Worsening Trends in the Management and Treatment of Back Pain: SPARK National Radio Media Tour

In an article published in JAMA (Journal of the American Medical Association) Internal Medicine,

Mafi JN, McCarthy EP, Davis RB, Landon BE. Worsening Trends in the Management and Treatment of Back Pain. JAMA Intern Med. 2013;():-. doi:10.1001/jamainternmed.2013.8992.

we get some clarity on how physicians have been attempting to diagnose and treat back pain since 1999.

Findings show that prescription of opiate pain reducing drugs has increased by almost 10% while lower risk over the counter medications and proven effective conservative physical treatment has plateaued or decreased; this in spite of consistently produced evidence that this is a more effective first line for the acute and chronic back pain patient.

Along with over prescribed dangerous and habit forming medications, the use and overuse of CT scans and MRI adds to health care costs with little in the way of improving outcomes.

We were approached by Fox News Radio to do a media tour to shed some light on this subject and the overall topic of how to be your best advocate for all-the-way-well care.

I had a great time sharing our experience and discussing the most current evidence for self and professional treatment. If you missed the radio spots on August 2nd, check the links below to see how it went down:

http://www.600kcol.com/pages/600kcolmornings.html

http://www.1140wrva.com/pages/jimmysnewpage.html

http://www.wilm.com/pages/elliott.html

http://www.whas.com/pages/tonycruise.html

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is.

Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races. He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com

Improved Performance: It's Not Just for Athletes

As specialized performance physical therapists we deal with a wide range of patients, from athletes on the field to athletes in the game of life. If you're a collegiate or professional athlete you already understand the importance of having the right team in your corner to keep you moving in top form. However, most of us are not professionals in sport or movement. We enjoy it for the sake of the activities we perform. Each of us can strive to be the best golfer we can be, the fastest marathon runner or best player on your co-ed flag football team. No matter the sport, if you enjoy doing it, you should highly consider seeing a Physical Therapist to help improve your performance.

So you play a sport or prefer a certain activity but you have pain?

Very often, pain with movement is related to acute injury or repetitive trauma in a movement picture that isn't operating with the best mechanics or structural balance. ‘Movement patterns’ is a phrase that is flying out of the mouths of movement pros everywhere. You will hear strength coaches, personal trainers, athletic trainers and physical therapists use it. What you have to understand is that a physical therapist is the only pro who can watch someone move, understand the pattern and address the deficient pieces.

These patterns are based in neuroscience, primitive reflexes, and some very specific anatomy that no other pro is trained in to this combined detail. A strength and conditioning pro talking about these pieces of the movement puzzle is like a busboy trying to bake the perfect souffle; it might work out in the end but not after a LOT of trial and error. It's best left to the right professional.

Who's in your pit crew?
While the majority of us may not be competing at the highest levels, lots of smart folks are becoming aware that you don't have to be paid to play in order for you to have the team of pros that will keep you moving well and having fun.

In the past, these people might seek the help of their local PT Mill physical therapist. This is a good start. That physical therapist is going to be able to diagnose the cause of pain with great accuracy and then develop a plan to decrease it both acutely (right now) and for good. Problem is that the 'Mill' physical therapist isn't really equipped to take their clients much further than just "good enough". There are lots of reasons for this which we've chronicled in previous posts.
 

What if you want to get better than "good enough"?
Some people turn to their exercise pro. Strength coaches and personal trainers are great resources. Their skills in exercise technique, safety and effectiveness are excellent. Problem here is that they are not trained in any way to handle a client when pain creeps in. Some people think to themselves, “I’m not moving the way I want I move, I’ll just go see my personal trainer and I will become a better mover by becoming more fit.” We in physical therapy have a phrase for that – "adding fitness on top of dysfunction". It's a common problem and the one's who are the most blind to it are the trainers and coaches themselves! The best your strength coach can do is avoid the painful movement and design programming 'around the problem'.

Each of these strategies will help you deal with your pain but neither of them alone is the way to your highest movement efficiency and lowest pain possible. The power of a performance-minded, HYBRID physical therapist AND strength pro is unmatched in this niche of recreational and professional performance. The ability to directly address pain right when it's happening and then design and implement the plan that will knock it out for good is the most powerful skill set around. And now, you can have this high level treatment approach too! There are lots of HYBRID physical therapist/strength coaches out there. Problem is they are too quiet! That and they're too busy! These pros are highly trained, highly sought after and have the most profound impact on people's lives that most just let their work speak for them.
Your right hand man (or woman) should be a hybrid NEW BREED physical therapist. We will most efficiently pick out the areas of poor function, address them and then systematically reinsert them into the overall high level movement pattern they belong to. Even if you're not complaining of acute pain, we can help you work to keep it that way. With this approach, if something does occur, we can pinpoint why and what we should do to correct it immediately.

