COVID-19 Precautions

We remain dedicated to protecting the health and safety of our patients, our staff, and our community.

What to expect:

We ask that you put on your mask before entering the building. Let us know if you need one.
Sanitize your hands at the station in the entryway before entering the clinic.

We continue to follow stringent cleaning and sanitizing procedures before and after each patient visit.

It is a privilege to work with you. Together, we can work to keep ourselves and our community safe. Thank you!

Forty-One Steps to the Boat

Is a boat ride a workout? When you are a 94-year-old man who walks with assistance of a rolling walker in your assisted living home, it definitely is!

My father in-law Tad has always had an upbeat attitude toward life and gets much joy from being with other people and family. He remains independent in all aspects of his personal care, walking daily to meals and to see his wife in another part of the facility where he lives. His good attitude, perseverance and rolling walker get him to where he needs to be every day.

A few weeks ago, Tad’s son asked him if he would like to go for a boat ride from the family camp on a New Hampshire Lake. He had not visited the lake in a couple of years and was excited to do so. Reaching the boat would involve descending along a rocky dirt path with elevated tree roots to get to the camp, then negotiating 41 stairs of various heights and composition (wood and rocks) down to the dock. (And that doesn’t include getting back up to the car!)

Tad has faced many challenges in life: combat duty in Iwo Jima during WWII, losing his right leg to cancer in his 30s, losing two wives to cancer, and raising four wonderful children and three adult step-children. He was ready for the challenge. He derives great joy from family, and this opportunity would be no exception. The family gathered for the event, including his son, stepdaughter, two grandsons, granddaughter-in-law and great granddaughter, Corinna.

Down to the Boat

Tad negotiated the rocky, rooted path to the camp using his two wheeled rolling walker, a gait belt, and assistance as needed to control the speed and security of the walker. A lot of exertion and careful foot placement allowed for his safe passage to the camp itself, where he enjoyed a brief sitting break, preparing for the more arduous journey down the stairs to the dock.

On the uneven steps to the lake, Tad needed to switch to using a cane because using a walker was just not feasible. Fortunately, he could steady himself on a metal railing for most of the way. Four of us provided support for balance and careful foot placement on the stairs. This was very hard work for him. About halfway down, Tad shouted, “I see the water!” and he put renewed energy into the remaining descent until we heard “I see the boat!” and we at last reached the dock. Once on the dock, we were able to again use the walker to reach the boat, though climbing into it required assistance. At last, Tad was able to sit and relax and enjoy a picnic lunch as we toured the lake.

And Back Up to the Car

Of course, at the end of the boat ride, we had to reverse direction and climb back up to the camp. Once again, four assistants helped, along with the railing, to ascend one step at a time. Care was needed to be sure his prosthetic foot was in place on each stair. Although not usually how a physical therapist would teach stair climbing, stepping up first with his prosthetic limb first seamed to work best for him. Halfway, we rested for a bit before continuing to the camp deck for another rest. Tad eventually made the final climb (what mountain is this?) to the car using the rolling walker, again with assistance.

Although he was glad to reach and be seated in the car, it was clearly a wonderful challenge and achievement. We all enjoyed the outing very much and were amazed by his persistence and effort.

~ Jeffrey Clough, PT

Stretching: Knowing What’s Best for Your Unique Body

Stretching has been an ever present component of my routine for just about as long as I can remember. It has played a role in my flexibility for dancing, sports, and yoga. And it has been a critical part of my own personal physical therapy treatment and ongoing maintenance following an episode of severe low back pain and leg weakness related to disc herniation. This occurred when I was barely 20 years old and at the time completely confused me. I didn’t think I’d had any injury at all, but just seemed to wake up one day with pain and so much difficulty moving my body.

In retrospect and with education, I eventually recognized two things that contributed to my initial back problem: 1) I had been spending very long hours sitting (likely hunched) at a computer working on a term paper or lab report with a deadline; and 2) My instinct was to just “stretch it out,” and I definitely stretched wrong!!

When a joint ends up with limited range of motion, regular stretching can help gradually improve then maintain flexibility for better motion.

Taking stretching into consideration is something we all need to do because we don’t live perfectly balanced lives. We may spend a lot of time in a particular position such as sitting or looking down, or repeating particular motions, depending on our vocation or recreational activities. This ends up putting certain muscles in shortened positions and over time results in decreased range of motion of the joints those muscles cross. Each of our joints needs to be able to move freely through an adequate range of motion in order to do what we need to do without injury. For example, prolonged sitting can result in tight hip flexors at the front of the hips and tight hamstrings at the back of the knees and thighs. Over time, these tight muscles impact the normal muscle balance needed for proper upright posture, pelvic alignment and biomechanics when standing and walking.

