Neck & Shoulder Knots
Hey there! I’m Dr. David, Physical Therapist from El Paso Manual Physical Therapy.
I’m Dr. David, Physical Therapist from El Paso Manual Physical Therapy.
I was just doing some paperwork on the computer right now & answering some emails from some current patients of mine.
I was getting a little knot developing right here in my neck and shoulder area.
This is the space between my shoulder and my neck.
I exercise and I do some things to make sure I take care of it, but here’s one of the tricks that I use because I have to work at the desk quite a bit, and I know many of you out there probably have desk jobs where you’re working at the computer or maybe doing like paperwork at a desk.
Here’s a tip that you can use to help prevent those knots from getting worse.
You’ll even help prevent the knots to begin with, and be able to get through the end of the day so that you’re not just flared up by the end of the day.
Those knots might just be killing you, and you just want to go take some pain medication or get a massage or something, so you can get to the end of the day and feel pretty good.
First, make sure that your computer and your desk is set up so that you can put your arms on the desk like this and actually shove your shoulders up just a little bit. And it’s okay to slouch from time to time so that you can move your shoulders up. You see how when I lean forward a little bit, it raises my shoulder?
And it’s okay to slouch from time to time so that you can move your shoulders up. You see how when I lean forward a little bit, it raises my shoulder?
You see how when I lean forward a little bit, it raises my shoulder? Well that takes some tension off this area.
Part of the problem in getting these knots is that if I’m not supported from here pushing my arms up, the weight of my arm pulls down on these muscles right here, and it starts to stretch them out over time.
Now, it’s no big deal for a little while, 15, 20 minutes, especially if you don’t have a problem going on. But let the hours pass by. Say an hour or two, three, four hours, eight hours passes by, and this is hanging down, this is going to start to get really, really tight, and you can start to develop some spots in the muscle where it bulges up, and you create a knot.
Say an hour or two, three, four hours…. eight hours pass by, and this is hanging down, this is going to start to get really, really tight, and you can start to develop some spots in the muscle where it bulges up, and you create a knot.
Another thing that can be setting up a knot … Well, let me back up a little bit.
Have you ever had that type of knot that is hard?
You dig in here, and it just feels like rock solid, like it might even be a bone. Well, sometimes it is a bone. Let me show you what I mean on my skeleton here. So this is the shoulder right here, collarbone.
Well, sometimes it is a bone!
Let me show you what I mean on my skeleton. So this is the shoulder right here, collarbone.
So this is the shoulder right here, collarbone.
The first rib is right here, and your second rib is right here. Those ribs can actually pop up and contribute to that knot.
You might actually have a bone from one of these ribs sticking out.
They’re about right here, and they can pop up a little bit, and they can be really painful.
It can be really tender. It can feel really hard as well.
And that’s something that you’re not going to massage out. It’s a shifted bone up in the neck and shoulder area, and just rubbing it might make it feel better temporarily, but what needs to happen is we need to find a solution to get that rib to sink back down.
It’s a shifted bone up in the neck and shoulder area, and just rubbing it might make it feel better temporarily, but what needs to happen is we need to find a solution to get that rib to sink back down.
There’s a ton of reasons why those ribs can pop up. That’s something that we look at here, we talk to clients about all the time. And we can get them to come back down and settle down so that they’re not a recurring problem.
That’s something that we look at here, we talk to clients about all the time. And we can get them to come back down and settle down so that they’re not a recurring problem.
And we can get them to come back down and settle down so that they’re not a recurring problem.
But it’s just something I wanted to tell you about today. Now, if you work at a desk, make sure, just to review, your arms are supported like this, or if you have a chair that has some armrests, especially if they’re adjustable, make sure those armrests push your shoulders up a little bit from your elbow down here.
Now, if you work at a desk, make sure, just to review, your arms are supported like this, or if you have a chair that has some armrests, especially if they’re adjustable, make sure those armrests push your shoulders up a little bit from your elbow down here.
I hope this helps you out.
I hope that if you have a desk job, you’re not running into those shoulder knots.
If you do have knots in your neck and shoulders, try these things.
And if you’re still getting problems, you might have a shifted rib, or there could be some other problem.
There’s nerve problems that happen up there too.
Sometimes there are muscular problems that need a specialist’s help as well.
Give us a call. Reach out to us. Contact us on Facebook.
Contact us online, and we’d love to help you out and talk to you more about it.
Thanks so much. Have a wonderful day.
