating massage guns in physical therapy.

(Intro)

Student: All right, Daniel from Birmingham asks, “What is your opinion of using vibrating massage guns in PT practice? You consider this skilled therapy in order to bill for it?”

Mike Reinold: I love how people jam three questions into one sentence, right? That’s kind of cool. What was his name again?

Student: Daniel.

Mike Reinold: Daniel from the ‘ham. Good question. So vibrating massage guns. So again dissecting the question. Do we like vibrating massage guns? Right? Is it skilled? And how do you bill for it? Which isn’t our world, but that’s pretty interesting.

Mike Reinold: So why don’t we start with this. Dewey, who here uses vibrating massage guns?

Dan Pope: Like in practice?

Mike Reinold: Yeah, that’s a good one. Who likes them? Do we have them here at Champion?

Dave Tilley: Yes, yes.

Lenny Macrina: Yes.

Mike Reinold: We have a lot. Do our clients like them?

Lenny Macrina: Love them.

Mike Reinold: Love them. Something to keep in mind. Well, okay, we’ll talk about that. The clients love that. That’s interesting. So it must make them feel better.

Lenny Macrina: Right, right.

Mike Reinold: Good. Do we use them in physical therapy here?

Dan Pope: Sometimes I think.

Mike Scaduto: I rarely administer the treatment myself.

Mike Reinold: I feel like I’ve tried it a couple of times and just felt bad about it the whole time. I feel like, well, you know what, it’s, it comes down to a big question that always happens in physical therapy. We have limited time with our people. Even if you’re in a one on one setting with a person like we are here, even if you’re in that setting here, we have limited time with our people and you have to pick and choose what we decide to do with them.

Mike Reinold: Now that being said, I am one of those people that like to think about the end game and what is our outcome that we’re trying to achieve and then we’ll figure out any way to get there in my mind. So I think what I’m saying here is I don’t necessarily think it’s a bad idea, but I think none of us are currently using it. And maybe we kind of talk about that as to why, right? Because we’re big vibrating massage gun fans. We have them, we use them here, but I don’t think we use them in physical therapy. Who wants to start and kind of talk about that? I kind of led into that a little bit, but I don’t know, Dan, you said you’ve tried it sometimes. Why don’t you comment on why you decided to use it on that person and why aren’t you using it more?

Dan Pope: Yeah. I guess this kind of ties into Dan’s original question. Whether or not it’s skilled physical therapy. I think it’s a tool just like anything else. So if you have someone that you feel like the muscle is related to their pain and/or you’re trying to gain length in that muscle, something along those lines and you think that the gun is going to be the best possible tool that you have at your disposal, then yeah, use your brain, figure out the area that is limited. You want to try to address this and the tool that you have is the best for that. That being said, Mike and I came to this conclusion that we don’t have all the time in the world to work with our patients. So is it always the best tool that we have at our disposal?

Dan Pope: I would say a lot of times it’s not. A lot of times I’m using my hands and maybe I’m using some needles. Oftentimes I’m outside teaching people exercise technique, going through exercise programs. So it’s not always going to be the best thing that I do use. But I do think it’s probably going to be beneficial in some areas and some people, especially people that like it, have that buy in for it.

Mike Reinold: Right. I think that’s well said. And then I think the other thing too is the skilled therapy and do we use it, is if it’s something that they can do to themselves equally as well? It’s almost like then an exercise for me, it’s more prescribed as an exercise. All right, go do your vibrating gun, like me. And why am I doing that for you?

Mike Reinold: I think that’s another thing that kind of comes up a little bit sometimes. Why would we use it? What’s a scenario that would be appropriate to use it as a skilled therapy?

Mike Scaduto: I think the skill is deciding who would benefit from it more than someone else and when to use it and where to use it.

Mike Reinold: Perfect.

Mike Scaduto: And how long? And that’s the skill involved, not the actual administering of the modality.

Mike Reinold: Perfect. I could not have said that any better, Mike. The skill is you decided that for what was happening, this was the best tool for you to use. So I think we’ve now officially answered the question: is it skilled therapy? I think we could argue it technically is because it’s not the tool. It is your decision to apply it that was skilled.

Mike Reinold: So we got that. That’s an interesting kind of point right there. I think if there’s other things that we can do that’s on the table too. Anybody disagree or anybody think differently? But I think Mike nailed the skill. The skill is our decision making process, right?

Dave Tilley: Yeah, I would agree. I think, again, you guys mentioned it, but we’re trying to maximize the time they need us for. The critical thinking skills, the creation of a program, the teaching of specific exercise, selection technique. And I don’t think it’s bad to have that on your list of things to maybe do, if manual therapy is appropriate. But I feel like there’s so many other things that they want me to be involved in that I’m trying to take the big rocks down first before I do that.

