Ask Mike Reinold Podcast Archives

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Should Physical Therapy Clinics Have Productivity Standards?

On this episode of the #AskMikeReinold show we talk about productivity standards for outpatient physical therapists. There are definitely two different perspectives on this, one from the therapist and the other from the clinic owner, but there is also an ethical line we need to be careful of not crossing. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 187: Should Physical Therapy Clinics Have Productivity Standards?

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Transcript

Mike Reinold: On this episode of The Ask Mike Reinold show, we talk about how you should deal with productivity standards in your physical therapy clinic.

Evan: James from Minnesota, “What are your guys’ thoughts on handling productivity standards in private practice outpatient setting? I have expectations for billing four units in a 40 minute treatment session and expectations for starting patients at three times a week for 50% of overall caseload. I believe in putting the patient’s needs first and tailoring my treatment to meeting their needs. Love the show guys, keep up all the great work.”

Mike Reinold: Wow, that’s pretty great. So, I like this. This is a good question on productivity standards which I feel like the cycle of physical therapy in this country kind of continues. Like, you see these big neck, big conglomerates get larger and then they all kind of like foul.

Mike Reinold: I don’t know what happens, right? But you get a big mass of HealthSouth and then things happen and then it disperses and you get these like waves and what tends to happen is you start with like a nice small private practice, right? And you do things right, you do things the way you want to do it, those sorts of things. And then over time you get into these big conglomerates and it becomes more about like less about the person and it becomes a business, right? And productivity standards, how many people per hour should you see? How many units should you bill? Stuff like that. Right. So, specifically to this one though, four units in 40 minutes? Is that legal? Yeah, I guess so. Right, right. So this is like pure hitting the limit of like how to maximize it.

Mike Reinold: And then the other thing is you should be seeing your patients three times a week?

Evan: For 50% of the overall caseload.

Mike Reinold: Yeah, so it sounds like what they’re doing in your environment is there, there’s probably a larger corporation type thing and they probably have some metrics that they know are the averages, right? So they’re trying to say, “Hey, you’re below the averages.” Right? And what they’re saying is hopefully is, this is the average, but if you do enter a situation where somebody is saying like, “Hey for every avow they should be scheduled three times a week initially.” Then yeah, that gets a little awkward. So who wants to start? I mean, you guys, Len, we’ve had some experience in the high kind of volume type thing. Like, did we have productivity standards like that or is it more just…

Lenny Macrina: I know later on in my time down in, Alabama we did and I was definitely, I was part of the management so we were challenged from higher up to relay the message to staff of where their units were, units per charge and we’ll charge just per unit and units billed per visit and blah blah blah and reimbursement. So we did, we tried to, relay it along. I don’t think I, certainly wasn’t like, a stickler, but I just did what I was told and, and it was what happened. But it definitely does happen. I think we’re definitely bordering on, a very gray area of what, what’s legal and not legal by telling people they have to come three times a week for a certain, fraction of the patients that you see. This just doesn’t sound right. Like who definitely needs three times a week? Not many people. Right? So…

Mike Reinold: It sounds like they’re, they’re making decisions based on the business.

Lenny Macrina: No doubt.

Lenny Macrina: I mean, I don’t know if I’m- we definitely don’t do any of that stuff here. We don’t even think we really have much productivity that we look at. We’re not, I don’t think we’ve ever told you guys do you have to see more people? It’s just, how it happens we have stats that we look at, we’re looking at trends and who comes in, but we’re certainly not telling them that they have to see more, never.

Mike Reinold: I think like from a business owner perspective, it’s not necessarily bad. Like let’s say, let’s say you were, billing a certain code, but you think that you could substitute it for a different code that would be ethically and logistically fine, but you would get more reimbursement. I think that’s appropriate, right? Because the clinician doesn’t understand that. So there are some games we typed up. We tend to play. Or billing like based on time if, if you don’t quite understand it. I think there’s, there’s a strategy towards billing that I think people get with productivity.

Lenny Macrina: I am on, I’m always scouring Facebook and looking at, the different groups and it’s amazing the lack of education and the lack of conformity amongst PTs and how to bill, how to bill private insurance versus Medicare. Is there a difference? Eight minute rule versus 15 minute rule. We are lacking severely in how to understand billing and what codes should be used for a manual and therex neuromuscular rhea. And if we can bill dry needling and if a Medicare patient is there, how that affects things. It’s, it’s all over the place. And I think, I think even management struggles to, to get that to trickle down to staff because I think people are still all over the place. And so I think fundamentally, we don’t know. We really don’t know. Yet we’re just trying to use these parameters to track and bill accordingly. So…

Mike Reinold: So, and that’s always a, that’s not necessarily bad, right? It’s just trying to maximize, the game here, right? But when does it cross the line, Dan, what do you think? When does it cross the line to what we’re starting to do isn’t in the best interest of the patient?

Dan Pope: It’s, that’s really hard. And obviously I kind of left a facility that was kind of like or physiotherapy associates, nothing against a company. I liked the company but I think that people, physical therapists in general, we have to have a little bit of empathy for the business. Right? And I think in general physical therapists are undervalued. So the reason why we got to see more and more people is to try and make money. Right? So we can pay for the overhead. So we’re in a tough situation from that perspective again, obviously I kind of left that type of facility.

Dan Pope: I like to be able to treat people less frequently cause I feel like that is optimal for a lot of people that I do see. But the flip side coin is that these business have to run and we have to value yourself as clinicians. So part of it is that, if you are able to see people more times throughout the course of the week. And you think that will actually benefit them further? I think that’s okay for more perspective, but I think as a physical therapist here, you got this, and I read this, there’s a term for this, I forget what they’re calling it, but you’re forced to see people more than you think you need to see them and when you leave at the end of the day you feel poorly for that. Right? But if you are able to actually fill that person’s time with stuff that’s very valuable and you’re adding to them and adding them from a physical therapy or wellness perspective, that might help you deal with some of those feelings. Right. What was your original question?

Lenny Macrina: But I think ultimately it’s the PTs decision to figure out if that’s appropriate. If you think you can add stuff two to three times a week and it’s going to help them get better faster and back to their goal, then fine, but not management telling them you have to see people three times a week and I know it happens. Trust me, I know it. Besides this question, I heard it a gazillion times in my career. It does happen. I don’t agree with it. It’s something that I hope will change. But.

Mike Reinold: Yeah, I mean, and every patient population is going to be slightly different like a post-operative person, like come in more frequently than a non-operative person, for example. Right? So I think we’re stating the obvious with some of these things. I think the question comes down to is just making sure that as a young clinician you understand that there is some part of a business behind it. I think Dan brought up a really good point is look, it costs a lot of money to run a business, right? And there’s a lot of financial risk that happens from the ownership group with running a business, right? There’s a lot that goes into this. So you have to understand that a little bit and you have to do your best to maximize how much profit you make. But if that is how you are making decisions on your clinical career, on your clinical decisions, then that’s where we cross the line. And it becomes a real, real problem, becomes very unethical.

Mike Reinold: So it’s one thing if you’re being educated on, hey, maybe there’s some ways that we can optimize revenue without sacrificing your clinical judgment. I think that’s completely appropriate. But if somebody is telling you to just see people more often than I think you’ve learned right there, that that is the type of business that you probably don’t want to be associated with or you wouldn’t have asked this question. Right, right? And I think a lot of people will feel uncomfortable in that situation too. And over time maybe that manager, that person will understand that that’s not the best way to do business. And hopefully, when all the therapists leave and they kind of keep replacing them with new grads and then churning them out and spitting them out and then moving onto the next one, they’re going to realize that that’s not the best sustainable business model over time. Right? So I don’t know.

Mike Reinold: Any other feedback? Let’s flip gears because we can talk about this over. Let’s flip gears and I didn’t want to interrupt you if you have more, by all means. But like if you’re in the situation, what’s our advice to that person?

Lenny Macrina: That’s what I was going to say. So flipping it a little, if it was me, obviously I don’t know, to me results speak volumes. If you get good results with your patients and your clients. And I think we do a pretty good job here. Word gets out. So I think management has taken it from a different view. They just get people in as much as possible. But I think the people will automatically come in if you are producing good results where you’re with your patients and they leave feeling good about how they’re progressing. And I only had to go to PT once and I felt amazing. That word gets out on the street in the community and then people want to come in and get that same approach because they know they’re going to get better faster than going down the street where they had to go two or three times a week.