When a joint ends up with limited range of motion, regular stretching can help gradually improve then maintain flexibility for better motion. So how does this work? How does stretching result in improved range of motion over time? The answer, it turns out, is not that simple or fully understood scientifically. Proposed theories include mechanical changes that result in structural lengthening of muscle and connective tissue. A newer sensory theory suggests that with regular stretching, our sensation (what we feel when we stretch) actually changes and allows increased tolerance to stretch. This allows our muscles to lengthen further and increase joint range of motion.

As a physical therapist, my guidelines for how to stretch are informed by these various theories and by the properties of the individual tissues (including muscle fibers, fascia, tendons and even nerves) on which tension is placed during stretching. In addition, each person’s unique body structure and unique daily activity requirements will affect how best to stretch.

Some general tips (things I find myself saying a lot!) for good stretching practice:

Warm muscles are easier to stretch and more resistant to injury, so warm up with 5 to 10 minutes of light activity before stretching.

Pay attention to proper alignment and stabilization so that each stretch is targeted to the tight muscle tendon unit and not being transferred to other areas that may be already hypermobile; we don’t want to stretch joints that are hypermobile.

Don’t bounce in a stretch; this can cause tissue injury. It is best to gently move into a stretch to the point where you start to feel it and then hold for about 30 seconds.

If using a piece of equipment or strap to help with this kind of stretching, make sure it is unyielding. I find that sometimes people try to hold stretches with the resistive bands that we use for strengthening exercises. In this case, the stretch is less effective and harder to hold because the tension causes the band itself to stretch out.

Finally, back to the back problem that I had when I was younger. It’s important to be cautious when considering stretching around an acute injury. This is obvious if there has been some trauma and you have a broken bone, sprain or torn muscle. It’s less obvious if you have woken up with severe pain in your neck or back seemingly out of nowhere. In both cases, it is not the time to start working on flexibility by static stretching, since holding a stretch across a compromised structure can disrupt the initial healing process.

When I initially began physical therapy for my back problem years ago, stretching was an important part of my rehab. In particular, my hamstrings and hip flexors were tight at the time. This was toward the end of the semester in the tennis off season, and much of my time was spent sitting in classes and working at computers. In addition to stretching, it was important that I learn how to use my core to stabilize my spine. Over the years since then, my activity patterns have changed and I feel lucky that I rarely spend prolonged periods sitting now. However, I am finding that, as I settle into my postpartum body and get a little older, I have new stretching needs. I now notice that it actually makes a difference when I warm up, and my old stand by stretches are not necessarily the ones I need most. It is a reminder that when a new pain occurs, however similar to past problems, it should be evaluated in the context of one’s current daily routine.

~ Elizabeth Maynard PT, DPT

Recognizing Resources: Learning to See What’s Right

One great thing about being a physical therapist is that I am always learning. Sometimes I learn in the clinic; sometimes studying on my own; and sometimes at a workshop. Recently, I attended a workshop called Body Reading 101. What struck me most and has stayed with me since I left is something the instructor said as we were making our very first observations. What resources does this patient, this body already have?

This question is interesting to consider as a physical therapist. We are kind of like mini private investigators, trying to follow the body trail map to figure out “who done it.” When a patient comes in, we do a lot of observational assessment. What is different from side to side? What doesn’t fit in this particular body’s overall scheme? What doesn’t look the way we were trained it should look? But the question of what are the body’s resources had me conceptually challenged—I’ve been trained to see what’s wrong, not what’s right!

And that blew my mind. I realized that I do this in so many different aspects of my life. What doesn’t fit always attracts my attention. I notice when there is something out of order, different schedules than I expect or dissonant notes that are little off key. But the little unexpected happenings of daily living that go right happen all day long! This phrase, “what resources are there,” made me recognize that there are so many things that go right for us! They need to be addressed and acknowledged, possibly even praised!

That’s what we did in the workshop. As each lesson was instructed, a participant or two would be in the spotlight on whom the rest of us could practice the new technique of finding what isn’t quite right. What we were asked to do FIRST was to find three things about this subject’s form that were assets to him or her. At first it was a little difficult. We haven’t really been trained to appreciate what is going well. But small details such as appearing well-grounded, having strong shoulders, demonstrating good spinal posture or an open chest began to be easier to see.