Dental Health – Dr. Philip Buckler DDS
/in Podcast/by dmiddaughDr. David
Hello El Paso! This is Dr. David, expert physical therapist. I'm the owner of El Paso Manual Physical Therapy. Welcome to the Stay Healthy El Paso Podcast. I've got with me here today Philip Buckler, he is an expert dentist and has, to me worded most clearly, and most succinctly explained things about dentistry, that I never understood.
Of course, I've grown up going to the dentist my whole life. But I love the way that Philip explains things, whenever asked him questions. Full disclosure, he's a patient of mine. He's really close. He's had an awesome experience here at El Paso Manual Physical Therapy, and I wanted to bring him on the podcast, because he has fantastic advice for dental health.
I wanted you guys you listeners, to be able to experience that from Philips. I've got some questions for him, but before we go into that though, Philip, please tell me a bit about yourself. Where are you from, and how did you end up in El Paso?
Philip Buckler
Okay, I'm originally from Oregon. I went to dental school in Michigan. I ended up in El Paso for my job and I fell in love with the city, and also met my wife here. I've lived in El Paso since the end of 2011 actually integrated from dental school in 2010.
Dr. David
Fantastic, awesome! And of course, you've been practicing as a dentist since then.
Philip Buckler
Yes, with a one year add residency, which is kind of an additional year of training beyond dental school.
Dr. David
Awesome. So, you're a super dentist, then…
Philip Buckler
I wouldn't go that far. But the extra training was very beneficial.
Dr. David
Awesome. And your experience, you've treated a variety of ages and specialties. Is that right?
Philip Buckler
Yes, I believe the oldest person that I've seen was 96, I want to say, and the youngest person that I've seen, I've seen a few children as young as a few months old. I'm not a pediatric dentist. Pediatric dentist tells you something that contradicts what you hear for me, go with what the pediatric dentist says with regards to children.
Dr. David
I wanted to pull out of Philip here for you guys. Just some clear up some general health tips. Get clear on a few dental ideas, dental hygiene ideas, and hopefully this is helpful for you listeners at home or wherever you are in the car, at the gym, wherever you're listening to this right now.
One of the most common questions that I hear people talk about is, how many times a day do I need to brush, is it once or twice? Is it after every meal? Should I be impulsive about this? What do you have to say about that? Phil?
Philip Buckler
Well, the answer to that is, for me, it's more comparable to any other area of hygiene. You just need to keep the surfaces clean, a tooth surface that is kept clean, will not develop decay. Unless, there are a large number of other factors present. But good hygiene will cover over a multitude of other potential drawbacks, either genetic or coming from additional treatment like cancer, that sort of thing.
Dr. David
Gotcha. If you had to make a general recommendation, and we have talking a little bit before, as you mentioned about assuming that your genetics aren't that great, so you have to just brush so often.
Philip Buckler
Assuming each surface in your mouth is cleaned at least once every 24 hours each tooth surface is cleaned once every 24 hours, you're good. The standard recommendation is two brushings a day. But if you can get them all in one brushing, or one brushing and flossing, right before bed, so everything's nice and clean before you go to bed. For many people that will be adequate.
The criteria for success will vary from person to person. Because the criteria for success is your teeth are staying in your head, you're not developing periodontal disease and you're not developing decay. If you aren't developing ant new cavities, and your teeth aren’t starting to get loose and fall out, and your dentist tells you that you're not losing bone around your teeth, then whatever level of hygiene you're practicing is adequate, or at least close enough to it for long term sustainability to have your teeth last as long as you do.
Dr. David
So basically, you have to figure out a little trial and error, work with your dentist to get feedback on is what I'm doing enough? Can I back off a bit and be okay still that that's generally how you should proceed?
Philip Buckler
Yeah, many people, if you brush and floss very thoroughly once a night before bed. That's often adequate. My wife, before I met her, she hadn't seen a dentist for seven years, but her teeth are better than mine. And they are clean. I'm jealous. I hope our kids get her teeth. So that just shows the disparity. Some people have to work at it more than others. So again, don't assume that you fall into the easiest portion of the population because that's a good way to lose your teeth. But there is a wide variability.
Dr. David
My wife's the same way. When I met my wife, I had just started flossing regularly because I had the dentist told me I needed flossing. I didn't know how to floss. I finally had a dental hygienist take literally, maybe three minutes, four minutes and showed me how to do it. She taught me about the hug and pull,
Philip Buckler
Using it as a scraper on the inside of the teeth, as it helps to see go back and forth.