Lenny Macrina: So I think you flip it that it’s the results that matter. Marketing is going to be important. Whether you go to a doctor or you going to some kind of a other facility, if you’re trying to be become nichey, you’re going to a crossfit facility, baseball facility where you’re spending time and learning and then that gets out into the neighborhood that you’re making an effort to make yourself better and you’re trying to get a certain amount of clients in or some type of client in. And so I think all that snowballs and I think that’s a better approach than just blanket three times a week.

Mike Reinold: Yeah, I think we’ve always established business here, and this is the same way of what we do online is we just do what’s right, right? We do, we do what we think is best and we do what’s right and we don’t ever focus on profit. And when you, when you don’t focus on profit, I think you end up having a better product and over time you become more profitable, right? So that’s a general strategy. The second you start making decisions for finances, it tends to just spiral out of control in the wrong direction because you’re making decisions for the wrong reasons. That’s not why any of us got into this. So anything else, Dan?

Dan Pope: I was going to say it. If you’re kind of going for what Lenny said, you probably need to communicate with the management a little bit. I think that’s a tough sell because I’ve kind of had this same conversation because you’re trying to get maybe people in the door get them better, faster, right? Giving them more autonomy. But if they don’t understand what you’re actually trying to do and they keep on looking at your numbers, it doesn’t make sense. They’ll be upset at you and meanwhile you’re not communicating what you’re trying to accomplish and then you’re going to go home and be upset at the end of the day and probably going to leave your work eventually. So if you communicate well with the that the managers, I guess it sounds like you’re dealing with right now, maybe you’ll feel a bit better at the end of the day and you’ll, you’ll hit some numbers that are more profitable and maybe they’re not breathing down your neck quite as much, I guess.

Mike Reinold: Yeah, I would say keep an open mind. And have a conversation with your manager first about, all right, well what do you think I’m doing wrong? Here’s why I’m treating this way. What do you think I’m doing wrong? Maybe there’s an educational opportunity for you here. So I would definitely say I would recommend go talk to your management and say, “Hey, I’m not comfortable with this productivity standard,” but instead of just immediately saying that they must be wrong, just ask like, “what am I missing here?” And let them try to explain it to you. And if it becomes really clear that all they care about is the money and not the person, then I think you just figured out a lot about that place and whether or not that fits your values and if you want to continue working there. But maybe during that conversation, like Dan said, you’ll kind of get like, like some thoughts and maybe you’ll realize, okay, no I think you’re right.

Mike Reinold: Like okay, maybe, maybe if I did see people a little bit more often I would have better outcomes. Right? Because they might be comparing you and your frequency of visits and your outcomes or something like that. You never know what they’re comparing. I’d say hear them out first and let’s not immediately take it as an insult. Right? And hear them out first, but then it’s no big deal. Don’t get stressed out, don’t get flustered about it. Hear them out and see what they have to say. And then you make a decision. Is this business doing it the way I want to do it and do I want to be a part of this? Right? It makes sense? Awesome. All right, good question. I mean, tough situation to be in, right? And it stinks that sometimes we are, but you never know, right? Maybe they’re about to go out of business.

Mike Reinold: Maybe their lease just went up and who knows, right? Maybe they’re about to go out of business. Figure out the situation in there and figure out what’s going on and ultimately always do what’s best for the person in front of you. Otherwise, you got into this for the wrong reason. And plus there’s way better professions to make money than being a physical therapist, right? None of us got into this to be rich, right? We did this because we want to help people, so hopefully that helps. So if you have questions like that, head to mikereinold.com click on that podcast link and you can fill out the form and ask us more questions and we’ll see you on the next episode.

How Physical Therapists can Specialize in Sports Rehabilitation

On this episode of The Ask Mike Reinold Show, we talk about ways that a physical therapist can start specializing in a specific sport. There’s a lot that goes into the evaluation and treatment of sports injuries, here’s how to get started. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 186: How Physical Therapists can Specialize in Sports Rehabilitation

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Transcript

Mike Reinold: On this episode of the Ask Mike Reinold Show, we talk about how you can start specializing in specific sports rehabilitation.

Mike Reinold: All right. What do we have for questions, Ryan?

Student: We have Chris from New York. He says, “Hi guys, I’m a young physical therapist, less than two years out of school in an orthopedic setting and I’m looking to specialize in baseball related injuries and rehabilitation. I was wondering what your best advice would be to move toward a specialization such as baseball.”

Mike Reinold: All right. So two years out of college.

Student: Two years.

Mike Reinold: Is that what it was? Good. So pretty common question I think that we have. And I don’t think we need to talk about baseball, right? We can all talk about anything we want, but I guess the question is the young clinician two years out wants to start specializing in some sport or some activity. This one specifically baseball. Probably a good question. And I’m glad you’ve done it this way ’cause we have students and young clinicians all the time that come through and immediately want to specialize in something. And I kind of like how you’re two, three years out of school. You kind of learned a little bit of everything, right? Doing some general kind of approaches and now want to get a little bit more specific. I like that.

Mike Reinold: So who wants to start? I mean, let’s answer this as a kind of how to specialize into a niche population, right? Or as Dave would say a niche population.

Lenny Macrina: Classic.

Mike Reinold: Who wants to start first?

Dan Pope: Want me to do it?

Mike Reinold: Wow, man. I don’t know. I definitely would take a poll by the audience. Doesn’t sound like Dan’s into it, but yeah.

Dan Pope: Yeah.

Lenny Macrina: Dude, how’d you get into baseball?

Dan Pope: So when I was 14… No… I actually played baseball a little bit, but I can’t throw anymore. Any way, I think what’s really important is you have to be embedded into the community that you want to be a part of, right?

Dan Pope: So for me, I do a lot of fitness. I also did a lot of CrossFit. So the first thing I did is I was a CrossFit coach, right? So if I want to try and be within this community, I have to actually be within this community first and foremost. And part of that is networking with a lot of local coaches. So what I did is I did a ton of going from CrossFit gym to CrossFit gym speaking to the coaches, talking to them a little bit. If they’re sending athletes to me, I communicate back with them. We collaborate a little bit over the course of time. I also allied myself with different surgeons in the area that knew about fitness and knew about kind of the physical, or excuse me, the surgery side for the fitness population as opposed to just like regular surgery I guess. And that was really helpful and that was really good for getting more people in the door for me that were specific to CrossFits I guess.

Mike Reinold: So it sounds like what what you did, you took the approach of… And you actually became a CrossFit coach although that was before you were a physical therapist, right?

Dan Pope: Yeah.

Mike Reinold: You were doing some strength stuff back in the day.

Dan Pope: Yup.

Mike Reinold: Before you were PT, but what Dan did was he not only joined the community, which I think is a very valuable tip, right? Join the community. So that way you understand the culture, you understand the experience, you understand even the passion, right? Like a lot of people want to get into something like fitness, right? But then don’t enjoy working out. Well, that’s going to be really challenging because it’s not going to be very authentic that you don’t train yourself. How are you going to work with advanced level trainees? I think that that’s an important concept, you know?

Mike Reinold: So you have to understand the techniques. You have to understand the specifics of that particular thing. But also, I think you said this really well, the culture and the community. I think that’s a good one.

Mike Reinold: So who else wants to talk about maybe… Like Dave, maybe with gymnastics. How much do you think your being a gymnast and knowing not just the culture, but how to communicate to these athletes? How much do you think that’s important that you have the experience to talk to these athletes that you work with?

Dave Tilley: Yeah, I think that’s probably the biggest thing in terms of being able to like develop rapport with a person. I think that we see this in here all the time. Whether it’s you guys with baseball and crossfit and Mike with golf, it’s like the second that you start speaking their language and you understand their terminology. You understand what their competitive situation looks like. You understand their goals. You can have a very different conversation with them that I think allows them to feel comfortable. And one sharing all of their problems with you in terms of why it hurts or what they’re maybe not telling their coach, what they’re not telling their parents, but then also they probably have much more buy in terms of actually following what you prescribed to them.