Many times, our health problems are ill-timed. We don’t expect them! When we are facing this new challenge, we often look at the things that we are no longer able to do that have been part of our routine. I challenge us to look at what we continue to have available.

Using this technique of recognizing resources, I could tell that it also made the subject feel much better. They were willing to take the plunge to be picked apart for our learning, but they could also be made to recognize what they are doing that is useful and good. The swimmer might have the strong shoulders. The weightlifter might have well-developed muscles. Even attitude shows through: the person who is able to stand relaxed and smiling in front of 40 pairs of eyes has an innate strength that demands to be appreciated!

Taking this new frame of mind into my everyday life was transforming. I can’t promise that I have been able to do it all of the time, but I was able to put it into immediate action with my family. I have a 12-year-old daughter. Although she looks like an adult, I forget that she still has a developing brain. I often expect her to be completing her work and thinking forward in an adult manner. But, with this new concept, I was able to re-adjust my framework of her choices. What are her strengths and how was she able to make a decision that relied on those resources? And in that question, I am able to stop my critical eye and recognize how her differences make her resourceful in her own way.

Many times, our health problems are ill-timed. We don’t expect them! When we are facing this new challenge, we often look at the things that we are no longer able to do that have been part of our routine. I challenge us to look at what we continue to have available. If I can’t be out and about with my normal exercise, maybe it is time to sit down and catch up on some reading. If I am not able to continue eating the same foods, what fun can I have with finding new recipes? If certain movements are quite uncomfortable and painful, what movements can I do that still feel good? It also helps if I can recognize how those things that I am able to do are nourishing to me. As they become part of my resource strategy, I am also able to build my resilience. (Check out our recent newsletter, which focused on resilience.)

It isn’t easy to accept change or injury. But I see that the choice to recognize resources is similar to choosing direction at a fork in a road. If I choose one direction because it looks like where I came from, I’ll be disappointed that, even though it looks similar to where I have been, familiar branching paths are closed to me. But if I allow myself to be curious about my new path, there may be new opportunities and choices that I couldn’t have foreseen. Of course, it may not have been my decision to be there in the first place, but the only place to go is forward! We may as well appreciate what we’ve got.

~ Courtney Germano PT, DPT

Hang Loose? Think Again and Consider Your Ligaments!

My daughter recently asked for my advice. She’s been having some elbow and shoulder pain since joining a climbing gym near her home in Pennsylvania. That’s too far away to ask her to just come in to Foothills for a physical therapy assessment, so I had to get creative in order to give her some long distance tips.

In the process of looking up exercises specifically relevant to climbing, I came across Grassroots Physical Therapy out of Salt Lake City, Utah. Their website has some excellent free exercise videos and it referenced an article titled, Hang Right: Shoulder Maintenance for Climbers, that focuses on disproving the old axiom, “hang like a bag of rocks” or simply, “hang loose.” The author points out that “hanging” can cause pain for climbers because of the undue stress that it places on joints and muscles. That statement reminded me of my patients who hang like a bag of rocks on their hips or knees.

So why is this “hang loose” posture so bad?

In the human body, a joint is formed when two bones come together. Ligaments do the job of holding these bones together and are considered a type of connective or soft tissue, made up of both collagen (stiff) and elastin (loose) fibers. This means ligaments create stability and mobility at the same time—we can bend our knees without the bones falling apart. The amount of collagen or elastin in a ligament determines if you are stiff- or loose- jointed. If you think you are double jointed, you most likely have more elastin than collagen in your ligaments, allowing the joint to move too far and thus creating the illusion of a joint that moves in two ways instead of just one. In the medical world, this can also be referred to as hypermobility.

This is an example of standing with both the knees at their end range of motion. Notice the knees are “locked” back, therefore stressing the ligaments of the joint and requiring no muscular effort. The orange line represents where the body weight is centered; notice that it goes through the front of the knee joint, therefore compressing the joint in the front and gapping the joint in the back.

Muscles, on the other hand, control and create the motion in a joint. Muscles connect to bones by tendons and tendons cross joints to create movement and give strength and stability to a joint. When we lift weights at the gym, we are improving the ability of our muscles to support our joints and move our body. Tendons and muscles are also considered part of our connective and soft tissue system.