Dr. David
It's been a game changer. We taught our kids, but my wife said, when she saw me regularly flossing every day, she said “Really, you floss all the time who does that?” And she put her hands in her hips and said, “I've never had a cavity and I've never floss” and I was like “well I've had a lot of cavities!”
Philip Buckler
Good for her. I'm glad she can get away with it. But most people can't. And for anyone who doesn't like to floss, then in your case, the best form of dental insurance the best gift you can give yourself and it will save you thousands of dollars is a very high-end electric toothbrush. Very high-end Sonicare or an Oral-B. Something that will produce enough agitation inside your mouth against your teeth that will help flush out there in between the teeth.
Now that's the next best thing, and I actually have had people who use those, fool me into thinking they were flossing on a routine basis, which probably doesn't impress my fellow practitioners or any hygienists but I'm sure it's happened occasionally.
They're good products and I don't get any kickback from them. I've used both of them myself. It's just individual preference. Yeah. Other products that help her Water pick super floss. I'm not particularly picky about how my patients get their teeth clean as long as they are clean and they're not developing cavities and they're not they're not losing bone so it looks like the bony support for their teeth will last them through the rest of their lives. A lot of time.
Dr. David
You know about the motorized toothbrushes, what did you call them again?
Philip Buckler
Like a Sonicare or an Oral-B? Those are the two big brands, but there are a lot of other good brands.
Dr. David
I'll never forget, growing up, and I heard you use the same words that I've heard of the dentist say, a high-end toothbrush. And automatically when the dentist said that. I remember telling my mom that I needed a high-end toothbrush and I got the sense of “Oh, we can't afford that it's too high end.” Then when I actually bought my first one, I said that was 40 bucks, relative to a normal toothbrush is maybe 10 times more, or however many times more it is, but those… I got a Sonicare and it has been one of the best investments ever made. It is completely different brushing your teeth, one of those rather than a regular toothbrush.
Philip Buckler
And as long as it prevents at least one cavity, you've more than made your money back. Or if you get one of the $200 toothbrushes, then it might take a couple of cavities prevention. But it's an investment that will repay itself. It's cheaper and more effective than dental insurance.
Dr. David
Oh, yeah. So, we started taking our kids to the dentist, because they are getting bigger, they get more teeth of course, and from the get-go, we didn't want to get them kid’s toothbrushes. Because the brush heads on the Sonicare toothbrushes that we have, are actually kind of small, smaller than the normal toothbrushes, and they fit in my kids mouths better.
Plus, they think it's entertaining to the thing buzzes in their mouth, and they loved it. So, from the get-go, we started having them get used to Sonicare toothbrush, and every time we take them to the dentist, they're like, wow, your kids teeth look great. their gums look great. Just keep doing what you're doing, is what they tell us. I've loved those toothbrushes. I can't go back anymore.
Philip Buckler
Yeah, I'm going to be making sure that each of my kids has a good electric toothbrush. One that runs off double A batteries, does not qualify as a high-end toothbrush. It's more of a gimmick toothbrush better than nothing. Now, don't get me wrong, some people can do everything with a manual toothbrush. I've seen plenty of people who do that, but if you need that extra umpf, it'll really save you time and money, and time and pain in the dental chair.
Dr. David
Oh yea, that's no fun.
Philip Buckler
But dentistry is very friendly these days, relative to how it used to be.
Let's see what else to talk about. Oh, yeah. So generally speaking, I tend to compare people's teeth to the treads on your tires, they will wear down over time thousands of cycles a day. Every day, every year all your life. Your teeth are like anything else mechanical. They are like any other part of your body. They do wear down, they will get sensitive. Some people have problems with their knees, some people don't.
It's the same with people's teeth. A lot of people ask me about jaws clicking, cracking and popping. Again, there's a lot of individual variation on that. I generally say that some people's jaws are more flexible, and others cannot. It's kind of like some people can crack their knuckles or make a habit of doing it.
Again, that's an oversimplification. There's a wide variety of things that go into that. But when your jaw opens, it actually goes through two forms of movement. The first is a purely rotational type of movement for the first half. And then the second half is when you're opening to the full extent. That is what we call a translation movement where the combine all of your mandible is actually moving against the maxilla and physically shifting out of place rather than just rotating to the socket.