Dave Tilley: And so, I mean blessing or a curse, we’ve had people in here who have probably gotten similar advice than you’ve gotten elsewhere in physical therapist. But because you put it in a context of baseball or golf, they’re like, “Oh, okay. Like this person understands what I’m trying to get back to or they’ve done this themselves they understand it.” So I think it’s really important because one, you can never… like I said, have rapport that person. But two, is that you can be a pretty good communicator between the whole party of people involved, the parent, the coach, and then obviously you, yourself as the therapist, and the athlete. If you guys have common language, it’s easier to talk about problems.

Mike Reinold: Yeah. And the other concept I think too is that you understand their life and their future expectations, right?

Dave Tilley: Sure. Sure.

Mike Reinold: So we deal with this a lot in baseball, right? We may have an athlete that sees a doctor and because it’s magically week eight, right? They can start like a throwing program or whatever it may be for whatever that was. When we often times… We sit down and we talk about, “Well what’s your strategy for the year? When do we need to be ready? What’s the most important part of your year? Is it the spring or is it the summer?” And we kind of have like a more… Almost like a concierge level discussion with them that we can help guide them because we know their goal is to get a college scholarship or to get drafted or whatever it may be for your sport. We know that that’s their goal.

Mike Reinold: Where a lot of times doctors and other physical therapists, they’re just, “Well it’s week eight.” And I can do this exercise now, right? And it’s very simplistic with a timeline versus understanding the broad scope of not only their injury right now, but their competitive season and their career if that’s important. Mike, what do you think on… What’s your experience with golfers? I mean obviously you’ve done a great job. Ton of golfers in here. Something you’re passionate about. I think they all see that you’re a very average golfer on Instagram if they follow you, but what…

Mike Scaduto: There’s so many come backs. I would say the big thing, and this is a little more in general than just golf specific, is recognizing what your primary referral source is going to be. So for golf, if you want to work with golfers who are looking to improve their performance or if they’re injured… The primary referral is probably going to be the golf coach and for baseball a lot of times it can be a pitching coach and baseball coach. If you want to work with a lot of post-op patients, if you want to work with post-op shoulders is probably going to be more the surgeons. So then you have to network within those referral sources. But you have to identify first.

Mike Scaduto: So for golfers you have to… Or at least in my experience was we kind of infiltrated I guess a golf instructor that gives lessons that we aligned with and we kind of took lessons from him from while. And then, eventually started talking about what we do. And then, kind of grew a relationship that way. But it wasn’t like we were trying to convince him to work with us. We kind of just worked with him a little bit and got to know him. And over time we developed that relationship.

Mike Reinold: Because you guys shared a lot of shared values, right?

Mike Scaduto: Shared the values.

Mike Reinold: Like you shared how to help people, right? And you’re doing it for the right reasons. I think that’s a great example, right? Is putting yourself out there. So Dan said, “Become a coach.” Mike said, “Well go work with those coaches.” Right? Because you want to understand what the coach is teaching. So we’ve all done lessons with particular golf instructor around our area. We understand the way he thinks. So if he sends us one of his clients to look at them, we know how we can then articulate what we’re going to do that aligns with his instructional strategy. So it’s this easy kind of connection with that. Len, anything to add?

Lenny Macrina: Yeah. Everybody summed it up really well. I think a couple of points that I’d like to make is you don’t have to play the sport in order to be a master in it. But I think-

Dave Tilley: Still hope for baseball.

Lenny Macrina: …definitely. Right. Exactly.

Mike Reinold: You have a doctorate in it.

Lenny Macrina: But I think it definitely helps to be able to talk the talk obviously. So I never played major league baseball, but I’ve treated a lot of major league baseball players. But I understand the sport. I can treat a gymnast, but I would definitely defer to Dave for more of the specific terminology.

Lenny Macrina: I think of it in two different ways. I think of it learning locally. Learning locally with doctors, learning locally. Especially for baseball, learning locally with like Mike said pitching coaches, hitting coaches, just coaches in general. Get in that relationship and then more of a broad educational thing. You want baseball. I’m going to challenge you again like I challenge somebody else. Go to Atlanta in January and go to the injuries and baseball course from ASMI. And learn from the best, what we think of the best, in baseball that are educating on that. So bring that back with you and network in that fashion.

Lenny Macrina: Go to Mike’s baseball website, the elite baseball website. And you can learn from there. And so, I think-

Mike Reinold: He must have it bookmarked.

Lenny Macrina: …have that so you’re always reading those blog posts and reading research. And then, you start putting content out and then people recognize you as a leader in your area. So I think there’s a bunch of different avenues that you can take that the guys have mentioned. And I think it always comes down to networking. When in doubt, just have relationships with people and that will open up doors for you.

Mike Reinold: So I like it. Relationships are a big one. Immersing yourself into the environment and community I think is huge. But I think Lenny just really nailed it with that end point. You need to become a huge student in that specific genre, right? If that’s what you want to get into, right? So you have to learn everything. Read every book, every article that comes out, every expert that you can learn from, go to courses and actually master that. So you actually have to be very passionate about this to be able to sustain doing this because you’re going to put a lot of effort to this.

Mike Reinold: But then on social media, that is what you should be focusing on, right? If all I put on social media was low back pain people? Guess who would come find me and want to work with me? Low back pain people, right? So it’s whatever you put out there and establish yourself as someone that understands that and you’re constantly promoting that, right? Dave’s all gymnastics on his social media feeds. You never will check Dave out because you heard about them and think, “Oh wow, this guy doesn’t know about gymnastics.” But if you’re all over the place and you’re doing a little bit on the ankle and then a little bit on the spine and a little bit on the shoulder and then an overhead athlete and then you have a total knee patient, that’s fine, but you’re not developing that specificity. So I think that’s… Educate yourself very specifically and then educate others very specifically on social media. I think that’s how I’d probably wrap it up, right?

Mike Reinold: So great question. We get similar questions a bunch. I think it’s important to kind of address that. So hopefully that answered your question. If you have more like this, head to mikereinold.com and click on that podcast link. You could fill out the form and we’ll keep asking… Oh no, we’ll keep answering questions.

Using Physical Therapy Interventions with No Evidence of Efficacy

On this episode of the #AskMikeReinold show we talk about what to do when physical therapy interventions have little to no evidence showing they are effective. This is actually pretty common, here’s how we decide what to do when there is limited evidence. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 185: Using Physical Therapy Interventions with No Evidence of Efficacy

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Show Notes


Transcript

Mike Reinold: On this episode of the Ask Mike Reinold Show, we talk about how we choose some of the PT interventions that we do when there isn’t enough scientific evidence available.

Mike Reinold: Trey, are you the question asker today?

Trey: I am.

Mike Reinold: Fantastic. What do we got today? Trey?

Trey: David from San Francisco. How do you determine which PT interventions you perform when there’s little to no evidence available?

Mike Reinold: Ooh, good question. That’s a big one. Yeah, and it’s funny like I kind of got the sense reading the question a little bit too. You know, this is one of the biggest things I’m seeing on social media right now. It’s not the post, it’s the reactions to the post on how confused everybody is.

Mike Reinold: Well, so how do you choose what interventions you do when we don’t have evidence of it. So I’ll start off by by saying a lot of people do have this quest to only do things that have strict evidence-based validity, right? So something that has been shown in a research project to be, you know, valid for example. And everybody has the quest to do that. And I think that’s like a great quest, right? That you should try to do that all the time. But I think the reality of it, especially in our field, especially in healthcare, especially with the way our clinical trials work, it’s nearly impossible to do a well controlled study on the majority of things we do. So even though like we’re trying and we’re doing our best with research, it’s really hard to conduct these studies. So you know, oftentimes we’re faced with things where maybe it’s a new technique or an intervention that people are talking about on the internet or maybe it’s something that’s old but we still haven’t validated in there.

Mike Reinold: How do we decide what we do and don’t use in our clinical practice? Who wants to start?

Dave Tilley: I was just giving a broad overview in saying I’ve always tried to approach it at like 85% of what I’m doing in clinic is what’s available up to this point. Evidence based research from mentors of mine or things I’m reading or good RCTs or whatever, and then 15% you want to be somewhat creative and innovative and have new ideas in mind. Like I remember when blood flow was first coming, becoming popular. I didn’t really know a lot about it, but I knew I wanted at least like try a little bit on myself and like play around a couple of patients who were like pretty safe. And then from there the research flows then you’ll get that becomes part of your 85% as a research gets better, but you definitely should be investing almost all of your time and things we know that are pretty solid scientifically.