Dave Tilley: Maybe in follow up treatment it’s more appropriate. But definitely the first few, it’s not really on top of my list.

Mike Reinold: Yeah. You whip that out on day one, you’re going to lose some people, you know what I mean? They’re going to be like, well, I can do this myself. Why am I coming for you to do this? That’s always an interest. Is there any specific thing that we think that this would be perfect for?

Dave Tilley: Recovery maybe on your own?

Mike Reinold: Yeah, well I meant as a skilled therapist, but, yeah, we’re pro-massage guns for your own recovery and stuff. But what about like tone, spasticity and tone, or something like that, which happens, right? Like doing that for 30 seconds to a minute or whatever it may take to reduce some spasm and some tones and then that way maybe your additional things could have a better impact.

Mike Reinold: I like that. Right.

Dave Tilley: It’s kind of like heat too. Sometimes heat is just like there to relax it. You can do better manual therapies.

Mike Reinold: But I don’t think we see a ton of people in spasm. Right? But I think that’s kind of our point. So maybe it’s not there, but, I think that’s one way we would do it.

Dan Pope: Yeah. And I don’t do this a ton personally cause I’m not like going crazy in terms of manual techniques. But as a manual therapist you’re probably going to be overusing your hands, your fingers, that type of thing. I think it is another tool that probably has a similar effect to some of the other things that we do. But you could probably put in your arsenal so you don’t end up injuring yourself and keep yourself safe over the course of time.

Mike Reinold: That’s a good point? Another good pro for it. I think, solid answers right now. So just to recap a little bit, we are all very pro the massage guns, right? Our clients love them, our fitness clients, our athletes. I mean they love them. They end up buying their own, oftentimes. It is impressive.

Mike Reinold: So clearly they make them feel better, they feel more mobile after, they feel like they recover a little bit better. They love doing them before they train or they do their sporting activity, whatever. So these are good devices, right? I’m not here to tell you why or the specifics of it, but I think we’re all pro using them, right? We use them here all the time. I think we agree with you that there is a question of, is this skill? But by far the biggest thing that you’re doing here is it’s your clinical reasoning that is the skill to decide if it’s appropriate for the person.

Mike Reinold: So I think you could argue it’s skillful, but I do think if you are overusing this and doing it too much, I think you’re barking up the wrong tree. Right. That a good kind of summary? The best way I think you could use this as giving the person a tool to try to maintain some of the things that maybe you’ve helped them with, with your treatments, that they can do on their own in their home exercise program. And I think that would be a great way of engaging that person and really giving them a little freedom to do some of that stuff on their own.

Mike Reinold: Right. Makes sense? Sweet. So great question. I appreciate it. Again, head to MikeReinold.com. Click on that podcast link and you can fill out the form to ask us more questions like that. Keep them coming and we’ll keep answering.

Mike Reinold: Nobody listens this far in the episode probably. So we can just really talk right now, but I’m pretty sure I delete some of the questions there. We have over a thousand questions, we’ve had over a thousand questions come in. We answer a lot, right? We’ve had almost 200 episodes now. We get a ton of questions, but we try to pick out the ones that are most applicable to everybody. So keep them coming and we’ll see you on the next episode.

How to Prepare to Transition to a Cash-Based Physical Therapy Practice

February 13, 2020/in Ask Mike Reinold Podcast /by Mike Reinold

On this episode of the #AskMikeReinold show we talk about some of the things you should be prepared for if you’re thinking about starting a cash-based physical therapy practice. Transitioning to cash-based PT isn’t easy, but it’s rewarding if you’re prepared. Find out what you can do on this episode. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 191: How to Prepare to Transition to a Cash-Based Physical Therapy Practice

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Show Notes

Transcript

Mike Reinold: On this episode of the Ask Mike Reinold show, we talk about some strategies for you to best prepare to transition to a cash-based PT practice.

(Intro)

Mike Reinold: All right, what do we got? Andrew? We got the King?

Andrew King: So, we have Lindsey from Indianapolis: “As a newer grad looking to open a cash-based practice in the next few years, what would be the most valuable certification to pursue? Manual therapy, OCS, SCS, CSCS, or other strength and conditioning certifications, et cetera?”

Mike Reinold: Lindsey. Oh, Lindsey. All right, so all right. Let’s dissect the question. So, Lindsay is a new grad, wants to start a cash-based practice, wants to know what certifications, like a OCS, SCS, CSCS, all those acronyms, right? That will be best to help her get a cash practice. And, we can have a whole episode, Lindsey, on whether or not you should be opening up a cash-based practice. I think that’s a whole other question for a new grad on, do you want to immediately get into your own cash-based practice by yourself? Which, kind of sounds like you’re doing. But, let’s talk specifically about what is the best thing Lindsey can do to prepare herself for this?

