Five Things Lily Learned During Manual Therapy Residency

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After achieving a Doctorate in Physical Therapy (DPT) and becoming licensed to practice Physical Therapy, some therapists choose to continue their education through additional residencies, fellowships, and/or certifications. These post-graduate programs allow therapists to specialize in focused areas of physical therapy practice.  It can be very different to practice physical therapy in a clinic that treats muscular injuries as opposed to brain injuries, for example.  Or to work with the very old as opposed to the very young.  Therapists with a recognized specialty certification have demonstrated that they have an advanced skill set with regard to a particular patient type.  At Symmetry Physical Therapy, all of the therapists are specialists in Orthopedics, which means that they have advanced training and are recognized as experts in the treatment of the musculoskeletal system.  Even more specifically, each of the therapists at Symmetry holds advanced certification in Manual Therapy, which means that all have advanced skills in the hands-on aspects of Orthopedic Physical Therapy.

The program I chose for my initial post-graduate residency education is called the ‘Institute for Athlete Regeneration’(IAR).  After completing their program, I received a Certification of Sports and Orthopedic Manual Physical Therapy (CSOMPT).  Moving forward, I will continue through the IAR fellowship program, which will involve two additional years of advanced practice study.   During this journey, there are countless things that I have learned and will continue to learn that are invaluable to my day to day practice.  I thought that it might be interesting to share some of the them…

To that effect, here are 5 key things I learned from the Institute for Athlete Regeneration:

Advanced, Non-invasive Tests and Measures for Diagnostic Purposes::

When a patient comes in for evaluation with any sort of ache or pain that is not acute or traumatic, the source of their discomfort can be tricky to diagnose.  Considering which movements hurt and where and when pain occurs is extremely helpful information, but it is also important for physical therapists to be able to utilize specific tests to accurately determine what structure or body tissue is injured.  Physical therapy diagnostic testing allows the therapist to create an effective treatment plan and also determine a timeline during which a patient is expected to recover.  After a thorough hands-on evaluation, a skilled orthopedic specialist can develop an accurate working hypothesis and physical therapy diagnosis without necessarily requiring more extensive and expensive testing.  The therapist can also utilize the results of their examination to help determine if further imaging via tools such as X-ray, CT scan, or MRI are indicated.  Often X-rays, CT scans, or MRIs are considered a ‘gold standard’ for diagnosis.  However, these exams are also expensive and not always necessary and/or readily accessible.

Advanced Manual Therapy Techniques:

Manual therapy is a hands-on approach to physical therapy focusing on the utilization of multiple types of joint mobilizations, manipulations, and soft tissue release that are based on each individual patient’s needs.  Although movement and exercise are important components of physical therapy, it is difficult to truly fix musculoskeletal problems through activity if the injured joint or muscle isn’t performing properly or is not in the correct alignment.  Joint mobilizations are passive movements of the skeletal joint in order to reduce pain or increase range of motion. Manipulations are similar to mobilizations, but are much faster and often cause a cavitation or a ‘pop’. Manipulations are typically utilized to increase range of motion or to ‘calm down’ or ‘reset’ the nervous system. Soft-tissue release techniques treat muscle, ligament, tendon, nerve tissue, and fascia in a more specific and targeted way than a non-specific relaxation massage.   Manual therapy treatments often result in immediate symptom relief or reduction.  These improvements can then be maintained long-term when hands-on treatment is coupled with appropriate movement-based exercises.  In the IAR program we learned countless manual therapy techniques for both athletic patients and for anyone with a musculoskeletal pain issue.  Practicing these techniques throughout the course of the certification program allowed manual skill development that far surpassed the initial learning that occurs in a generalized graduate physical therapy program.

The Importance of the Thoracic Spine:

The thoracic spine is the area of your back between your neck and low back.  It is a body region that did not get much attention during graduate school and which appears to usually at best be only briefly screened in most medical offices and by many physical therapists as well.  Typically, the thoracic spine is a more ‘stiff’ area than the neck and low back, which in turn often demonstrate more excessively mobile joint segments.  The excessively mobile spinal segments are often areas causing pain and being treated as primary problems.   However, the stiffer regions of the spine are often creating an excess work load on the areas that move more readily and can often be the true root of neck and back pain problems.  In our society, the thoracic spine is very prone to be a ‘stiff’ area due to our tendency to be sitting at a computer for work for a large part of the day.  It is very important to make sure that there is sufficient mobility in the thoracic spine to reduce risk of neck, low back, and shoulder injuries.  Omitting this area from physical therapy assessment results in incomplete clinical pictures of back pain.

Loads of Sport-Specific Exercises:

The Institute for Athlete Regeneration certificate program is geared towards the treatment of patients involved in sports.  The program taught participants to critically consider the specific movements and muscle work required for different sports activities.  A gymnast, a volleyball player, and a long distance runner all require unique skills and will perform better in their respective activities if they are trained to successfully accomplish the tasks that are associated with their sport.   The IAR program also taught considerations for injury prevention for athletes involved in a variety of sport activities.

The Benefits and Limitations of Ice and Anti-inflammatory Medication:

Cryotherapy, or any sort of ice treatment has been a mainstay in orthopedic physical therapy practice for decades.  Ice is shown to be useful for acute injuries within the first 48-72 hours after injury.  But did you know that after that time period there is limited evidence that use of ice provides further reduction of soreness, inflammation, and recovery?  After the initial injury recovery phase, ice can actually be detrimental to healing, as its use results in decreased oxygen delivery to the injured tissues, which can delay the healing process.

NSAIDS are a class of anti-inflammatory medication often prescribed to slow the inflammatory process in order to reduce pain after injury. While this type of medication may temporarily reduce pain and other effects of injury like swelling, it can also actually delay the healing process.  Depending on the type of injury, the inflammation phase of healing can last anywhere from several days to approximately 6 weeks. While in this stage of healing, your body is working on repairing injured tissue. Interrupting this process with extended or excessive use of medication may delay the body’s full repair.  (If you are no longer in the inflammation phase, then taking an NSAID should not delay further healing.)

The Institute for Athlete Regeneration’s certification taught therapists to critically consider the use of ice and anti-inflammatories, so that patients can be given optimal guidance for the treatment of their pain.

My experience through the Institute of Athlete Regeneration has been invaluable and extremely beneficial for my physical therapy practice.  I look forward to continuing to pursue excellence in orthopedic practice through the rest of their fellowship program!

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