Mike Reinold: Right. So 85% of your time, but I’m going to say 85% of what you do is probably not validated through science.

Dave Tilley: Yeah. Well I guess theoretically I would say it’s not like an RCT, and a couple of blind controls, but at least like the sciences, like the histology studies are there, the rat models are there, that something is available that helps you out.

Mike Reinold: I’ll give you that because that is how we determine a lot of like what we do is it’s, but people are going to argue that that’s not scientific.

Dave Tilley: Definitely better than just swinging it.

Mike Reinold: Exactly. So, so I think that’s a good start is like a lot of what do, and like a lot of our protocols that we write for after a surgical procedure are based on some of the understanding of, of tissue, right? And understanding of physiology and how things heal.

Mike Reinold: So we may not know that this is effective at that, but then we have a theory based on some of our basic science that does it. So I actually think that that’s a good approach. A lot of people are going to argue that that’s not valid though. The social media people that are ‘nope there isn’t a trial that says that’s good,’ even if you maybe have like a basic science theory as to why.

Dave Tilley: Yep, And I would say that if you, if you get really honest with yourself and you’re examining what you’re doing and how much like elite level evidence there is, you’re going to have very little to do in the clinic.

Mike Reinold: And I think that’s the main point here. So Dave I think has a great first strategy right there is if we don’t have pure evidence on it, then we base it as much as we can on our, on theories based on what we understand is the basic science, right?

Mike Reinold: So that’s a good first strategy, right there is is we do our best understanding things. That’s why like we do EMG studies, right? And a lot of people critique EMG studies, you know, for various reasons and rightfully so to an extent. But again it’s like we’re never going to know if exercise A is the best exercise for this intervention, right. But we base it on as much sound scientific principles as we can. Dan.

Dan Pope: Yeah, I was just going to say that it would help if who was asking the question?

Trey: David.

Dan Pope: David gave us some better information about the specific person from or you know, what kind of intervention their trying, and I can definitely see this. I work with so many fitness people and a lot of times I get jealous of like let’s say baseball players or maybe even runners.

Dan Pope: There’s quite a bit of research on how to treat those problems. You know.

Mike Reinold: Right.

Dan Pope: If I have someone who has like impingement, rotator cuff tendinopathy and all the available evidence is in six year old individuals that don’t do any sort of fitness activity and I got like a 23 year old that wants to like bench press 400 pounds, it’s very challenging. Right?

Mike Reinold: Right.

Dan Pope: And there’s no research out there about people who want to bench press 400 pounds. You know that have shoulder impingement, there is some, some research there, but very, very little. That becomes very challenging. And one of the things I borrowed a lot from you guys is that there is some available evidence for baseball players. You guys have done a lot of that and we can extrapolate a little bit from other populations that are kind of athletic, right?

Mike Reinold: Right.

Dan Pope: So a lot of what I do is take prior research study, so one good example is patellofemoral pain syndrome and runners, right?

Dan Pope: Or let’s say like field sport athletes. I apply a lot of those principles of rehab to my athletes who are squatting. They’re not running, but they have patellofemoral pain from squatting. So we can extrapolate at least a little bit from that perspective. You know.

Mike Reinold: I like that.

Dan Pope: Yeah.

Mike Reinold: So, so taking the basic science right and then maybe taking a similar population or a similar pathology or something. I think these are good strategies, right? Cause again, I think a lot of the students and new grads are saying like, well I want to know if this exercise is good for shoulder impingement in this person. Right. And I think this is, you know, Dan taking like maybe from other sources or from other pathologies and applying that, right? Like if we have a study on tendinopathy in the knee, right? Maybe we can apply that to tendinopathy in the shoulder for example without having a definitive study. Right. Who else? Anyone else want to ..

Dave Tilley: I kind of want to hear what Mike says. Sorry go ahead. But he’s like brand new out of school. So I feel like he’s…

Lenny Macrina: There’s so many variables to try to consider.

Mike Reinold: A few years.

Lenny Macrina: and there’s so many. When you do it, you sit, sit down and try to do a research study. Right? Let’s just go basic. So Mike and I have done a bunch of research on, especially baseball, but various topics and when you’re trying to cope with inclusion criteria and exclusion criteria and all the variables that could be affecting the independent and dependent variables, nearly impossible to control for everything.

Mike Reinold: Yeah.

Lenny Macrina: So if you’re trying to conduct basic research and try and extrapolate that to people who have emotions and stresses and everything else, we throw everything out the window, you just, you got to, you got to be able to interpret it and then you throw it at the wall and see what sticks, with your patient population. And if it works, great. I think it just comes down to movement and education and being good to people. I think that usually is going to hit 99% of,

Mike Reinold: there it is.

Lenny Macrina: Get them moving, get them moving.

Lenny Macrina: Being good to people. Get them moving comfortably and then, and then educating on why we think that that helped and how they have hope.

Dave Tilley: Mike graduated last week so.

Mike Reinold: Mike’s been a therapist for several years now, but Mike any thoughts and now that Dave’s thrown into the fire.

Dave Tilley: It’d be interested,

Mike Scaduto: No, I mean if I’m, if I’m considering a new intervention and I don’t have the years of clinical experience, I only have like a week or two to go back on. So I guess I look at it, like, is there a major safety concern? So something like is there going to be like an ethical issue if I use this on my patient, if not, I’ll go to the best available evidence. Just kind of look at what evidence is there, how we can utilize it and if there is limited evidence then you have to go based on the experience that you have, or you have to consult with somebody and ask their opinion on it, who has more clinical experience.

Mike Scaduto: So for blood flow restriction for example, which is relatively new and a couple of years old in the literature and yes we’ve been using clinically, we’ve been using it for a little while and that kind of like asked you guys like what what your opinion on it is like what some of the signs you kind of take a step back. So I think it doesn’t have to necessarily be one study that says ‘this is the best intervention for X’ and you can use a couple of different resources to kind of like form your opinion on it and then you can try it and form your own experience with that modality if it’s modality and you can see if it works for your population.

Mike Reinold: I think that’s great.

Mike Reinold: I think it’s a great approach, too, because I don’t know how else you do it. I mean there’s, there’s so much gray out there. So I go, I always call it like the light system. I call it like a red light system, right? But essentially like if there’s a, if there is a trial that shows that you what you want to do is ineffective and it shows ineffective, not lack of conclusion but ineffective, then you shouldn’t do it. There’s a trial that shows that it is effective, then you should do it, but 85% using Dave’s number something. It’s all going to be in the middle and you’re going to have to like play with that a little bit. But one thing I want to caution everybody, maybe we’ll end the episode on this. One thing I want to caution you on is that a lack of a conclusion does not show in effectiveness and I think that’s one of the things that we’re struggling with right now, especially on social media because I’m not kidding.

Mike Reinold: We’re seeing things like systematic reviews that show that like manual therapy doesn’t work for shoulder pain, but what does that mean? Right? How do you define manual therapy? Who did the manual therapy? What type of manual therapy, were they all the same experienced person? Was this like this? You combine all these studies on manual therapy, but how do you define that and then how do you define shoulder pain, and then what was the diagnosis? The right patient population? I just wrote an article, I think it was the impingement article, but I did a system that showed a systematic review. I think that the patient population range from 25 to 68 that’s absurd. That’s absurd. So of course the conclusion is is going to be, it’s inconclusive that they couldn’t find anything. It’s so diluted of a study, that you’re not going to find any.

Mike Reinold: So a lack of a conclusion. Right. So inclusiveness does not mean it’s ineffective.

Mike Reinold: And I think that is where the majority of young clinicians are struggling the most right now is that they’re getting confused by a systematic review or a meta analysis or whatever that may show that there was a lack of findings and then they’re saying then it must not be effective. That’s not what that study says. It either didn’t have the right power, it didn’t have enough control or it’s too diverse of a patient population for the subjects in that study. Right? I mean, but I mean like you guys agree, right?

Dan Pope: Yeah, it makes sense.