To help facilitate that, your body has a disc of cartilage, like it does in many other joints in your body, and occasionally, that disc or curtilage doesn't move optimally, or when you get older. Sometimes it just wears down period. Like arthritis, you can get arthritis in your jaw joint. Oftentimes, that will produce a clicking, cracking, popping sound.
Most of those sounds are not something that needs to be directly addressed, as long as you're chewing comfortably and functioning normally. Oftentimes, it's keeping an eye on it. If it really is messing with your quality of life, there are treatment options, and I'd advise you to see your general dentist and possibly get a referral to a specialist to get that looked at.
Dr. David
Yeah, I think that's good. Just to summarize that in a super concise way, I think the takeaway points from that is, the jaw joints are complicated. It's not just like a hinge joint. There's a bunch of funny movements and then just like you hear about in knees, there's a movable piece of cartilage in there, discs is what they call it, kind of similar in the spine and having compare that to, it's not an exact analogy, but it's very effective.
That disc can be injured, or it can shift in funny ways, or in that can produce clicking sounds. Even can hurt or make the jaw move unevenly. But it basically would fill up here is saying is if it doesn't hurt or isn't affecting, eating or doing anything with your mouth, then not a big thing to worry about, at this point, just monitor it makes sure it's not getting any worse.
Philip Buckler
In general. Yeah. And just kind of like you keep an eye on a knee that tends to pop when you move in a certain way. Same deal with your jaw. There's actually a very in-depth sub specialty of dentists, that and often general dentists will become certified through additional fellowships through this, that specializes in treating disorders of the jaw joint. If it's really messing with your quality of life, that's when you might want to consider seeing one. However, for most people. It's that degree of intervention isn't warranted. It's pretty extreme. But for those people who need it is it can often be very beneficial.
Dr. David
Yep. Super good information. I love this. One of the things that we were talking about, before we started recording here, was about diet and about what you're eating and how that might affect your dental health.
Philip Buckler
Yeah, so when I see someone with good hygiene, who also was developing a bunch of decay, and they don't have anything in their medical history, like radiation therapy, that would decrease their salivary flow, then it's the typical culprit is diet. The way cavities form in your teeth of course, like any other part of your body bacteria likes to live there. It's a nice warm, wet environment. So, bacteria like to live there even more than most places bacteria like to live.
That's why you need to clean it once every 24 hours in order to keep those bacterial colony sizes down. Whenever you put something with calories, or burnable calories in your mouth, the bacteria that are living on your teeth will metabolize that as their waste product, secrete acid, and that acid will not only decrease the pH of your saliva below the point where your minerals start leaching out of your teeth. But of course, they'll also do that in a much more localized focused area on the teeth, which is why you don't want to let any bacterial colonies grow in specific areas on your teeth for any extended period of time.
A lot of areas that people miss, tend to be done by the gum line, especially on the canines and second molars, because those are those areas that people miss. So, don't let plaque buildup back there. But when those areas, those bacteria in those colonies are fed, the pH of your mouth will drop below the mineralization threshold for about 20 minutes according to the classic studies. Every time you take a bite of something with calories, or sip something with sugar, or any other calories, not just sugar, but oatmeal is kind of a Greek culprit that a lot of people don't know about.
That will basically restart that 20-minute timer. So as far as your teeth are concerned, it's usually not how much you eat. It's, in terms of sugar, how often you eat it. If you're nursing an energy drink throughout the day, that's a lot worse for your teeth than say, downing three meals a day, even if they're pure sugar, the rest of your body, your pancreas would object to that much sugar. Your teeth you won't have nearly the problem. So again, it's kind of a moderation thing and unsweetened coffee, unsweetened tea will stay in your teeth. But if you're looking for some kind of an energy buzz or a caffeine buzz, I would suggest developing a taste for unsweetened teas, unsweetened coffees, because well, they'll stain your teeth, but they won't damage them. Caffeine in and of itself doesn't actually lower the pH. of your mouth.
So, it's kind of an indirect effect, but your body actually deals with that because your saliva is super saturated with minerals. When the pH in your mouth is at normal resting pH your teeth will actually absorb minerals, from your saliva, which is good in general. But at the same point in time, once they've absorbed enough minerals, you start to get mineral deposits on your teeth.
It's a very fascinating engineering trade off. You get the deposits on your teeth, but those calculus deposits will irritate your gum tissue. And, of course vector you'd like to live on the calculus deposits because they're much more varied in terms of surface area, and they're harder to clean. So that tends to lead to more gum disease.