How are hybrid physical therapists/strength coaches changing the field of physical medicine?

In a perfect PT world, clients would have their hybrid physical therapist at top of mind for all movement related pain and to constantly be looking for ways to make them maximally efficient and powerful movers. Clients see us, similarly to how they see their dentist. You have your check-up set once every couple months. If everything checks out, we schedule another check-up 3-4 months out. But if the client is in pain or during a check-up we find a movement issue we address it with a few treatments and have that client back on their way. It all comes down to the way physical therapists assess MOVEMENT– even people without pain may have room for improvement. When we say, “all the way well”, we mean the solid foundation for an overall improved quality of life.

What’s the danger in throwing some endurance and strength at a faulty system? Further dysfunction. Simple example: If you had 50% strength in one hip, and do a normal back squat, you use one side more than the other and build strength in an asymmetrical manner. This widens the disparity between the sides and leads to greater compensatory movement and imbalance; the type which your trainer will never understand so don't bother trying to explain it to them. Now, if that trainer decided to go and become educated as a physical therapist, they would soon see the error in their approach. It's novice level physical medicine thinking. I'm not going to give my plumber a hard time for giving me incorrect info about an electrical problem I have, so it's not fair to blame a trainer for a physical medicine mistake as they've never been educated about it.

Are you a physical therapist who wants to boost their skills and truly be an asset for your patients, you know, like the actual reason you went to school for all of those years....?
Start sharing posts like this. Write your own. Connect with mentors and like minded physical therapy friends and have these conversations with your colleagues. If you're not incorporating some formal training of performance, physical strength, flexibility, or power movement, progression you aren’t what's best for your field or your clients.

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is.

Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races. He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com

SPARK Physio Radio Show: Invest. Improve. Ignite. The new-breed approach to save physical therapy.

In this episode of the SPARK Physio Radio Show Dr. Carlos Berio talks about the SPARK Physio mantra of: Invest. Improve. Ignite!

Listen to internet radio with SPARK Physiotherapy on BlogTalkRadio

SPARK Physio Radio: Athletes: Your Body IS the Game - Play It Well

In this episode of the SPARK Physio Radio Show Dr. Carlos Berio discusses the importance of Physical Therapy for performance improvement and injury prevention in athletes.

Listen to internet radio with SPARK Physiotherapy on BlogTalkRadio

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is.

Carlos remains active in several sports and is an avid agility training, power lifting and adventure race runner. He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.

SPARK Physio Radio Show: Improved Performance = Less Pain

In this epidosode of the SPARK Physio Radio Show Dr. Carlos Berio discusses why improved performance can be good for everyone and how you can improve your performance to get all the way well!

Listen to internet radio with SPARK Physiotherapy on BlogTalkRadio

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is.

Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races. He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.

A First Line Resource for Nutrition: Your Physical Therapist? Boost Healing AND Performance

Nutritionists and dietitians are highly trained members of the medical and lifestyle team who's skills in designing food plans aren't matched by anyone in medicine. That said, did you know that prior to seeking their Doctoral degrees, the vast majority of physical therapists earned Bachelor's level training in a health related field where they too have gained useful skills in nutrition. What many don't realize is that this is the same EXACT training that most nutritionists and dietitians have. Some practicing physical therapists actually have advanced training in nutrition. The biggest difference is that instead of seeking licensure in nutrition, we chose a physical medicine practice. So how does this info help you, the client??

Nutrition plays a large role in the way that people deal with pain and also the way they are going to heal. To be a truly complete NEW BREED PHYSICAL THERAPIST, you must address your clients' nutrition concerns and barriers to ensure that you are having an impact on all the dimensions of getting all-the-way-well.

As I practice physical therapy and strength and conditioning, clients often ask questions about how their nutrition could impact their outcomes. In most cases clients don't need to be specifically walked through a diet plan. It sure is helpful to have this kind of structure and when clients ask for it. When this happens we send them to some of the country's best nutrition pros. However, most people are making such HUGE mistakes with their personal nutrition that very basic biochemistry and physiology recommendations can be made that have a long and lasting effect.

There are a couple insights we offer to almost every client. These are the ways in which most people get their nutrition back on track for healing and performance:

Eat Frequently:

The importance of this cannot be overstated especially in people who are struggling with being overweight. The 'thermic effect' of food can account for up to 15% of your total caloric expense throughout the day.
Think of it like this:
Let's say you are eating 2000 calories per day. If you eat those calories over three meals, you may be losing out on this extra energy expended to "turn on" your digestive system. If you ate SIX smaller meals throughout the day you could effectively increase your overall caloric expenditure to 2300 calories per day (2000 + 15%). That's 300 calories you leave on the table, so to speak, if you eat the 'standard' breakfast, lunch and dinner.