Mike Reinold: I mean, so we’re seeing that quite a bit and then people are saying, well manual therapy doesn’t work for shoulder pain and whoa, there’s like lots of complications in that. So I’m not saying you know, pro manual therapy or anything. I’m just saying that studies like that are not helpful and a lot of people are taking that to the wrong endpoint. If that makes sense. So keep that in mind and I think that’s what you do. You do your best. Mike I think laid it out really well. Everybody has some good stuff. Dan, you want to add to that?

Dan Pope: One thing I will say, and I know we don’t want to drone on for too long, but I think when people are so evidence-based, they stop critically thinking. And the problem is that we got to use our brains to figure out why this person got hurt. And you can also use your brain to figure out how to get better based on the principles you know, as a therapist, and when you’re always looking at literature and you’re not doing anything that’s not evidence based, I think we lack the ability to use our brains to that point. We’re not actually utilizing all of our critical reasoning skills to get that person better. When you know, evidence helps with that process, it shouldn’t hinder you.

Mike Reinold: Yeah. Evidence has to drive us, but you also can’t be paralyzed by a lack of evidence. I think that’s like the biggest take home. So, awesome. So great episode. Another good question. I think a lot of people have that question. And I think that’s a pretty common thing. So good one. We really appreciate it, David, right David? We appreciate that one. If you have a question like that, you can head to mikereinold.com click on the podcast link and fill out the form to ask us more questions and we will try to answer it on a future episode.

Is the Sleeper Stretch a Thing of the Past?

On this episode of the #AskMikeReinold show we talk about using the sleeper stretch to restore internal rotation range of motion in the shoulder. There are probably more “cons” than “pros” with this stretch, but more importantly, probably better techniques we can do anyway. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 184: Is the Sleeper Stretch a Thing of the Past?

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Mike Reinold: On this episode of the ask Mike Reinold Show, we talk about the sleeper stretch and if it’s a thing of the past or something that we still use here at Champion. Do we have a question from the audience today?

Student: We do. Brady from Iowa: Is the sleeper stretch a thing of the past? If so, what other options are there to address gird in overhead athletes?

Mike Reinold: So I’m going to throw it on the students here because I think I get why people are saying this, right? People still recommend the sleeper stretch. And you’re probably getting a script from a drug doctor that says do the sleeper stretch, right.

Lenny Macrina: I got one yesterday. But I don’t want to date the podcast, but if we could somehow pan the camera, which we’re not to the whiteboard. I put this on my Instagram and Twitter recently because I literally got a script from a doctor that said gird poster capsule, tight, sleeper stretch were the three things in a 13 year old softball player.

Mike Reinold: I’m going to send a script to a doctor with a patient that says do a meniscectomy. Just send it to the doctor when we send him in there.

Lenny Macrina: So we still get these in our area.

Mike Reinold: Did you guys learn sleeper stretch in school and did they say it was like a thing like you should use it?

Lenny Macrina: Do they teach it in school though? Is it a part of the curriculum or this is a social media thing?

Dave Tilley: I was never taught it.

Student: I wasn’t told it.

Student: We went over it one day in school as an option to increase IR but not really a specific application for [crosstalk 00:03:59].

Lenny Macrina: It could be that they’re just presenting all of the options. Right.

Mike Reinold: And don’t forget in the early two thousands there were some articles about how this was the greatest thing in the world.

Lenny Macrina: Sliced bread.

Mike Reinold: Right. So if you were to Google this and you were actually to like go on Pub Med or something, you would actually find articles that say it’s pretty good.

Lenny Macrina: Yeah.

Mike Reinold: But Brady, in all honestly you got dig in and read some of these articles that have on the website because we tackled some of the negatives as a sleeper stretch. So sleeper stretch is fine I guess. It’s torquing your arm into internal rotation but it really just assumes that your approach to restoring the range of motion is just to torque where there’s a lot of other options we could potentially do before we just started torquing it. And there’s a lot of negatives to the sleeper stretch to like the position of it. You could argue it’s an impingement based position. You could argue that the arthrokinematics of the joint are kind of awkward and it’s really sore. But I think the kicker that I always kind of tell everybody with this is, and this is kind of to answer your question, is the sleeper stretch bad or whatever he said is when you’re doing a stretch and you feel this sharp pain on the front of your shoulder and people are like, ah, yeah, that’s it.

Mike Reinold: That’s the feeling I want. I always tell him that that’s the equivalent of you flipping on your stomach and me stretching your knee and instead of feeling a nice stretch in the quad, you’re feeling a sharp pain on your tibial tuberosity. And you’re like, yeah, that’s it. Keep pushing. And that’s what we want. We would never do that with the knee. Right. And that’s kind of the same thing with the shoulder. So to answer your question about baseball and stuff, if you immediately just assume you do sleeperr stretch with somebody that has tight internal rotation, then you’re missing the boat potentially on this complete population of people on whether or not they even have a loss of internal rotation or if gird is normal. So based on that, let me open it up to you guys. Is there a population that you think sleeper stretch may be still applicable? Like rotator cuff repair or osteoarthritic or a adhesive capsulitis like a frozen shoulder or what do you guys think? Does anybody still do this?

Mike Scaduto: It definitely wouldn’t be where I would start at. I don’t think I’ve ever given a patient a sleeper stretch. I mean with like a rotator cuff repair, it doesn’t seem like a great position that you want to do.

Mike Reinold: Probably opposite.

Mike Scaduto: Definitely start with a way more gentle approach in terms of less aggressive stretching. Probably start with soft tissue, passive range of motion [crosstalk 00:06:13]. And if you’re getting some capsular tightness maybe do some low, low long- duration, but maybe not in that provocative of position, like the sleeper stretch. So probably not.

Mike Reinold: It seems like we’re jumping right to a really aggressive thing by going sleeper.

Dan Pope: I guess one thing I learned from you guys over the course of time, thank you very much and one thing that Lenny mentions a lot is that the posterior capsule is not necessarily a super robust structure.

Dan Pope: It’s not something that’s probably going to be limiting range of motion of time. So if you assess the capsule and maybe it is really stiff, maybe do you need to address it? The other part is that what is limited in turn rotation if that’s actually occurring, right. So we can work on some of that musculature and maybe do a cross body stretch or something that’s not going to irritate the joint further. We’re probably going to be more effective because the reason why I’ve in turn rotation of limitations, maybe not that capsule and even if it is capsule, probably not the intervention that you want choose first. Right.

Mike Reinold: Right.

Lenny Macrina: Let’s think about, we’ve talked about the capsule in the past and previous episodes and how we think we can potentially try to stretch it out is a prolonged stretch with a light load, right? So low, low long-duration. Are we going to have somebody lie on their side for 15 minutes and do a sleeper stretch and try to get posterior capsule stretching and just the concept just doesn’t make sense.

Lenny Macrina: And like he said, this is a very small population that may get a millimeter or two thickening of the posterior capsule that’s already the thinnest portion of the capsule anyway. If you look in the anterior and inferior portions of the glenohumeral capsule. So I think we’re missing the boat and we put a paper out in 2008 but if we’re talking baseball players that showed immediate changes in internal rotation, you lose internal rotation from throwing. There’s no way the capsule is becoming tight right after throwing, right? If we think it’s muscular tendonous and that’s probably where we should be targeting our efforts is in the muscle and the tendon, not the capsule. So I think we just, we completely missed the boat. We’ve gotten on this sleeper stretch thing and I’m guilty. I helped coauthor paper with Kevin Wilt and trying to come up with a modified sleeper stretch, put him in an open pack position [inaudible 00:08:05] roll him away so you’re not really lying on the shoulder joint.

Lenny Macrina: And I just think I’ve gotten away from it 100%. I know I hate to use this term but I never give it to anybody anymore. It’s not the most effective way in my opinion. I think this stretch, horizontally deduction has been shown to give similar results if not better results with people that have tightness in the back of their shoulder. Posterior shoulder tightness not posterior capsular tightness. We keep calling it the capsule and we’re giving it the wrong name I think from the get go.

Mike Reinold: So even if you have a limitation in IR, then the next question always comes down to what about a home exercise program? Because you can’t do manual therapy, can’t do soft tissue, that stuff.