The areas of your mouth that are most resistant to decay, also tend to be the most prone to Calculus buildups and bone loss and gum disease. Usually, that's where your salivary glands empty so there's no direct solution. It's only engineering tradeoffs, and it's very interesting, and you can hope that by keeping your teeth clean. Some people with more mineralized saliva just tends to build up more calculus. So, life isn't fair. Some people do need to visit the dentist four times a year, and some people can get away with visiting the dentist one time every seven years. And they're good.
Dr. David
Yea my wife is lucky. I have to go on a regular basis and I'm happy to. I always tell people I will use a Sonicare, I will get a high-end toothbrush, I'll floss, I'll use the water pick whatever it is. I want to go to my grave with good looking teeth.
Philip Buckler
Yeah, and one thing I hear oftentimes, I'm never quite sure how serious people are about this, that they'll just get their teeth taken out and get dentures, and that dentures are way better than nothing. Don't get me wrong, newer dentures that are Implant Supported. I'll be honest, that costs about the price of the new car to get an implant supported set of dentures, but man, they're functional jewelry that's worth it.
If I ever get into a major accident and lose my teeth, I'm going to remortgage my house to get implants supported dentures, because the difference is amazing. But even normal dentures, or even little dentures are still way better than nothing. But they are like prosthesis for your mouth.
You don't get the same kind of function with a denture that you would get with normal teeth, you don't get the same tactile feedback. And it's almost like wearing a custom-made pair of shoes in some ways. Your mouth also changes over the course of your life like the rest of your body. And one of the things that goes on in the case of dentures is that your bone sticks around to support your teeth. When you have no teeth there, the bone will gradually remodel and recede. So, the dentures gradually become loose and fallouts.
Oftentimes, dentures have to be remade, and by oftentimes, I mean once every three to five years and oftentimes more in order to keep them functioning well. And if they don't function well, if they develop sore spots, they're very uncomfortable to wear and they can be normal situations and so there is a learning curve to using them. You don't get the same tactile feedback. But again, they're a lot better than nothing. And if your dentist recommends dentures, it's probably because the health benefits of keeping your teeth in place are now outweighed by the benefits of taking those teeth out.
Because when teeth get loose enough to the point where you can't clean them, or the bacterial colonies get big enough, your mouth is very resilient, and it has an excellent blood flow and can bring far more white blood cells to the site than almost any other part of your body. But at the same point in time, that bacterial load does still play stress on your body. So eventually, if a tooth gets loose enough, the question isn't going to come out. But is it going to come out on your terms or its terms and are you going to have to get it out when you have a chronic infection that's losing puss…
I'm sorry, I don't mean to gross everyone out. but I've seen cases, so generally a controlled plant removal of teeth followed by the delivery of a prepared denture or followed by multiple impressions to make a denture for your mouth as it is, once it finishes its healing remodeling process is a much better alternative to letting things go on their own.
That being said, again, there's compromises and tradeoffs. Everyone has to decide for themselves, as an individual where they're at. And of course, there's costs for dental treatment, you just have to make the best judgment call you can about how you're functioning with the teeth that you have.
Now, if you if you ever have to look into that situation, or you're ever faced with that choice, see where your teeth are at now, versus where you would be with dentures, and just kind of make that call and decide when that would be right for you. That will vary from case to case. I see my role as a dentist to give people the information they need to make the informed decision that's right for them, rather than necessarily dictating to the decision to them.
Oftentimes people ask me what the best option is. In that case, I look at their teeth and I'm like, well, if your teeth are my teeth, here's what I did. But oftentimes there's plenty of good options. There's a joke that if you go to 10 different dentists you will get 10 different treatment plans.
That's not because dentists are blind, it's just because there are multiple ways to approach a problem. And a lot of these teeth problems are not just medical, but they're also mechanical. And there's multiple ways to get to the right solution. Dentists are individuals in terms of what works best in their hands, it's the same thing that you would run into in terms of a surgeon who recommends a particular procedure that they're very good at, which is where you get the Doctor of Dental Surgery degree or a different approach.
If you're in doubt and you're contemplating a course of dental treatment, whether it's expensive or invasive, or just because you want to educate yourself, one of the best investments that you can make is to get a second opinion. Once you find a good dentist, stick with them, and there's a lot of good dentists in El Paso. The El Paso district dental society actually does have a large number of good people that I know quite a few. And there's a lot of excellent dentists in El Paso. And that number is growing.