Back to the statement, “don’t hang like a bag of rocks.” Both ligaments and muscles support or “hold together” a joint. Ligaments do it passively, meaning we have no control over their work. Muscles do it actively, meaning we have total control. When we stand with our knees locked back or hyperextended, we are relying only on our ligaments for support and we are therefore not using any muscular effort. This puts too much stress on the ligaments of the joint to the point where the ligaments become stretched out and can’t hold the joint together. This is called instability.

Hanging on your ligaments also causes abnormal stress on the bones in the joint, and that stress can lead to bony changes we recognize as arthritis. If the ligaments can’t passively support a joint, the muscles have to work even harder. All of that can lead to muscle imbalance, weakness and ultimately pain.

This picture shows good alignment, with the joint being held in its normal position, supported by both the ligaments and muscles. The orange line represents where the body weight is centered. In this picture, the orange line goes straight through the knee joint, loading the joint in the center, therefore distributing the weight across the broadest part of the joint.

Another good example of hanging on our ligaments is when we carry something heavy in our hand and let the elbow just hang down. When we go to bend the elbow from that overstretched position, it hurts. Imagine how that would feel if you held your arm like that all day long!

It’s really important not to abuse one of your major support systems for your joints!

The solution is to support your joints! Use your muscles. Stand with your knees unlocked or “soft.” Keep your pelvis under your shoulders, not pushed forward in a way that puts all your weight on your hip ligaments. And, rock climbers should never hang like a bag of rocks, but they should support their arms and shoulders by engaging the muscles and holding themselves up. Simply put, don’t stand or sit with your joints at the end of their range of motion. A common, everyday example is when people slouch in their chairs or hang their heads down, looking at their phones. Both are hanging the spine at the end of its range.

Whether you are sitting at your desk, standing at the copy machine or climbing the steep vertical face of a rock, be kind to your body and support your joints by engaging your muscles and actively hold yourself up. Your muscles and joints will thank you.

~ Brigitte Cook PT

The Art of Physical Therapy

I’m in the weight room at the Y. Focused in. Feeling my shoulders work, then my hips and knees and always my core. It is 8 a.m., quiet and only a few people here. I am in my zone. I love the exertion and the movement.

I am an old jock—an aging one. Both vocation and play have put a lot of wear on my body over the years. And, I have struggled to follow through on what I know I need to do to take care of myself. I want to keep working as a physical therapist without damaging my repaired shoulder. I love feeling strong when I’m trucking up the hill to the maple grove on 15 year-old replaced knees. I look forward to the refueling energy that comes of long hours in my vegetable garden.

It is not by accident that I have stayed committed to this new routine for more than two months now. Finally, I have developed a routine that works for me. First, I am a person of routine. Same days, same time of day. Routines ground me. Second, I need structure. Going to the Y, working parts of my program for time, counting a certain number of repetitions and sets for others and beginning and ending with Tai Chi all create structure for me. Finally, it is doable. I am an early morning person and I come here on the days I start work a bit later. So it fits the rhythm of my day.

I think a lot about the practice of physical therapy. The science of physical therapy has informed how I work on strengthening my body, but it is the art that has gotten me to a place where I can experience success. Art, for me, is the creativity, imagination and skill involved in producing an result that is meaningful and has its own beauty. I feel stronger and I am more engaged in a process that moves me towards my goals. As my friend Ray says, “That’s a beautiful thing.”

There is much that could be said about the art in evaluating and diagnosing a patient’s problem and about the art of knowing where to begin in addressing the major dysfunction. Or, the art of knowing which treatment technique to use at what point. But the question I ask today is, how do I help my patients be successful?

How am I going to help this person get to where they need and want to be? How am I going to facilitate change that will keep them moving forward long after they are done with physical therapy?

It starts with the first part of the initial evaluation, when we are “taking the history.” What brings them to PT? What is their primary concern? What is the mechanism of injury? How does their issue limit them? What is functionally impacted? Can they describe the pain? What makes it worse or better? What medications are they taking? What past medical history is important to understand? What is their work, activity level and social support?

Underneath this, I am asking myself, “Who is this person?” I am listening. What is important to them? What do they care about? What is going on in their life? How have they related to their body in the past and how do they relate to it now? What other issues or concerns do they bring that will impact how I work with them? What is the path that brought them here? What has been the impact of their condition on their life and where do they want to go? As I listen to each person’s story, I can start to understand and start to develop a connection that allows us to work as a team.