Adequate lean protein:
This is an area that is ambiguous for many and can be frustrating. Protein is an essential building block for repairing tissues. Your body metabolizes proteins for many bodily functions and missing out on enough of it can seriously slow your overall recuperative ability. 
A rule of thumb for "How much protein should I eat?" is to take in 0.8 - 1.5grams of protein per kilogram of body weight. This is a BIG range but it makes sense.

IF you are exercising regularly and at a high intensity, you are going to rapidly break down your body requiring more of the building blocks to repair. This client should be on the higher end of this range.
IF you don't exercise very regularly, you still need protein but you will need less.

I know the metric system is lost on many, me included, so here is the conversion:

1 pound = 0.453592 kilograms

For example if you weigh 160lbs, you are 72.57kg 

High complex carbohydrates and fiber:
CARBOHYDRATES ARE ENERGY! They aren't fat. They don't make you fat. They are essential for fueling your body to produce the effort to do real work that makes people better... AT EVERYTHING! You've got complex carbohydrates and simple carbohydrates.

Complex  carbs = fiber, wheat, bran, oats; foods that are overall less easy to digest and therefore are broken down in such a way as to give you energy over a longer period of time.

Simple carbs are found in highly processed products, anything with added table sugar and in a lot of 'junk' foods. There are also natural foods high in sugars such as many kinds of berries. That said, there are times and situations when simple carbs are OK or advisable. At most other times, complex, high-fiber carbohydrate foods are the way to go.

When choosing the types of carbs to eat, the rule of thumb should be to ask yourself, "Am I going to use this energy NOW?" If the answer is no, you have absolutely NO reason to eat food or drink a drink that is loaded with sugar. This type of food is FUEL! Fuel up with the high octane stuff and watch your performance improve almost IMMEDIATELY!

Hydration:
Most of us don't drink enough water! It's among the most plentiful resources and by most accounts it's still almost free. Yet, we elect to drink so many kinds of fluids that contain sugar, carbonation, caffeine and overall nothing good for you. The gold standard for the amount we should be drinking varies depending upon who you ask or where you read but you'll never go wrong getting eight to ten 8oz glasses of water per day. If you are performing a good bit of high intensity exercise you should drink more. Not rocket science here. You are made up of mostly water. You should do your best to make sure that all of your tissues are properly hydrated to maximize your body's ability to heal and perform.

We don’t specifically offer nutritional guidance as a stand-alone item. That being said, we do include these basic nutritional insights to our clients as all-the-way-well care. All physical therapists have the biochemistry and physiology training to play a larger role in our patients’ nutrition and health. A major barrier to this is that most physical therapists cannot spend adequate time or effort needed to address nutrition- most of them don’t even have the hand’s-on time that they need to do their best work! This is why it's vitally important to take the extra time to find people and form relationships that are guaranteed to help you and/or your clients get all the way well.

Fad diets and the repackaging of standard diet and nutrition information come and go! There is some good to fad dieting – structure! Almost all PTs can give you excellent nutrition advice without overstepping their scope of knowledge. Some of the simple tricks will always apply: fewer "bad" calories, less sugar, more lean proteins, high fiber, etc. Once you get that foundation down you figure out the specifics based on your body and your needs.

 

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is.

Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races. He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.

 

SPARK Physio Radio Show: A First Line Resource for Nutrition: Your Physical Therapist? Boost Healing AND Performance

In this episode of the SPARK Physio Radio Show Dr. Carlos Berio discusses what nutrition has to do with Physical Therapy and how it plays a role in getting you all the way well.  

Listen to internet radio with SPARK Physiotherapy on BlogTalkRadio

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is. 

Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races.  He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.

Your personal trainer is more valuable than your physical therapist; just sayin'

THERE. I said it. If you have never done BOTH, then you probably don't have a good grasp on where I'm coming from. I'll start with a story from my not so distant past.

I was a first year physical therapy student (SPT). Until that point, I'd earned two degrees in exercise science, held several "lofty" certifications and owned my own personal training business. I worked full time as a trainer in a small private space and handled my school load without too many problems. I also found that my Master's degree actually took a lot of pressure from my course load. I was more easily able to grasp some of the movement and biophysics concepts and none of the anatomy was 100% new to me. That said, the depth which we would eventually get into the anatomy and biomechanics study was far beyond my training to that point. I was excited. I was now working toward my ultimate goal of obtaining the highest level of useful knowledge to maximize my ability to help people. 