Dr. David
This is awesome Philip, this has been phenomenal information. I feel like we cover the whole gamut. We talked about kids a bit. We talked about, what you should be doing normally. And then we even went into end of life, dental hygiene, talking about the dentures and all that stuff.
Philip Buckler
Yeah, thank you for your time. I know I can get long winded on this, and there's so much more that could be said, and people are keeping their teeth longer. It's just great. What's going on dentistry as far as the advances that are being made even just every year.
Dr. David
Yeah. That's awesome. It's very exciting. Well, thank you so much for your time, Philip. I really appreciate it. Hey, everybody, for those of you listening right now, go on to the platform that you heard this podcast on, whether that's Apple platform, the Google platform, Android, wherever you're going listening to this.
If you want to get more health information just like Phillip said, so that you're in the best position to make the best decision about your health. Educate yourself and hit subscribe so that you get notified about when we put out more information so that you can learn more about how to stay healthy in El Paso. Thank you so much, and we'll talk soon. Bye. Thank you.
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Choose which one works best for you…
Special PT Student Interview
/in Podcast/by dmiddaughDr. David
Hey, welcome to the Stay Healthy El Paso Podcast. I'm your host, Dr. David Middaugh, physical therapist, and I've got a special episode for you today. I've got with me here Lilly. Lilly is my physical therapy student. She's in her last week of her final clinical rotation. She's about to become Dr. Lily soon here. As long as everything goes fine with this podcast and we don't automatically fail her… I'm just kidding.
But no, she's doing fantastic. I was so happy that she agreed to do this little interview, to help out any students out there in physical therapy school, that are looking to do a clinical internship at a manual therapy clinic like we are. Or a private pay clinic, otherwise known as a cash-based clinic. Because we're both, we're a private pay manual therapy clinic.
I just wanted to get her thoughts, and her honest answers, on what her experience was like. So that if you're thinking of doing something like this, then you can have it straight from Lilly here. So, without further ado, hi, welcome, Lily. So, let's get into it. What were you expecting? Prior to coming to this clinical rotation, you knew about us a little bit already, you explained about how you heard through some friends, about us. What were your thoughts prior to coming?
Lilly
Yeah, like you said, I had heard about you, and my big sister in the PT program actually did her internship here. She said great things about it. She said she learned so much. And also, when I was at my second rotation, my CI actually recommended you to one of our patients who needed some orthopedic work. So, I just heard all around great things from you. And I didn't know what to expect, it being private pay, and just manual therapy. I didn't know how you could just do manual therapy for the whole hour or whatever. But I was expecting just something new and something really good. I didn't know what to expect actually.
Dr. David
Cool. I always just think some people get nervous or concerned, because it's not your typical setting with insurance and your gym settings as well, sometimes people come into the clinic here - because you actually visited us before starting your clinical rotation - and most people that come in for the first time, they're like, where's the treadmill? Where are all the weights?
Lilly
It’s very different here. But I have a massage background. So, it being small and intimate. It's very familiar to me with being a massage therapist. So, I wasn't turned off at all. I actually was welcomed by it. And it was cool. I knew it was going to be different.
Dr. David
And we only take students in their last clinical rotation. What did you feel? How did you feel that that went for you? Did you feel like that was a good thing? Or like it maybe should have been different? What are your thoughts on having to come here on your last clinical rotation?
Lilly
Well, I'm definitely glad I had the experience from prior rotations, before coming here because I mean, this is a hard rotation. So just even being able to talk to people about having to pay out of pocket, and not using their insurance. Having that experience from being able to talk to people, and have rapport and all that from other rotations, helped me out.
And then of course, like some of the orthopedic background that I had, and being comfortable with bodies, that helped me out too. But I honestly wish I had this rotation first, just so I could continue to use all the skills that I learned here at other clinics, so that I could better help them. I felt that, learning what I learned here now, and then looking back on the experiences I had with other patients, I could have done so much more with them.
But I mean, obviously I feel like I needed that experience first to get here. And now just having this experience I'll just be better whenever I start as a clinician, so I feel it's appropriate.
Dr. David
Yeah, I can see that for sure. Here in the clinic we weighed, do we want to take students, earlier in their clinical rotation, part of their education or later. And the main reason that we decided to take a student at the end was because, at the beginning, you're probably aware of how to go to metric measurements, do manual muscle test, do other special tests, but you just don't have that many reps doing it.