Mike Reinold: And I think what Lenny’s getting to is just cross body kind of horizontally deduction is probably even better for that. So even the people that say, well but is sleeper stretch a good home exercise program? And I still think no. So we never ever use sleeper stretch here and I’ve never used sleeper stretch almost my entire career. I think the first time I did it a few times it’s like this is all wrong. I just had this, none of this makes sense, right? So I never really did it. I do not have problems with maintaining internal rotation in my people, especially baseball players. So is it a thing of the past? I think so. I think it really is. We don’t use it. And I would say we get a lot of people that come here that maybe were getting therapy elsewhere and one of the first things we do is we tell them to stop doing that.

Mike Reinold: And that was one of the thing that helps get them better, I think in my mind is they keep aggravating it by doing it more and more. So like I said, Brady, I apologize from the beginning again sort of. But head to my website. There’s a ton that you can read about that on the sleeper stretch. And I think you kind of digging a little bit on and make that decision yourself if it’s even the best thing to do. Even if it’s an option, is there a better option? Right. Does that make sense? So good question. Appreciate it. Head to mikereinold.com, click on that podcast link to ask us more questions just like that, but try to read my website first to answer the question yourself before. Anyway, sorry Brady, and then we’ll be sure to answer them. See you on the next episode.

The Best Ways for a Physical Therapist to Start Learning About Weight Training

On this episode of the #AskMikeReinold show, we talk about ways physical therapists can learn more about weight training, and use that knowledge to start working with high-level fitness athletes. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 183: The Best Ways for a Physical Therapist to Start Learning About Weight Training

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Show Notes


Transcript

Mike Reinold: On this episode of the Ask Mike Reinold Show, we talk about how physical therapists can learn more about weightlifting, Olympic lifts, power lifting, etc. So that way, you can help your patients with that sort of stuff.

Mike Reinold: All right. Who’s got this question?

Ryan: I got it. Aaron in Tacoma. “Are there any weightlifting certifications or courses that you recommend for physical therapists? We received a tiny amount of instruction in PT school on things like barbell squats, dead lifts, bench press, etc. And I feel that this would be very useful when working with athletes. Thanks for any info.”

Mike Reinold: Aaron. I think it’s actually pretty cool that he had some exposure, probably more than most people are. And I think that’s pretty good. So I think that’s a great concept, right? And I would say one of the more popular questions we get on this podcast and continuously get, and we don’t answer anymore, is should a PT get a CSCS? And we can potentially talk about that too when we get into this.

Mike Reinold: But I like the concept. You want to learn more about the lifts and stuff like that. Let’s start by answering his question directly. Is there a certification? So CSCS, anything else like that? An official USA weight lifting type thing. What do you guys recommend? I don’t know. Has anyone gone through any of them? Dan, have you gone through any of them specifically?

Dan Pope: I haven’t done USA weightlifting.

Mike Reinold: Because some of our coaches have, and so we all share the knowledge in there. But is there any certification or even a con-ed program you’d recommend?

Dan Pope: We do. Well, I’m biased. I’ve been preparing my entire life for this question.

Dave Tilley: Yeah, what if I wanted my my fitness very pain-free?

Dan Pope: Yeah. Yeah. I mean this is one of the reasons why I went to PT school in the first place is because I loved weight lifting. I loved weight training and I just felt like there wasn’t a lot of good information out there on how to help people have pain that want to get back to these lifts. So I went to school and then tried to figure all this stuff out myself. First and foremost, Dave and I just, we both worked for a company called Power Monkey Fitness and they had these seminars throughout the course of the world. They have a camp twice a year in Tennessee and their goal is how to teach these movements appropriately.

Mike Reinold: Great.

Dan Pope: It’s not just you want the glyphs, although it’s very much they want the glyphs, but it’s also all the basic gymnastics movements, running, rowing, everything that you see from a fitness perspective that people are doing in the gym.

Mike Reinold: What about power lifts?

Dan Pope: They don’t go over specifically power lifts for power lifting, although they go over the squat in depth.

Mike Reinold: Squat, but not deadlift bench?

Dan Pope: It’s just not designed for how to deadlift for deadlifting.

Mike Reinold: Got it. Okay. So Power Monkey, great resource for some of the only lifts in gymnastics, which is, huge nowadays, to do that. So building off that, and I know you’ve got more in your head, but building off that, like what about CrossFit? Like going through a CrossFit level one cert?

Dan Pope: They do. They go over all those movements. I’m CrossFit level one. Are you, Dave, anyone else Crossfit level one?

Mike Reinold: Nice.

Dan Pope: Yep, big time. The certification does prepare you on how to teach these lifts pretty well. That’s a big thing. So you’re going to be in front of a class, how do you teach these progressions well? How do you have simple progressions and help a novice get to a proficient level with the lifts? So it’s pretty good from a baseline perspective, you’re not going to go super in depth from nitty gritty perspective in terms of programming, how to perform lifts for legal athletes, small tweaks to change for those high level people. They’re definitely going to give you a really good baseline for the Olympic lifts and then some of the basic gymnastics.

Mike Reinold: It could be a good baseline for a new grad type thing. Good, those are only lift baseline, anything else?

Dan Pope: Certification wise, there’s a few right now. So John Rusin has a course out right now. Ice is also Zack Long barbell physios course, and then also Quinn Henoch has a few courses right now for Olympic weight lifting as well as powerlifting. So if you’re looking for certification right now, those are some good guys that I trust. I haven’t been to the courses myself, but they’re catered more towards physical therapists.

Mike Reinold: What about the USA weight lifting certification?

Dan Pope: That’s another good one, I haven’t been through it. I have a lot of friends that have done it and a couple of our, I guess coaches here have done as well and they have good things to say. I think that’s going to be a little bit more comprehensive in terms of specifically olympic weightlifting, but you’re not going to find the power lifts, you’re not going to be talking about the bench press. It’s not going to be relevant from that perspective.

Mike Reinold: So from the power lifts, I’ll jump in with a couple that I always recommend. So one is our friends in Massachusetts here, but Greg Robbins, Tony Delvecchio, they’re the strength house but they do live seminars around and they have a great website, but they teach the big three all the time. So I don’t know, there’s probably… Think about if you have any other recommendations for the big three-

Dan Pope: Greg Nuckols is a real big guy.

Mike Reinold: Yeah, Greg Nuckols, they have good programs to teach. That’s the power lift. So you know, squat, deadlift, bench type thing.

Mike Reinold: The other one that I think is actually pretty good, it’s a little bit less like training for competition, but more training for the right technique and functional is Strong First. And I don’t know if anybody has gone through that, but Strong First certifications, they get a bunch of good stuff like kettlebell based stuff and they also have the good the main lifts and they include press and stuff like that. So I think Strong First, as a physical therapist, is maybe one of the first ones I would gravitate towards, and kind of go from there.

Dave Tilley: Dean Somerset in Antonio, have the complete hip and shoulder blueprint. I think they talk a lot about that stuff. It’s not all that, but there’s some of that stuff in it.

Mike Reinold: So tons of con ed, a few certs in there. Anybody else have any other suggestions or ideas? I mean, I don’t think the CSCS is going to teach you this, right?

Dan Pope: Yeah, I don’t think so. I think the big thing is that we want these certifications. We want to learn more about it. Probably one of the best things to do to learn these lifts is to go practice those lifts.

Mike Reinold: Bingo.

Dan Pope: I’m guessing you’re already doing it at this point, but find a gym that has a really good coach, right? Or a really good community or culture there that focuses on the lifts you want to improve and practice those lists on a very regular basis, and then potentially go out there and coach a little bit if you want to.

Mike Reinold: Right. I honestly, when I read this question, I thought that was going to be our answer. Right? And, and you want the cert, right? So you can study for this. Like you get your CSCS, you can study for this here, you’re still not going to be able to teach it really well. You’re still not going to able to do it. You need to do it. So you need to join a gym that embraces that culture and loves it, and you need to be part of that. If you can’t do it, how can you teach it? I always say that all the time. So join it. It doesn’t matter what it is near you, if it’s a Crossfit gym or if it’s just it’s own private facility. I don’t care what it is, but go there and learn and experience it and do it yourself. And I think you’ll have a much better understanding of how you can then apply that to your population as a physical therapist. Right? Make sense?