As I start to develop a person’s home program (the work they will need to do in this healing process), I need to appreciate what is on their plate. Do they have work demands that make it difficult to decrease overuse? Are they in the midst of a major life transition? Are they taking care of a family member, and is that responsibility physically and emotionally stressful? Is this a chronic condition that has taken a toll? Is there a history of trauma resulting from an accident, injury or something earlier in life?

These stories impact the body differently. They can contribute to tension and protective body responses. They can lead to high levels of anxiety or a to a person feeling disconnected from their body or from the injured part. We may need to incorporate breathing techniques, relaxation techniques or movement patterns to facilitate easier movement. At the same time, we are starting the process of muscular recruitment, strengthening or stretching they need. It has to be doable: something they can fit into their day, that they can do and are willing to do.

While the science may define the most effective exercises for strength of a certain muscle, for example, the art says you have to consider different personalities and interests. Is this a hard-pushing person who needs to be held back? Is this a person who needs a cattle prod? Does this person have a history of being active and wants several exercises or is this a person who has been more sedentary and needs to learn how to feel their body move and would do best with a simple plan? And, how do you connect with them? Does humor work? Do they need a lot of listening and empathy? Or, do they do best with a really straight forward approach?

Above all, I may know where they need to go in terms of strength, changing old patterns of gait, regaining balance to keep them safe or learning new movement patterns to stop an overuse and get them to their goals, but it has to work for them. And from the get-go, I tell everyone they know more about their bodies and themselves than I do, so they need to give me feedback about what is working and what is not. It requires creativity, communication, connection and skill. We are human beings with complexity, not robots with moving parts. We need to practice the art of physical therapy to help our patients be successful.

~ Julie Dewdney PT

Celebrating Nordic Skiing in Concord

You may wonder what a flatlander from Indiana knows about Nordic skiing? Growing up in the midwest, we did our fair share of sledding and ice skating. After moving east, I went into Eastern Mountain Sports on Boston’s Commonwealth Avenue in 1981 to buy a backpack, and came out with Nordic ski boots, skis and poles instead. I learned to ski by trial and error and have managed to find hours of enjoyment, fitness and beauty while skiing ever since. Just as with snowshoeing, ice skating, downhill skiing and hiking in the winter, the scenery is stunning. There is something ethereal about gliding across the snow in silence. The only sound you hear is the squeak of the snow and your breathing.

Here are a few thoughts about Nordic skiing.

Classic skiing is a great winter activity. This form of skiing involves a gliding motion as you shift your weight forward from ski to ski. If you can walk, you can classic ski. Skip the waxable skis and go for the waxless unless you know how to use kick wax. Classic skiing is great when the snow is deep, conditions are cold, and in narrow trail conditions. Skis should be selected based on weight, not length. Google the ski manufacturer for the specs.

Skate skiing will require a bit more fitness and different boots, skis and poles. The technique can be difficult to master at first, so a lesson might be helpful. If you have ever played hockey, skate skiing may be easier to master. Skating involves shifting your weight side to side. You can ski faster with this technique in most conditions. Deep snow conditions will make skate technique very challenging.

Take a lesson and rent equipment. You can choose from several Nordic centers in New Hampshire that offer great instruction for beginners. Waterville Valley, Bretton Woods, Gunstock and Great Glen offer rentals and instruction. SkiNH program offers a free learn to ski day once a year. Your confidence as a skier will grow quickly with lessons. Well-groomed trails and decent rental gear will also make your skiing much more enjoyable.

Dress in layers. You will quickly build up heat as you cruise along the trails, so dress in layers that you can remove or add in case the temperature drops. Clothing and socks that wick away moisture can keep you dry and comfortable. Outer wind layers are essential in the New Hampshire climate.

Go out and have a blast! Nordic ski season is short, so enjoy a ski outing when there is good snow cover. We are really fortunate to have groomed trails in Concord at White Farm, Beaver Meadow and Carter Hill and they are free! Carter Hill even has equipment to try. All the grooming at Carter hill and White Farm is done by volunteers and the grooming at Beaver Meadow is done by Concord Parks and Recreation. Concord is a great community for enjoying Nordic skiing close to home!

There are many ways to get started, but don’t wait, because snow doesn’t stay too long in New Hampshire. With these excellent local ski spots, we have every reason to get out skiing on a whim. I’ve been privileged to coach Bill Koch and middle school Nordic programs in Concord, and it’s fun to know there’s a new generation of Nordic skiers gliding through the fields and woods.