Because we are teaching students here pretty advanced stuff, we'd rather spend our time on the advanced stuff, on the cool manual therapy stuff, instead of like, here's how you get force on a muscle test. We didn't want to spend a bunch of time doing that. We figured it's probably best if they do that in another clinic on their first or second rotation.
But I went through that myself, actually. My first clinical rotation was at a pretty strong manual therapy clinic, and so I know what you went through where you're like, I wish I could have applied this but what I ran into was my second clinical rotation, and the one after that was not manual therapy based. And when I wanted to implement manual therapy techniques that I was comfortable doing my CI that weren't trained in manual therapy weren't comfortable allowing me to do it. They couldn't monitor the effectiveness of it, they didn't feel comfortable putting their license on the line, in case something bad happened with the patient, and they weren't familiar with it.
So, they weren't sure of what the side effects could be, if any. It was a little frustrating on my end, but I'm glad that you made it this far. So how do you think this whole experience, going through clinical rotation here in a in a manual therapy clinic? How was this beneficial for you and your practice as a future PT?
Lilly
All this was awesome. I'm so glad that I had this experience because, I mean, you went through fellowship training and you had five extra years of advanced training after PT school, and I got your Cliff Notes. So, I got that specialized training in a shorter amount of time. And, yeah, I'm not going to be as advanced as a fellow, but I have that training. And that some of those techniques that they use, I feel comfortable with.
I probably won't ever get to that level that you are until I go through the program, but at least I feel confident and I know that my skills are way, way more advanced than I ever could have imagined, especially with manual therapy. I just know that I'll be a better clinician overall. I feel confident just talking to people that I run into in everyday life that aren't patients and they have problems and they say yeah, you know, I can't play soccer because I have a meniscus tear, and I don't want to have a surgery. And I say, come in, have some PT. Because this is what we specialize in, and I'm going to help you avoid surgery and you don't have to have the surgery. Let me help you.
If I hadn’t had been event here, I wouldn't have been as confident to say that. I would have done the usual PT stuff, but now it's a lot more specialized and customized. So, I just feel like, I know I'm better off having this experience than if I had never had it.
Dr. David
Nice, awesome. I'm just going to inject what I went through as a student going through my clinical rotations, and once I figured out that I wasn't inpatient material. I didn't know honestly, when I started my clinical education, I went into it with an open mind saying, maybe like inpatient, maybe I'll like neuro, maybe I'll like outpatient. I didn't really know and then once I discovered manual therapy, outpatient orthopedics, I fell in love with it.
I had an inpatient rotation and absolutely did not like it. I did not like dealing with bodily fluids of any sort. This wasn't my thing. Wound care? Forget it! So, I got deep into the outpatient part of things. But it's just so difficult to get specialist training throughout, and then I felt like all my outpatient clinical rotations were very similar and I didn't really learn much. I felt like I learned more about coding for CPT codes. You know, how to manage three, four plus patients all at once and allegation, tech and assistance.
Although that's a valuable skill, it's not like directly clinical in my opinion, it's more so, I mean, it is clinical in the sense, but it is more managerial, like managing people, which is important for the health of the patients that you're responsible for. But as far as doing a technique or learning a new exercise or patient education, explaining something to a patient differently. That's not something that I quite got when I did three outpatient orthopedic rotations which are all very similar.
Lilly
Yeah, no, this is a whole new world. It's elite. It's specialized, for sure. The manual therapy, and I'm just grateful that I got the opportunity to catch a glimpse of it, and see if I want to further my education become a fellow on that now, who knows? But you're right. I forgot how fresh and green I was during the first rotations and we were talking about CIs having to say, this is where the going is, and just getting reps in, in doing range of motion and all that basic stuff. I'm glad I had that elsewhere because we were able to focus on the good stuff. And we were able to get into the meat of orthopedics and manual therapy. So, yeah, it's been awesome. Being a part of that.
Dr. David
Good. So, what do you think was the hardest thing for you to learn here?
Lilly
Definitely doing manual therapy on Dr. David Middaugh. I'm pretty small and he's pretty big. So, the mismatch of our bodies, it worked out, for sure. Every time I really had to adjust to his body type. But I think that also helped me, because patients that we get in everyday life, they're going to be bigger than you, or they are smaller than you or whatever. So, you have to be able to adjust and modify. I definitely got really good at modifying. Working with you specifically.