Fast Forward to today: 
The realization that the public has little knowledge of the depth and breadth of a physical therapists' training compared to that of a personal trainer, athletic trainer, massage therapist, chiropractor or any number of alternative medicine practices... 

Now I'm a cynic. I am highly critical of the poor exercise technique and progression education offered to physical therapists. I'm also embarrassed at the lack of quality and standards in personal training with regard to formal training, work ethic, customer service and accountability. How did my views of these once esteemed fields fall so far?

Working out the other day I couldn't help but to have an almost visceral reaction to another jabroney trainer who was "working" with a client while he alternated between staring at his phone and having a completely non-verbal conversation with another member across the gym; Oh, and the entire time was sitting down. I'm sure many of you have witnessed something like this. 

I'd seen this scenario many times before but on this occasion I literally could not help myself and loudly asked 'WHY IS HE SITTING!?'. Needless to say, the trainer, the client and even I stopped in our tracks for a brief moment. I didn't expect to have this outburst and to ease tension I continued on my way. Upon looking back in that direction, the trainer was standing.

If I were only a physical therapist it wouldn't be my place to criticize this trainer. There was no OBVIOUS reason he needed to be sitting to work with his client but not all reasons to be seated are obvious. Yes, he did stand right up after I called him on it, but that might have been coincidence too. But here's the thing: my work as a trainer shaped the way I feel people should be treated when they purchase a premium service like training. This brings me back to my original thesis: Personal training is more valuable than physical therapy. This client paid a premium cost for the highest level service that this gym could offer. I have a difference of opinion as to how this service should look and feel, but that's important to me and maybe not so to this gym.  

"Cost is what you pay. Value is what you GET"
The question you need to realize is 'would a person off the street pay YOU, a physical therapist, the amount they would pay their personal trainer?' Even if the above low-quality scenario isn't the norm, how do you think a random person would answer this question? 

After years of asking it, I will tell you: The vast majority of clients (in the Northern Virginia area) would pay a trainer $75-$125 per hour of their time. Ask that same person about what they would pay for physical therapy and the answer is invariably, "Well, I have health insurance, so I would have to pay my $20 copay". 

And that's it. This is the value difference between personal training and physical therapy. We, physical therapists, are completely to blame. We are the supposed ‘movement professionals’ but my colleagues often find themselves stumped by simple exercise and ‘return to full activity’ questions. 

Why is 'Training' so important? We're just training, right?
Physical therapists spend at LEAST 7 years in formal training; earning first a Bachelor's Degree in a health related field, and then to graduate school to earn Doctorate Degrees in Physical Therapy (DPT). Once you're done with that, you study for three to six months FULL TIME to pass the NPTE (National Physical Therapy Exam for licensure). A proud achievement and each grad is excited about being able to help lots of people with their pain.

To become a personal trainer, you "must" be 18 years of age, there is NO REQUIREMENT for formal education, legitimate licensure or stringent continuing education. The number of organizations that will 'certify' someone to teach exercise and nutrition grows each day and there are no standards for these companies.

That said, the good and great personal trainers will almost always have at least a Bachelor's degree in something. The best fitness pros concentrate from an earlier time in their development in seeking relevant education. The trainers you KNOW are a crap shoot of differing experience, training and skill sets. I say that to mean for every "Jillian Michaels", there are a dozen skillful and dedicated exercise pros. However, DO NOT LET THE MEDIA FOOL YOU. A trainers' exposure has NOTHING to do with their skills or education. In fact, if you know a trainer who has appeared in TV, commercials and in every fitness magazine you can think of, you're probably looking at someone who is more of a fitness model than a fitness professional. Not a value statement, just a fact.

Another story from my past:
I was told early on that, "We train people to be physical therapists. Not personal trainers who also do physical therapy". Aside from being told outright that I should not work through my physical therapy education, this was one of the more unsettling blows to my future plans. Was I in school to do all of my work from a treatment table? Is "making sure those knee arthrokinematics are perfect" really the thing that's going to get my patients back to health? I'm glad I questioned this thought process then because it's proved to be faulty. 

There is a HUGE gap between personal training in the "pain-free" public and physical medicine, the pain sciences, orthopedics and sports medicine. Since early in my career my goal has been to focus my energy on FILLING THIS GAP. Far too many personal trainers are attempting to do this. While I respect the talent of some trainers world wide, this gap MUST BE FILLED FROM THE TOP DOWN.