Mike Reinold: So, Dan, in all honesty though, we mentioned a bunch of great resources, you’re a great resource. So I’ve learned a lot about these things at fitnesspainfree.com. What do you have in the works for people that want to learn more about this stuff?

Dan Pope: Yeah. So obviously if you guys want some information right now, you can just go over to my website. I talk a ton about injury mechanisms for the lifts, how to get back to these movements after you get hurt, proper technique, all that stuff. I just finished up last night, although it won’t be out for a few, probably four to let’s say eight weeks, depending on when this is released.

Mike Reinold: Oh, wow. I thought you were going to say months. But I love that you said weeks. That’s awesome.

Dan Pope: No, I just finished up my full Fitness Pain Free Certification last night myself. Right? So look out for that. But basically, I feel very strongly that physical therapists don’t have a great resource for how to apply these movements properly from an injury perspective. So I’m talking about how people get hurt in the gym, right? And how to progress back out of pain and get back into movements they love and how to stay injury free for the longterm. So look out for that in the next, let’s say four to eight weeks.

Mike Reinold: And that was a great blurb. But I’ve been watching Dan build this for a long time. I know this is going to be awesome. It’s like the summation of his career and everything. But essentially he’s going to teach you how to do the lifts, how to coach the lifts, how to tweak the lifts, how to get people back to the lifts. And it’s going to be pretty dang good. So keep an eye out for that.

Mike Reinold: But I think, summary, putting it all together, I think what we need to do is we got to consider that it’s not just getting a certification, so going to USA weight lifting or something like that and getting a certification. But it’s also learning the basics behind it, right? Doing it yourself so that way you’re in a gym and a part of a community that’s doing it and practicing it on yourself and then helping others and then going through a program like Dan’s that’s going to kind of tell you how to tweak it and how to put it together for the person in front of you that may be your patient. So you’ve got to understand how to do it, learn the basics. You’ve got to do it yourself. And then figure out how to tweak it for the person that wants to do it better or get back to it. Right?

Dan Pope: You got it.

Mike Reinold: Make sense? Awesome. So another great question. We appreciate it. If you have any more questions like that, please head to mikereinold.com. You can click on that podcast link and fill out the form to ask us more great questions like this, and we will see you on the next episode.

Tips for Regaining Full Knee Extension After Surgery

On this episode of the #AskMikeReinold show we talk about some of the strategies and techniques we use to restore knee extension after surgery. To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.

#AskMikeReinold Episode 182: Tips for Regaining Full Knee Extension After Surgery

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Transcription

Mike Reinold: On this episode of The Ask Mike Reinold Show, we talk about some of the strategies we use to restore passive knee extension range of motion after a surgery.

Trey: Ellie from Florida asked, what are some methods you find most effective for gaining full knee extension in a post-surgical patient, with increased tone in the hamstrings?

Dave Tilley: I’ll answer this question. Jump on it.

Mike Reinold: Yes. All right. I like this, it’s a good question. What are some of the methods that we use to regain full knee extension after surgery? Now they, Ellie, specifically mentioned, with tone in the hamstring, which definitely is a thing and is definitely something that happens post-op, but not the only reason why you would have loss of motion. There’s a million ways to do this. What do you guys think? Who wants to start? I mean, somebody can ramble on a million things, but what do you think is the most important thing to do? A post-op patient comes in to you with limited knee extension. Lenny, why don’t you start with this? What do you look at to determine why, maybe, they have this loss of motion?

Lenny Macrina: Yeah. I mean, usually it’s because they weren’t educated at the beginning on how to keep the range of motion. So, a big portion of my education when I first get somebody in, especially after an ACL, where there’s a lot of pain or a knee replacement, is prop the heel up, allowing that knee to get into extension. The position of comfort is going to be slight flexion. Open-packed position of the knee is about 20 degrees. So you’re going to want to put a pillow under their knee. So education by all means, first, is to get them to understand that getting extension is the most important thing after surgery. You mentioned tone in the hamstrings. Yeah, probably, maybe. Because, they are going to get shortened over time. But, there was a study that came out last year, I think it was Med Science Sports and Exercise, that showed that it was the capsule that gets tight and not necessarily the hamstring. For me, I want to do things that are going to address both hamstring and capsules. So, I’m going to look at how you stretch out capsule or collagen tissue? You need prolonged stretch on the knees. You need prolonged, low-load long duration stretch. So, you need the person to prop the leg up and give a good 15 minutes at a time. We recommend usually 60 minutes total in a day, to get the knee to into full extension, whether it’s beyond 0 or not, and symmetrical to the other side. So, getting the collagen to stretch out, I think, is the key and hamstring stretching, maybe some foam rolling, maybe some soft tissue work.

Mike Reinold: Let me jump in and ask you a question here. A couple things… One, I liked your approach at first. If somebody comes in tight, the first thing you do is blame them. Love it.

Lenny Macrina: Yes.

Mike Reinold: It’s awesome.

Lenny Macrina: It’s not my fault.

Mike Reinold: It’s their fault.

Lenny Macrina: Blame it on them.

Mike Reinold: Make it very aggressive, too. I like that. No. But, I think that was actually an excellent point you made, because everyone’s always looking for the reason. Is this tight? Did that happen? Did this happen? When realistically, sometimes they weren’t educated enough. Maybe they spent a week home after surgery and nobody told them to go straight. So I’m jesting, obviously. But, I think that was actually a really good point, that I like. Tell me about that study though, because remember, in my mind, the hamstrings attach and blend into the capsule, to an extent.

Lenny Macrina: Correct.

Mike Reinold: So, how do they differentiate between the hamstrings and the capsule?

Lenny Macrina: Unfortunately, they use wraps or something on mice. I think it was mice. Because of their biology, it’s very similar to humans. They basically, should put the mice in a cast, their little legs-

Mike Reinold: Dork.

Lenny Macrina: … for a period of time. I know. We appreciate their contributions to research. Then they looked at the collagen under a microscope to see the changes in the elongation of it, versus hamstring. I use it in my courses, as well as our online e-seminar course and anytime I speak. It’s the capsule that we primarily have to address. And how do you stretch out collagen is, you’ve got to get a prolonged stretch in the knee. If we can even get a substantial change, because it is collagen. But, you have a window. A window of opportunity. It’s not like the IT band. It’s this thick, fibrous structure that you need thousands of pounds of force. We can get it back. I think it’s more so, the tight collagen and the tight capsule that the study showed.

Mike Reinold: And let’s assume for the rest of this conversation, we’re talking about a postoperative knee that is not super chronic. Because man, that’s a whole ‘nother conversation.

Mike Reinold: You’re talking about somebody six months out of an ACL, that’s a completely different conversation, in my mind. So, I like that. We’re in the first acute, maybe even subacute, phase, like that. Collagen tissue, shorter intensity or less intensity, longer duration type stretching. I like that. I wanted to ask one question, then you jump in. Lenny brought up, it’s collagen and it’s the capsule. So, talk about prolonged stretching. Does anybody do joint mobs? What do we want to talk about with joint mobs for the knee?

Dave Tilley: Yeah. I mean, joint mobs are probably not going to be changing the capsule tissue or we’re not probably moving the caps around, but it’s going to blend to my point. People hurt, man. If they’re super cranky, the joint is real angry and they’ve been, probably, walking on it for a little bit and starting to get sore and they’re just in a lot of pain. Anything you can do, a little bit, to maybe make them feel comfortable or calm down a little bit. Sometimes the joint mobs makes them relax. They’re just completely chilling out. I think this is, again, the swing of social media is, everyone’s no modalities ever, no passive stuff at all, but five minutes of heat and a little bit joint mob would make someone’s knee range much, much easier. Maybe they’re just sitting down for 10 minutes. Honestly, maybe that’s it. But, that can go a huge way to help your manual therapy.

Lenny Macrina: I can’t tell you how many times I have people like, “Oh, I can heat it. I can ice it,” and they don’t know. And then you maybe heat them, because you want just promote healing and relaxation and maybe a little blood into the area and like, “Wow, that felt amazing.” So whether or not social media says it was bad, if that person says, “I like that,” you’ve got to go with it.

Dave Tilley: Even if you measure five degrees more range of motion by another session, who cares.