Mike Reinold: So, I’m going to rephrase your question a little bit Lindsey, because rather than just say which certification for you to get, I want to know, do we think any of those certifications matter? Did I sway that a little bit? Does it matter for what you want to do? And, maybe what you should do instead. So Mike, you just graduated college, right? I’m kidding. Old joke, sorry. Old joke.

Mike Scaduto: Fresh wounds though, fresh wounds.

Mike Reinold: So, Mike was a new grad three years ago, plus? Over three years now.

Mike Scaduto: Yeah.

Mike Reinold: So, three years ago that immediately went into cash-based practice, so I think has a different perspective. But, maybe Mike comment on starting cash-based practice versus insurance, and maybe the difference of what you did here with the group versus just going by yourself.

Mike Scaduto: Yeah. Well, I guess I’ve never worked in insurance based clinic, so I don’t really know how insurance based clinics work to be honest. So-

Mike Reinold: Well, I mean, you did in a clinical sense, right?

Mike Scaduto: I did, yeah. I did for clinical, and I worked as a co-op rehab aid and stuff like that. Never full time as PT, right? So, my first job was that Champion cash based clinic. It was a little bit intimidating at first, but I think the big thing for me was having the guidance of all the people sitting here, which kind of, I used them as my mentors. They were there to help me work with patients, and we see pretty specific patient population here. So, they were able to get me up to speed, and I’m still learning from them. Still making mistakes and still learning, but I definitely made a ton of mistakes early on. But, it was nice to have a solid crew of people that I could ask questions to when needed. I think that was the big thing.

Mike Reinold: So, I think that’s a great point for you, Lindsey here, is that Mike had a good group of people that are in a similar situation. All of us came from an insurance model prior, and then came into this model. So, we know a little bit about the difference. But, he had people he could talk to, and that’s one thing I get nervous about with new grads entering cash based businesses, because most cash based businesses that new grads want to start is, I’m just going to go to the gym down the street and put a massage table in the corner, right? And that’s great, but do you have enough clinical experience? Do you have enough people to talk to, to help you continue to grow? That’s a big challenge for a new grad, right? So-

Dave Tilley: And, my point too, I think that the reason that I was able to be successful in a setting transferring away from a busy insurance place is because I personally am not the guy for the finances. The back end, the billing, understanding, that kind of stuff, I-

Mike Reinold: The organization. I did it not rushing and keeping it… Oh no, sorry.

Dave Tilley: I did things to superficially obviously to understand my billing and coding, my involvement as a PT, but I definitely was not running the back end. So, for me personally, having you guys do that stuff or be good at it, and me being able to just focus on treating and getting better as a clinician, it was helpful for me. So, if you are considering doing that, maybe consult with someone or pay with someone to help you understand, because running a business and then being a good PT in a cash-based business to me are just two completely different things.

Mike Reinold: I would agree with that. So, so far, I’m going to start collecting responses. So essentially, what’s the best thing to prepare is make sure you surround yourself with people that that can still help you, right? Don’t work in isolation, I think that’s a big thing. Two is that probably instead of a OCS certification, I have no idea what that’s going to do for you by the way, Lindsey, you need to understand a business, right? And, how to get the most out of a business. So, what else? Anything?

Lenny Macrina: I mean, there’s a lot. And, when I heard that question, it’s just there’s so much as a new grad to learn, that I think learning to run a business is just going to make it that much more difficult. The first year to three years as a new grad, you need good mentorship, because you just need a lot of people to help you learn how to talk to people and address all these different pathologies that are going to come through the door. Whether it’s a post-op ACL when you progress them to this and that with rotator cuff repair, versus, I don’t know, some kind of random pathology comes in and you don’t know what to do with it. So, you need to learn all that stuff, and I’m still learning too 15 plus years into my career. So, having these guys helps me.

Lenny Macrina: So, you definitely need more experience just as a clinician. And then, hopefully as you’re doing that, maybe the clinic you’re working at, which is probably going to be an insurance based clinic, allows you to see the business side, and you start talking to managers, you start helping them with that stuff. I think that would be a good way to hack their system is to just learn the financials. What does a PNL mean, and all these different reports, and how to read it, and what it means to the business, and there’s so many different things to do.

Lenny Macrina: I think being a good clinician first is going to be priority, and that’s going to give you a little foot in the doorway in the community that when someday you want to start a clinic, which I would recommend probably three to five years at least into your work as a clinician, then you would consider it and hopefully have connections in the community that you’ve been working in that they would then trust you to want to come to you.