I don't care how many times a technician has observed cardiac bypass surgery, no one would EVER be comfortable with that person stepping outside of their scope because they thought the surgeon might have missed something. 

Guru-ism:
Everyone's an expert, except the ones who aren't. The term fitness-guru is completely overdone and anyone referring to themselves as one is deserving of immediate suspicion. The reality about fbook, twitter, the blogosphere and all manner of TV and radio is such that, for the most part, only the highest trained 5-10% are the ones worth listening to. This is good as it means that there will always be good information to guide your way.

The problem is that EVERYONE is speaking. Sifting through the myth, fad, cult and propaganda that is cleverly designed to drive revenue is difficult. If you've followed this blog, you have some strategies to be your own best advocate. Research credentials. Look for legitimate sources. Make sure that statements are grounded in solid science and logical and critical thinking. That said, I'd honestly take ANY orthopedic physical therapist's exercise advice/opinion over ANY trainer even if they've never gotten their hands dirty teaching someone how to clean and jerk. Even the most novice ortho or sports physical therapist would out-duel the most seasoned fitness pro in the realm of anatomy, physiology, health and biomechanics.

A problem that therapists have is communicating this to the public in a way that truly exhibits the knowledge base. Trainers have been over inflating their knowledge base for so long (I was guilty of this once too) that it's much more natural and convincing. The reality is that most people are looking for functional power, balance, flexibility and endurance. They aren't looking to perfect their clean and jerk. For those that are, referring to a seasoned olympic movement coach is a wise move.

This post reminds me of a recent comment I made on a fbook thread that related to a blog pointing out some very serious shortcomings of my own physical therapy colleagues. The blog was a sharp indictment of the knowledge and practice of solid movement fundamentals and advice by physical therapists and orthopedic physicians. The post was by a well-known strength coach and was overall a very well done piece but I fear that information like this left unchecked is poisonous to the truth about the level of physical therapy practice that is AVAILABLE if you look hard enough.

During the conversation, a therapist I respect argued a point that wasn’t well received but I feel that this was more a case of internet syntax error than a real difference of opinion. Unfortunate too because I believe that these two highly educated therapists actually share similar views. That said, I did miss an opportunity to point out a fundamental principle that I base all of my own work, writing, speaking and teaching. That is that physical therapy MUST begin to take the formal training in movement patterning, exercise progression and real world biomechanics more seriously. 

So what's the solution? 
The American Physical Therapy Association (APTA) has goals for the year 2020. As is stated in their materials, the APTA is pushing for physical therapists to be:

"...recognized by consumers and other health care professionals as the practitioners of choice to whom consumers have direct access for the diagnosis of, interventions for, and prevention of impairments, activity limitations, participation restrictions, and environmental barriers related to movement, 

function, and health."
 

As a former physical therapy student, current physical therapist and current strength and conditioning pro, I can tell you for a fact that we are WAY BEHIND the trainers of the world when it comes to the above highlighted portion of this statement. My discipline is partially at fault: 'Physical therapy' might think that we are “above” training/trainers. This is simply not the case. In fact, the public has dictated the exact opposite. Good trainers demand high hourly rates and do a fabulous job transforming people’s lives. The level of customer service seen at a “physical therapy mill” (our term for the churn and burn factory-like settings that most PT is done in) stand almost NO CHANCE at creating perceived value for clients. Trainers who pick fights with physical therapists are making their point based on the amount of time that is afforded a client who is paying for a full hour of service. In some cases, training sessions can be shorter than an hour but the difference is that the time is devoted 100% to the client. This is a value point that my discipline MUST recognize and move toward correcting. 

Until part or all of this issue is addressed we will not be considered by the public as the high-value-service provider for health; but we MUST be. Because pain is everywhere and the potential for pain is even more pervasive, physical therapists must take on a larger role in this field of influence. If our training programs don't address it, we need to seek these skills ourselves. 

The short story is that while there are quite a few good/great, very vocal, personal trainers and strength coaches, their knowledge base falls far short of that of an even novice level physical therapist.
The world of physical therapy, sports medicine and REAL healing and performance will be inherited by the professionals who take their assessment and treatment of MOVEMENT to the level of the PHYSICAL THERAPIST / PERSONAL TRAINER. I like to believe that I am one of these pros, I work with several others and am partnering with as many of the rest as I can. My goal of being a true advocate for patient healing and our powerful field of practice is paramount. The "NEW BREED HYBRID THERAPIST" skillfully combines the best parts of physical medicine with high level, high energy training to produce the highest VALUE movement product available. If your goal is ALL-THE-WAY-WELL find someone who can provide this combination of care.