Lenny Macrina: They buy in. You saw the objective change. They feel so much better about their knee, they feel better about their situation. It’s a no brainer, despite the social media world saying, “There’s no evidence. All the evidence is negative.”

Mike Reinold: So the funny part is, we call that positional release, because we have to make a fancy phrase for everything. They’re just sitting there and we’ll call it positional relaxation. I mean, there’s a little bit that we can add a little science to it. All right. So I think we’d all agree, with joint mobs, maybe we tell them we’re trying to get them to relax a little bit. But let’s say it’s two weeks out, they’re lacking full knee extension and it’s an ACL. Would you do a joint mob?

Dave Tilley: Yeah.

Dan Pope: I still would.

Mike Reinold: You’d do a joint mob on the knee two weeks out of an ACL reconstruction?

Dan Pope: Well not necessary an ACL, but I’m thinking a post-surgical knee. I would still attempt it. I think there’s still a period of time where you can have effect. But, if I’m trying to not stress the ACL, obviously, I wouldn’t do that. But-

Mike Reinold: Well definitely patella mobs. I meant more tibial femoral. So, if it’s not ligamentous we maybe would. This is good to talk about because you guys get to hear the discussion here. So maybe you’re right. Patella mobs, obviously. Patella’s an actually big one, too.

Dave Tilley: Especially superior, to try to get that last little bit if it’s extension.

Mike Reinold: Especially if you have a patellar tendon graft or maybe even a quad tendon graph, to an extent. Patellar mobility is going to play into this. We’ve got a whole ‘nother realm right there. So, I don’t Know. As a group though, ligamentous injury, we’re not joint mobing, right?

Dave Tilley: Yeah.

Dan Pope: Probably not.

Mike Reinold: All right. Thankfully. That’s good. Otherwise, we’re going to pause this and have a Champion staff meeting. I don’t know. I probably wouldn’t do it with a meniscus either, to be honest with you.

Dan Pope: Be careful with distraction, that’s a thing. There’s some things you probably still can get away with, but obviously, you’re not going to translate and try to tear that ACL.

Dave Tilley: Test the graph.

Mike Reinold: Yeah. Again, probably fine. But again, I think the reason why I brought up joint mobs is, Lenny talked about the collagen tissue and the capsule and stuff like that. I think theoretically, that sustained position, that positional release, that low-load long duration type stretch, is probably better than a joint mob on that. I know there’s a lot of manual therapists out there that would go right to join mobs. I think that’s showing us…. We may use some joint mobs on the right person, at the right time, if it’s to neuromodulate, try to get them to relax and move a little bit better. But, I think there’s other things to do.

Dave Tilley: I think we’ve said on a podcast before, but you have to have a consistency over intensity mindset. Like Lenny said, four sessions of 10 to 15 minutes a day, is better than one day where you’re trying to jam your knee. I mean, I made some mistake as a therapist. They come in, it’s not straight and you’re panicking, like, Oh God, we got to get the straight and you’re really cranking on someone’s knee in one session. It’s probably not the best thing to do, intensity wise, because that person’s going to leave really sore and they’re not going to want to do their exercises later.

Mike Reinold: Right. I like it. Good.

Mike Scaduto: And they further promote tone. They may get some guarding, especially if we’re putting them in a more painful position, trying to gain range of motion. I know Lenny talks about it all the time. A prone hang sometimes will promote more tone in the hamstring, because they feel vulnerable there and they want a guard. So, they’re going to get into more of a flexion contracture. It makes it tougher for them to relax the hamstrings.

Lenny Macrina: I think that’s a good point to know. The question was, what we do. I think that’s good Dr. Scaduto, (@ mikescaduto.com). Is prone hang sup high-low long duration and other things like retro walking on the treadmill or retro cone walking or something like that. I’m a supine. I want them supine. I want them lying down. I want their ankle propped up and I want a light weight, 5-10 pounds, to be pulling their knee into extension and beyond.

Dave Tilley: Above the knee, right?

Lenny Macrina: Above the patella. Yeah. So not squishing the patella versus the prone hang, because of the hamstring getting tight and people just freaking out that their leg is hanging off the table and their pelvis stops twisting out of control. Now, the whole thing just becomes chaotic, I feel like, in people that I’ve tried prone hangs on. The doctors recommend it, so you have to do it and then it’s just… All right, let’s just go back to what I know and trust. And that’s just lying down and working on supine.

Mike Reinold: So we talked about pain, we talked about guarding, we talked about some tone from the surgery and stuff like that. All great. What about swelling?

Dan Pope: Swelling is a point.

Lenny Macrina: Yeah.

Mike Reinold: Right?

Lenny Macrina: So basic.

Mike Reinold: Acute wise, sometimes it’s just swelling.

Lenny Macrina: Takes up volume in the knee. Causes pain. You want to protect the pain. So you-

Mike Reinold: Yeah. And that’s not even an effusions effect on pain. You’re absolutely right. But I mean, we tell everybody there’s not a lot of room in the knee for it to go, for it to pooch out. And what tends to happen is, it tends to pooch out in the back. If you get a big fused knee, obviously it kind of comes all the way around. But in the back, there tends to be a large pooch in that effusion right there and that’s definitely going to be impactful for both flexion and extension in the knee. You see that in both ways.

Mike Reinold: So sometimes, it’s just getting rid of their pain, getting rid of their swelling, getting them more comfortable, so that way they decrease their guarding and then getting them into these positional releases, like this low-load long durations stretching, frequently over time. So if you notice here, we’re doing nothing aggressive, we’re not doing any manipulations. We’d even talked about really not doing that much for joint mobilizations. It’s more about getting rid of the pain and getting rid of the effusion, getting rid of the guarding and getting them into these nice sustained positions, frequently, throughout the day. That’s our first attack.

Mike Reinold: If you’re talking about a chronic person, a whole ‘nother conversation that we won’t get into in this podcast. I’m sure we’ve talked about it. I don’t even know, we’re at like 200 episodes now. I forget what we’ve talked about, but that’s a whole ‘nother conversation. One other question, what about about soft tissue? Nobody said anything about soft tissue. Thoughts?

Dave Tilley: Gastroc maybe. Head to the gastroc or blending in behind the news, as well.

Mike Reinold: I mean, gastroc can be both across the knee. So theoretically, if you’re in a shortened position, those guys get toned up.

Dave Tilley: Not walking.

Mike Reinold: Yeah. I mean, is that a part of it, too? So we would all do that. All right. So let’s summarize. Let’s say you come in, you’re three weeks out of ACL reconstruction and you’re lacking a little bit of knee extension. What are we going to do?

Mike Reinold: First thing we can probably do is hop him up on the table supine. We’re going to probably put a hot pack on their knee and put their heel propped up and let it just slowly sit there 5-10 minutes. See what we get for range of motion. From there, I think we’re all going to probably go soft tissue. We’re probably going to go hamstring, gastroc, but then also effusion based off tissue, if there’s anything going on with the knee. From there, we’re probably going to go patellar mobilizations. Going to do some patellar mobs and then from there, we’re probably going to then try to actively get them engage their knee so that way it goes straight. So, knee extensions, retro cone walking-

Dave Tilley: Quad set.

Mike Reinold: Like Lenny said, even just walking… Or just a quad set. That’s a great point, just a quad set. We’re going to actively get them in that position and then we’re probably going to ice and then we’re probably going to compress it with a wrap or a sleeve, afterwards. Pretty comprehensive. There you go. So, summary in the last minute. But, I like how we brought that all together. Does that make sense? I think everybody wants to jump right into, Oh, this is a problem. I got to be aggressive and do something, where it’s actually pretty simple-

Dave Tilley: Fix it in 10 minutes.

Mike Reinold: … and you take a step back. Awesome. So good. I like it when we can answer a question like that. And we can almost have a little case at the end. So hopefully, maybe you can watch that again. Watch that last minute or two, again. Maybe put it down to 0.75 time speed on the audio there. I talked like Dave on that one. I apologize. But, good question. Hopefully that was a good understanding of our treatment approach, of what we would do with that person.

Mike Reinold: So if you have a question like that, head to mikereinold.com, click on that podcast link, and be sure to fill out the form to ask us anything. Really, we had so many diverse questions. We love hearing them, so keep sending them. We’ll keep answering them and we’ll see you on the next episode.



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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!