I hope you will try your hand at the Nordic tradition of skiing. You can get excellent cardiovascular training on nordic skis, and work on your balance, too. As a physical therapist, I encourage my patients to stay active in the outdoors year round. Nordic skiing is just another way to do exactly that—enjoy fitness and the beauty of winter. Don’t be tempted to stay inside and clean. Skiing is so much more fun!

~ Donna Lannan PT

Helpful Links

SkiNH – all kinds of good info on all kinds of skiing in New Hampshire, including good deals and where to go.

Capital Ski and Outing Club – This group donates lots of money each year to support Nordic trail grooming equipment in Concord, and you can donate to help their work. Don’t miss their annual equipment sale!

Carter Hill Orchard – Here’s some good info about the Carter Hill trails, coming to us from our friends at Five Rivers Conservation Trust.

Beaver Meadow Golf Course (winter fun page) Check here for updates about conditions and grooming on the Beaver Meadow trails.

Tools in the Toolbox: Dry Needling

Ask anyone at the office: I’m the “can do” person. The table won’t move up or down? Ask Maggie. She can fix it. Window stuck? Ask Maggie. She can get it unstuck. Computer not behaving? Ask Maggie. She will get it running again. And, usually I can.

My dad’s lessons have helped me throughout my career as a physical therapist. With his lessons behind me, I could relate all therapy techniques as tools.

My dad was my teacher. He always told me that if you can read about it, you can usually do it—like cooking by using a cookbook. He spent time teaching me and my brothers all sorts of things, from painting to basic auto repair. A large part of that education was learning about tools. Which was a phillips head versus a straight screwdriver? The difference between an open-end and a box-end wrench? Or different types of pliers like needle nose and adjustable? Once I could identify them, he taught me the importance of using the right tool for the job. There were special tools used for only one purpose, like an oil filter wrench and some used for multiple purposes, such as a hammer. All of his teaching resulted in my keeping a toolbox with at least the basic tools at home and in my car.

My dad’s lessons have helped me throughout my career as a physical therapist. With his lessons behind me, I could relate all therapy techniques as tools. I learned the difference between them and the best time to use them, for which type of patient, and for which diagnosis. I graduated from physical therapy school equipped with a toolbox of basic therapy techniques.

I have expanded my collection of tools over the years. Some are now higher quality than the original ones and some are more specialized.
A more recent addition to my toolbox is Integrative Dry Needling. While this technique has been around for several decades and initially used to treat trigger points (localized muscle knots), I already had several ways to treat trigger points. After having a conversation with other therapists, I decided to learn more.

Integrative Dry Needling (IDN) has evolved from exclusively treating trigger points to include broader applications. IDN combines the targeting of specific muscles and the accompanying neuromusculoskeletal dysfunction. In other words, it allows me to consider the muscles and their nerves in treating pain and dysfunction. The needle insertion stimulates the nerves which can then reduce pain, and causes a local healing response in the painful tissue with the hope of restoring normal function.

This technique can help with soft tissue dysfunction including inflammation, tissue adhesion, swelling and pain, allowing me to use other manual techniques and exercise more effectively.

Adding the IDN “tool” to my toolbox gives me one more way to provide better care to my patients. And, perhaps just as importantly, I believe my dad would be proud of me for learning his lessons so well and continuing to maintain my toolbox.

~ Maggie Donohue, PT

Forty Years as a PT: Life-Long Learning and Following Clues

After 40 years practicing as a physical therapist, I’ve been thinking a lot about what has kept my interest going all these years, long after graduating from PT school, and what’s helped to keep it all fresh. From the beginning, I’ve felt like a sort of Sherlock Holmes in my approach to patients. The challenge of patient evaluation and diagnosis has always been of great interest to me. Advanced, ongoing training with leaders in the field has taught me to “follow the clues” and establish a plan of care for my patients, but only after clearly identifying the issue and cause. I’ve enthusiastically studied under some of the most creative leaders of the PT world in the years between graduating and now, as well as orthopedic and osteopathic leaders. Some are still teaching, even as new leaders emerge in the field. The following are a few of the important lessons I’ve learned along the way from these excellent teachers and that I carry with me everyday in my work with patients.

Listen to the patient!

The greatest advice was to learn everything I could from the patient’s own awareness and story. Details of what came before, during and along with their specific complaint often leads me to a certain path of inquiry. By listening to the symptoms of the patient, a physical therapist can often get a precise direction for evaluation. “Listen to the patient!” is a mantra that rings loud and clear from my training.

Understand the clues of the shoulder.