This group is small but growing. I'm fortunate to work with lots of students at our practice. Some have just graduated high school and are contemplating a career in PT.  Others are in their undergrad studies and getting feel for what physical therapy will be like. The last and most abundant group are those who have already begun their physical therapy education. More and more of these young professionals already have backgrounds in exercise, yoga, pilates, sports... you name it. It's VERY exciting for our field, the mission of the APTA and for us as the collective movement specialists.

The winning formula:     Physical Therapy + Personal Training = WIN

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is. Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races.  He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.

SPARK Physio Radio: Physical Therapy + Personal Training. 1 + 1 = 3!

In this episode of the SPARK Physio Radio Show Dr. Carlos Berio explains the SPARK Physio difference, a winning combination of Physical Therapy and Personal Training.

Listen to internet radio with SPARK Physiotherapy on BlogTalkRadio

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is. 

Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races.  He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.

PT Treatments that Work but Your Insurance Won’t Let You Have

Physical therapists have tons of different tools in our tool bag. If each of us practiced solely with the goal of using these tools to get people all-the-way-well, the public would likely have a much better understanding about how a PT can improve their quality of life. What's the problem then? Why aren't we all treating people with highly researched and highly effective hands on care? Well, if you've been reading here, you know that the clinic that your talented PT works in isn't helping.

So what are some of the techniques that physical therapists can use that you aren't getting because of "PT Mill" models and insurance-company-dictated care? As patients, you may not even be aware that these treatments can be done by your therapist.

1. Trigger point dry needling:

This is a soft tissue manipulation technique that is used to treat people with muscle knots and pain. People who benefit the most from this technique are those with chronic headache, migraine, neck, shoulder, arm pain or leg "referred" pain that results from these knots. In our practice it is used in conjunction with other manual techniques to knock out soft tissue problems. 

The problem with getting this paid for by your insurance company is that takes a lot of time, a lot of training, education and practice.  From the perspective of 'quick and dirty' care seen in most PT Mills, dry needling is difficult to justify when you've got two patients on the table and two more in the queue. From a continuing education point of view, learning all of the skills necessary to master dry needling takes a long time and lots of resources that most PT Mills don't have and don't want to set aside.

FYI's on Dry Needling:
Some people, myself included, have an aversion to needles and the name of this technique would send some people running. That said, the type and size of the needles used in Trigger Point Dry Needling is probably far from what you have in your head.

Firstly, these needles are solid. There is no hole where any liquid passes through. This makes them very small and in the world of needles, the smaller the diameter, the less likely that the needle will be sensed at all. In fact, when working with patients, most don't realize the treatment has even begun because they don't sense the 'needle stick' they've come to expect. If the technique is done correctly, the sensation that we would expect is a deep cramping or aching sensation very similar to the patients' primary pain complaint but only when the poor tissue is stimulated. This sensation means that the needles (and the PT) are doing their job.

2. REAL Manual treatment:
This encompasses any treatment that involves a PT using their hands to manipulate the patient's joints, muscles, nervous system and soft tissues. This is commonly done in a lot of practices but in our experience FAR TOO little time is spent on this hands on approach and more is spent on passive care 'off in the corner' or with some machine attached to you. Insurance companies do pay for manual treatment, but in many cases they will pay more for different techniques and so those are the techniques that get done. This is bottom-line driven care, not outcome driven care.

3. Highly intense supervised therapeutic exercise:
The reality is that when a physical therapist is also in charge of your high intensity exercise program, ALL of your care along the spectrum of pain and performance can be taken into account. PAIN CHANGES MOVEMENT.  No one would really argue this. When you move differently to negotiate around pain, this will lead to more compensation and then more pain! This is why a physical therapist’s eyes are very useful.

Personal trainers are highly skilled at teaching exercise to pain free movers. Unfortunately, regardless of the number of years of experience, a trainer will never be able to break down movement in the depth that a physical therapist can. Many of our clients already have a personal trainer or strength coach. In these cases we work WITH their trainer to ensure that the client's care is coordinated and progressive and will only lead to the highest level of progress for the client's pain and movement.

Maybe one day, the health care payment system will place an emphasis on the use of early assessment, preventative visits and treatment from physical therapists to avoid big catastrophic injuries. There might be a long wait for this so the best bet for now will be to get connected with physical therapist who is highly trained in strength and conditioning or personal fitness.

What to do to get yourself all-the-way-well:
Research your pain and see all of the options for treatment. Once you've collected your info then ask your doctor or therapist about each treatment. If they don’t have time or aren't excited to hear that you've done some of your own research, it’s time to look for a new pro. This goes for all of your health care teammates!

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is.

Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races. He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.