Lenny Macrina: So, it’s not just, I graduated PT school, I want to start a clinic, a cash-based clinic. That’s going to struggle, trust me. You need people around you, not just clinicians, but people in the community that trust you, because they’re going to come to you for PT, not the facility for PT. They want to see you, the clinician, and that’s going to be huge if you can develop that rapport with people in the community to be able to come and find you when you open up your facility, whenever that’s going to happen. You know what I mean? And then, hopefully you’ve understood the business aspect, and what you need to buy, and how to pay people, and taxes, and human resources aspect. It’s so much stuff you wouldn’t even understand. Trust me.

Dave Tilley: It’s a venting session for Lenny.

Mike Reinold: So, it sounds like Lenny agrees with Dave, learn business, right? But, I think one other thing I picked up from Lenny here was that you got to be able to communicate and connect with people, which is a big deal. And, my guess is Lindsey, that’s what you excel at, right? Because, that’s probably why you’re considering doing this, is you’re good at connecting with people, you’re helping some people. It’s pretty neat.

Mike Reinold: Now, Lisa, you are jumping in and making the transition as we speak from insurance-based to cash-based kind of model a little bit with your stuff. There’s one thing you have that we all have, right? That makes you unique, right? It’s being a niche with a specific subset of people that not only you like to work with, but that you could say you’re an expert at, right? And, I think that’s a big deal right there.

Mike Reinold: So, Lisa’s a former rower, and former lots of things, right? But, a former rower… No one’s ever a former rower, right? You’re a rower. A former collegiate rower?

Lisa Russell: Sure.

Mike Reinold: That’s what I meant to say, right? So, right? But, Lisa understands rowing, and rowing injuries, and working with rowers, the mindset of rowers. So, she has this big niche. So Lisa, why don’t you explain how that niche has helped you be more confident making this transition?

Lisa Russell: Yeah, so I mean, I spent a good amount of time in the traditional insurance model, because I didn’t feel confident in just telling people, “Hey, I’m a PT. Come and work with me. I’ll help you out.” Even though I’ve been treating rowers essentially all through PT school, because all my teammates and everyone as I was learning my skills were like, “Hey, you want to help me out?” So, rowing has sort of been at the foundation of me developing my skills, but at the same time I never felt fully confident to just say, “Okay, this is the niche I want and this is where I want to be.” It’s more, as my skills have gotten stronger as a whole clinician, I felt more confident that I can say, “Okay, these are the people I enjoy treating and the people that I am as enthusiastic about it as I can be. So, let me kind of put myself into a little bit more of a specialized corner I guess.” But, if I hadn’t taken the time to do the broad, I don’t think I would feel the same way.

Mike Reinold: Right. It’s like you need two things, right? You need to be confident in yourself as a physical therapist, and then confident in yourself and an expert in something, right? So, is Lisa an expert physical therapist? No, but she’s an expert physical therapist for rowers. Am I an expert physical therapist? No, but I’m an expert physical therapist in the small world that I work in. I don’t know how to treat pediatrics. I don’t know how to treat neurology stuff. I don’t get that stuff, right? So, it’s about like being really good at one specific niche where you’re an expert, and I think that’s a big deal. And, I think that’s the one thing that a new grad is going to struggle with, too.

Mike Reinold: So, I think that was a bunch of good advice. Let’s not inundate Lindsey, because I think you’re doing good things and you’re obviously kind of thinking in the right direction. But, I think an OCS, an SCS, a CSCS, none of that matters. Those are just letters that only you understand and your peers understand, the person doesn’t understand any of that, right? What they do understand is somebody that is cutting edge, somebody that’s keeping growing by being surrounded by mentors, somebody that understands the nature of making a business so that way this is a good environment for everybody, and they’re an expert at a special niche. And, I think you kind of put all that together, I think that’s the direction you should probably start focusing on. Don’t worry about taking a test, worry about becoming an expert at a special niche, and understanding what goes into running this type of business. Make sense?

Mike Reinold: So, great question Lindsey, and hopefully that helps a lot of people. I know tons of people have that question. I don’t know, maybe a third at least of our students here at Champion say that that’s their goal, they want to open up a cash based practice next week, right? That’s their big goal. So, I think a lot of people kind of share that. So, great goal, and I hope we all get there one day, but I think if you take those steps, you’re going to get there even more successfully. So, if you have a question like that, the more the better, keep them coming. Anything related to PT, fitness, sports performance, business-related stuff, and career advice like this would be great. But, head to mikereinold.com, click on that podcast link, and you can fill out the form to ask us questions, and we will see you on the next…

Dave Tilley: Next episode?

Dan Pope: Episode. Yes.