Dr. James Cyriax, an orthopedic leader I was lucky to study with, helped me learn to follow the clues of the shoulder to discern between problems caused by the rotator cuff and biceps, or the tissues of the joint itself. I learned to be able to zero in on whether to assist with movement, or if other treatment was needed. Would I help with gaining range of motion, perhaps with mobilization techniques and home exercises? I remember a lady who flew hot air balloons, who worked hard to get her range of pain-free motion back. She was so happy that she offered me a ride up in her balloon! Or, would I approach the shoulder with ultrasound, ice, scapular and rotator cuff muscle strengthening, posture adjustment, as well as creating a home exercise program? Training with Dr. Cyriax gave me the confidence to know that I could figure out what to do.

Mobilize the extremities.

Freddy Kaltenborn of Norway taught me how to mobilize the extremities, from the shoulder to the fingers and the hip to the toes. Though this training was many years ago, I use his techniques to this day and see my patients get better. A recent patient who came to me after a total ankle replacement had lost her ability to bend her foot up. After lots of casts and boots, it was my job to help her do that. Those trusty mobilization skills helped us to easily achieve our goals.

Put patients’ muscles to work with the Muscle Energy Technique.

I then enjoyed learning from osteopathic leaders, Philip Greenman and Fred Mitchell, diving into the world of Muscle Energy Technique (MET). MET allowed me to treat areas of the neck, thoracic and lumbar spines gently using the patients’ own muscle contractions, rather than using a “passive” technique of moving the joints by myself. One of my patients in significant pain was able to tolerate being put into a position from which she gently pushed into my hands, and then relaxed and moved toward the desired direction. She couldn’t believe how much better she felt with such little effort! This then allowed her to relax for further treatment.

No need to mobilize if it’s moving well by itself!

The world of direct mobilization (as taught by Stanley Paris and others) was always combined with a careful evaluation of the patients’ movements as well as passive movement by the PT’s hands. I learned the valuable rule that there’s no need to mobilize if the joint is moving well by itself. I’m reminded of a young woman who had pain in her shoulder, and who had previous unsuccessful joint mobilization treatment. I found instead, by careful listening and evaluation of her shoulder, that she had loose joints and that her shoulder indeed sometimes subluxed, meaning the joint was moving too far and beginning to dislocate. Rather than working on mobilization, we worked on strengthening of her rotator cuff and the scapular muscles—a treatment approach that hadn’t been tried. I joked with her that she would be done in PT once she could throw me across her on the treatment table. Well, she went for it. As she pulled me, I threw myself up and across her, both of us laughing hard. Don’t worry. We were both young at the time!

Posture begins with core muscles.

I learned about posture and its importance through my studies with Florence Kendall and Shirley Sahrmann who taught that a patient’s posture begins with evaluation of their core muscles. This includes the upper back and shoulders and the abdominals, including the transverse muscles and the buttocks. Correct posture and awareness of it can be a strong preventer of ongoing symptoms. They talked about the need to avoid being fooled by a tight muscle in one region, causing another area to be hypermobile— relative flexibility. That knowledge has helped me to zero in on exactly what came first. For instance, with a patient who was hypermobile in most of her joints, a tight quadricep muscle on top of her thigh was adding to the hypermobility of her low back, causing ongoing back pain.

Feet are indeed connected to everything else.

I took a course called When the Feet Hit the Ground Everything Changes. I was working at a University of Michigan Hospitals runners clinic and I needed to understand how foot position can cause pain from the foot and ankle up to the knee, hip and back. Most importantly, I learned that back and hip weakness, along with knee position, can affect the foot and ankle. Strengthening of the hip and core muscles, awareness of knee and foot posture, and mobilization of tightness in the foot were key takeaways. Only then would we consider a program of foot exercises and possibly orthotics to maintain good function. I continue to love to work with foot patients, be they runners, walkers, hikers or those who stand a lot all day.

So, what keeps PT fresh after 40 years? I admit that I love it when I can figure out the answer and or direction, and know what to do—the Sherlock Holmes aspect of it all. Thanks to time, excellent teachers and great patients, I’ve been able to just “keep following the clues.” And, I love that I’ll never stop learning.

~ Martha S. Torrey PT

Finding New Exercise Routines with Ankylosing Spondylitis

I’m a 28 year-old woman with a young daughter, dog, husband, demanding job and an overall active life. After a time of troubling symptoms, frustrations and some worrying, I was given a diagnosis of ankylosing spondylitis (AS), a type of inflammatory arthritis that affects the spine and other joints. It can be quite painful and was at first difficult to manage. Medications and physical therapy have been important pieces of the puzzle, but finding a way to incorporate exercise into my life was both a huge challenge and a big triumph.