SPARK Physio Radio: PT Treatments that Work but Insurance Won't Let You Have

In this episode of the SPARK Physio Radio Show Dr. Carlos Berio reveals the treatments that work but your insurance company won't pay for!  

Listen to internet radio with SPARK Physiotherapy on BlogTalkRadio

Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is. 

 

Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races.  He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.

The PT Treatments You Don't Need Because They Don't Work

As we continue to examine the ways in which the physical therapy field can better serve the public, we realized that certain treatments are being done that we as patients really don’t need and/or really aren’t effective.

In many cases, most specifically in third-party-payer-dependent settings (the PT Mills), your insurance company is dictating a lot of your care. While your physical therapist may have some unbelievable manual skills and great clinical judgement to get you back to awesome movement, this pro is most likely handcuffed in the amount of useful service they can provide simply because of the setting in which they operate.

In the PT Mill, the physical therapist might want to give you lots of one-on-one attention and hands-on care but that would require stringent justification of the treatment(s) to the person who is paying the bills, everyones' buddy, your health insurance (tongue firmly in cheek). Because of this the professionals at PT Mills are more likely to perform treatments they KNOW they will be reimbursed for. Unfortunately, this leads to a lot of tired treatment that is almost NEVER what you need to get all the way well.

Here is a short list of the most common PT treatments that we don’t need because they don’t work:

Ultrasound:
The number one offender and we're pretty passionate about this one. It is used as a heating modality. The basic physics make perfect sense: the device creates ultrasonic waves that move the molecules and create heat. However, it's been used in a much more wide arching way for many years. It has been thought to decrease pain by a few different mechanisms. It increases the tissue temperature, increase blood flow and reduce inflammation. This is simply not the case and there is little evidence to back it up and quite a bit to refute it.

There is LOTS of literature to support the outright removal of ALL ultrasound units from physical therapy settings. For the more research minded patients and therapists, read below. You should find this interesting yet disturbing, mostly because there isn't a PT Mill in the country that doesn't have one or more US units.

Here a recent study in the Annals of Family Medicine, examined the added benefit of US to a more hands on approach to treating low back pain. They found NONE.

Here in a study in Rheumatology International, the researchers found that sham (read: fake, phony, intended to give the impression of the treatment) was AS EFFECTIVE AS the "real" thing. Ridiculous.

In this study in the Journal of International Medical Research, they also examined the effect of different types of US in treatment of knee pain. One of the types was sham-US which, over 10 treatments showed significant improvement of pain. While this study did show that a version of  US (pulsed) did improve pain more than sham, the fact that the sham also provided statistically significant improvements in pain in this group of knee pain patients is very telling. We should all go out and pretend to do US treatments on everyone because their pain WILL decrease.

The list goes on. Worse is that there exists literature that the tissue heating effects of US are no better and in many cases worse than what can be done using simple manual techniques for the same purpose. Good PTs use the most current evidence in practice in combination with best clinical practices and patient values. If I can't logically explain what I am doing and how this will benefit a client, WE DON' T DO IT!

This evidence isn't hidden anywhere. I just picked the most recent relevant articles and listed them here. So why are we still arguing the use of this modality? OOOOOHH, I remember, it's because your insurance company will pay for it, no questions asked. I guess if you've purchased one of these machines (about $2000-$3000 each!), you'll get your money back soon enough and save your staff some time having to defend it.

The Upper Body Ergometer (aka: the hand bike, the UBE):

This model: "The Time Waster PLUS"

You will see this one in a lot of Mills. It is simply a bicycle for your arms. There are some patients who need this piece of equipment because a limitation prevents them from performing cardiovascular exercise with their legs. For example, if you have no use of your lower extremities or the use of them is very painful, this might be a good exercise. However, in these cases, PT takes places in very different settings and the UBE is appropriate.

That said, the reality is that this huge and expensive piece of equipment is used to get folks out of the way while managing traffic. The UBE is the PT worlds' dirty little secret. It's not there because it's better than the regular bike or the treadmill. If you are on it, its because the PT is swamped and they need a place to put you that isn't technically "waiting", oh, and they can bill your insurance company for it. After all, if you're in a Mill, any minute that passes that you're not be charged for something is a wasted opportunity.

ANY PASSIVE heat, cool or "ESTIM" Treatment:
Electrical Stimulation therapy can be very effective. It comes in some different varieties such as TENS and NMES to name the most commonly used. ESTIM for short, it is a treatment that is over done and usually in conjunction with a hot or ice pack. There is evidence to support it's use in decreasing pain but the majority of this would dictate that it's effectiveness ends when the machine is no longer on. Are we to walk around all day with ESTIM units buckled to our belts? Pain is the signal of some problem. Wearing a 9V battery operated machine to remove or lessen this signal is NOT going to make you better.

"You know. That thing that makes your muscles tingle. That's what they did for me at PT" smh

The cases that see the best benefit from ESTIM treatments are almost always those who have lost some or all muscle function for one reason or another. NMES is proven effective at maintaining the ability to contract muscles for periods of time until full muscular control is regained by the patient. Lots of times, surgery will produce this side effect and NMES is appropriate. Note, NMES is best when performed WITH VOLUNTARY CONTRACTION OF MUSCLES and a good PT will be right there to coach this along. You'd be surprised how difficult it is to get a quadriceps muscle to contract after a knee surgery.

So not all people who get ESTIM 'treatment' will see real benefit from it, but you will be hard pressed to find someone who received treatment in a PT Mill that didn't have ESTIM.

The issue we have, as movement specialists, is that ESTIM and the associated hot or cold pack (inside secret: they need to be 'bundled' together in order for your insurance to pay for it so you'll almost never get one without the other in a Mill even if you don't need the hot or cold pack) are completely passive. Anything that the patient can do while immobile, sitting down, without supervision should be just that, done by themselves. This is not skilled care and a waste of time for the patient and the pro.

If one of these passive treatments is appropriate we send people home to borrow one of our units but our most important role as your PT is to spend the one-on-one time in treatment doing the things that you can't do to heal yourself.

Massage:
Physical therapists are trained to find muscle and tissue problems and treat them directly. While most times this isn't the most comfortable experience, it's what the tissues need to be 'reset' and allowed to learn the new function that will help relieve your pain. If you are in a Mill and your PT feels more like a massage, then go GET A MASSAGE. Massage therapists have become very skilled at providing this experience and making you feel nice. They don't think about soft tissue the way a PT does just like a personal trainer can't see exercise the way a PT does. It's simply a matter of perspective gained with the advanced formal education.

We at SPARK do lots of soft tissue work when it’s appropriate but there is a specific goal in mind. We also use a technique called trigger point dry needling. It’s a cutting edge treatment approach for the manipulation of those same tissues. It uses your body’s own nervous system to release trigger points and to decrease pain both locally and into referred pain patterns. It very useful in conjunction with our manual techniques. However, this is another technique that takes a LOT of time to learn and then perform. That is the main reason you don’t see this effective technique done in many PT Mills.

Trigger Point Dry Needling performed on a trigger point in the upper trapezius muscle

What to do?
If you must be seen in a PT Mill (you should be realizing that don't have to settle for it) you can still bring information to your therapist and also ask questions. You can help educate your therapist or ask them to help you start looking for a new therapist. If you are getting a massage at PT, ask your physical therapist, "why are you massaging there?" A tell-tale sign of a muscular restriction issue is the ability to reproduce the patients' pain by manipulating these areas. If your PT doesn't tell you that the muscles they are working on are a muscular restriction (trigger point/knot, etc) for the pain you are experiencing AND can't accurately reproduce YOUR PAIN, its probably time to start looking for a new PT.

It is OK to say, “This isn’t working for me, and I want to do it differently?” That is being your own best advocate. The majority of patients we see have been to the PT Mills and had that very same realization. As with all the techniques here it’s just EASIER to go with what has already been approved than it is to climb the mountain of getting a new treatment recognized and paid for even though it may be more effective. When the ease and reimbursement potential of the treatments you are given become the priority, YOU are no longer the priority. Seek better for yourself.


Dr. Carlos J Berio, PT, DPT, MS, CSCS, CMTPT is a licensed Doctor of Physical Therapy, Certified Strength and Conditioning Specialist and a Certified Myofascial Trigger Point Therapist. In addition he holds a Master's Degree in Clinical Exercise Physiology. He has treated high school, collegiate, recreational, and professional athletes of various sports including baseball, softball, football, hockey, tennis, swimming, golf and the martial arts. His experience as a collegiate and semi-professional athlete as well as a professional baseball coach make him a sought after resource among elite level athletes on the field and in the training room. The concept of 'all the way well' in his work as a physical therapist and fitness professional is what continues to drive Dr. Berio to be the best movement specialist there is.

 

Dr. Berio is the founder of SPARK Physiotherapy in Alexandria, Virginia. A clinic and approach designed from the ground up to set the new standard for integrity and patient satisfaction in the PT industry. Carlos remains active in several sports and enjoys agility training, power lifting and adventure races. He is an advocate for his patients, clients and his fellow PT colleagues. He can be reached at cjberio@sparkphysio.com.