Over time, AS can cause the vertebrae of the spine to fuse, which for me was the scariest part when learning of my diagnosis. Exercise became even more important to me because it helps to maintain joint function and motion, which helps to prevent fusion in the future.

I used to love to get out for a run and always thought that pushing myself was a good thing—at least it used to feel that way. My new reality became symptom flares of pain, stiffness and overwhelming fatigue. When I tried to run or do high intensity interval training, my symptoms would worsen and it began to take a toll on my daily life. I realized after a few tries at those old routines that they were the culprit. Over time, AS can cause the vertebrae of the spine to fuse, which for me was the scariest part when learning of my diagnosis. Exercise became even more important to me because it helps to maintain joint function and motion, which helps to prevent fusion in the future. I had to find a new way to exercise that would not send me into a flare and would also make my body feel better and stronger. I know now that I cannot do a heavy impact exercise; it’s just not in the cards for me anymore.

AS affects different parts of my body but my neck, back, wrists and hands are mostly affected. When flared, I have trouble doing simple daily tasks like folding a load of laundry and my energy level is very low. My symptoms are never fully “gone” but I do have days that are better than others. I used to try to do as much as I could on those days because I was feeling well, but realized that pushing my body was making my flares worse.

After many conversations with my body, I’ve learned that cardio is my best friend. I really enjoy indoor cycling and going for long walks with my dog. I know that, even on my worst days, the blood flow that happens when I cycle or walk does help me feel better. It’s a significant and positive change. I have also recently found my love for aerial yoga (yes, that’s me in the photo!). It’s low impact, challenging and fun. It has become a real passion of mine and I’m not sure I would have found it if I didn’t have to give up running.

My body has set limits for me and it’s my job to listen to it…

Learning when to push and when to back off really helped me keep up my exercise routine. When I’m walking, pushing through actually does help me. I can feel very stiff and go for a walk and then feel better when I get home. With all other exercises, I have learned that I cannot push through anything that feels painful or too hard while I’m doing it. My body has set limits for me and it’s my job to listen to it, whether that means modifying a particular exercise or trying something else completely. I took Donna’s core class this spring and it really helped me understand how to use my core in my daily life and while exercising. I have noticed that my core is getting stronger and I am able to put less stress on my joints as a result. (There’s a new class starting soon!)

I have a great team of supportive people who have given me advice along the way, including my physical therapist, who has seen me through this entire journey. Her advice has always been “listen to your body!” At first, it was hard because I was grieving the loss of the body I once had. I wanted to be able to do it all, but now I listen more than ever—to her and my body! I owe a lot of credit to my friends and family who have helped me through this, including my husband, who has been my number one supporter. He helped me to accept my diagnosis and has been consistently supportive on my good and bad days. Talking with people in general has brought a mix of advice, some helpful and some less helpful. People experience symptoms differently, so things that might work for others don’t always work for me.

As time has gone on, I’ve really gotten the hang of what’s happening in my body and how important my exercising routine is. If I get off track, my body tells me right away. I become very stiff, have pain in my joints, and am extremely fatigued.

The truth is, I will never have a pain-free day…In the beginning I felt defeated and frustrated, but as time went on I started to focus less on “why me?” and more on how I can live a full life with AS.

I have to be aware of what might send me in to flare at all times. Whether it’s an exercise, food, yard work or other chores, I have to make smart choices if I want to steer clear of a flare. It’s not always easy saying no, especially when trying new exercises or going for a run with a friend, but my health has to come first. This journey has taught me that I have to be flexible with my expectations for my body. There are somethings that I just can’t do and that’s okay. It was hard at first to let go of what I wanted to do and accept what I am able to do, but I can honestly say that it has improved my life greatly. I am more in touch with my body now than I have ever been.

The truth is, I will never have a pain-free day. It took me a while to come to terms with that. In the beginning I felt defeated and frustrated, but as time went on I started to focus less on “why me?” and more on how I can live a full life with AS. I am more careful with myself and have found new ways to move my body that I really enjoy. And I have a new appreciation for what I CAN do. It’s not always easy to look on the bright side when you aren’t feeling well, but to understand your body and find gratitude for it’s abilities is a true gift.

~ Chelsea Ahern, Administrative Assistant

« Previous