But yeah, I think also just building up my endurance to do manual therapy for a whole hour, because we are used to doing it on one body part, and then that's it, you do 30 seconds to a minute. But now you have to be efficient and be able to run through different parts of the body and building my endurance to be able to do an hour, I think I was pretty comfortable with it.
Also saying that I have the massage background but being able to work on a bigger body type and do manual therapy for an hour. That was that was pretty hard. Also, discovery visits here were hard. Being able to talk to a patient and explain to them and educate them.
The way that we educate here, I think it's really cool. We pull out pictures from the netbook and show them exactly what's going on in their body, show them how this happened, and then being able to talk to them in the way that they're going to listen to respond. I learned that from Dr. David here, and that's something that I didn't think I'd ever learned at a PT clinic.
Dr. David
Yeah, you know, for context, a discovery visit, is basically like the initial consultation or just meeting the patient for the first time and letting them know we can help them or not so that they can decide if they're going to work with us, you know, hire us and begin treatment with us.
And it's a critical visit just because we're building a relationship, we’re diagnosing their problem, doing our physical therapy, diagnosis, and then setting some expectations about how we can help them out, and what to do, and if you think of like a sales talk, that's kind of what it is. It's not in the sense of a car salesman.
I think whenever I say the word sales, people automatically think of a cheesy car salesman. But I mean, you could talk about it. It's literally just sharing your knowledge with somebody.
Lilly
Yeah, I think that was like, the biggest thing. We have such a large knowledge base and people don't know that stuff. For us, it's common knowledge, especially other PT students and other PT programs. But when you start telling them like, hey, yeah, I worked with cadavers, and I looked at this tissue in real life, like I see in your body, and I was able to see it and you share that with them. They're like, wow, you know that you went through that.
And that's part of you selling even though you're not trying to be cheesy, like you said, but it is kind of dabbling in sales, but it's just being genuine and sharing what you know, which is, we know a lot about the body but I think the difference here is you're trying to get them to buy in and actually take money out of their pocket because they're not using insurance here. And that I think, was kind of hard for me at first but with the right coaching and getting reps, I was pretty confident after about like six weeks or so.
Dr. David
Yeah about halfway through. She did a 12-week clinical here just to give you the context, and the first half was pretty much like familiarizing yourself with, getting grilled all the time.
Lilly
I was in the hot seat a lot.
Dr. David
Quizzed, checking her hands-on skills. From a clinician perspective, from a CI perspective, like her instructor, what I was doing during those first six weeks was gauging how fast she can go, how much information can she take, how good is she applying what I'm teaching her, so that they can determine how fast can I let her loose on clients independently.
From the get-go, she was touching patients and doing special tests. I was getting her involved in feeling certain things, doing some of the treatments as well. But as far as me stepping out of the room, because we do treatments in rooms, we're essentially in one room. We're not an open clinic so I can keep an eye on everybody as we're doing stuff, so it's a little tricky from a clinician, from a CIO perspective, because I don't want to be a fly on the wall the whole time. It's kind of awkward when it's just a small room and a table and the therapist, so I needed to feel confident that Lily could step in handle business.
I could step out and she's got it from beginning to end, and she aced that. She did really good. But it took a lot of coaching and training and her part on her part, just putting in the effort and making sure that that she was confident, and we had a lot of discussions about confidence along the way too. That was a big concern of mine.
You definitely have to come in with a certain level of confidence and be ready to stand on your knowledge base and your skill level.
Lilly
And then go home and practice. For sure. Because I did that a lot.
Dr. David
Tell us more about that. What was it like for you? I mean, how much time? How do that go?
Lilly
I remember when of the things you gave me a packet on how to prepare before I even got here. And one of the things that I read was practice your mental manual therapy skills 5 to 10 minutes every day. I really took that to heart. I was like, No, I really, really need to practice this. So, I'm looking at a massage table at home, a treatment table, and I remember, the first week I would go home, and I would write down concepts, like mechanics of the neck, or the sacrum, just to get those concepts down. That way whenever I come in, and I have to talk through with Dr. David and tell him like, no, this is where the restriction is. I know because this is how it moves, and this is how it works.
I'd have to visualize that at home. That way I can come in here and be able to say it without looking like I don't know what I'm saying. I practice the knowledge of it, and then also practice on my husband. I would work with him and he loved he loved it. He loved me being here because every day I would go home, and he thought it was a massage, but I'd be looking at joint integrity and assessing stuff.
So yeah, at least every day. And then whenever on the weekends, I'd be with my family and work on different body types. I know we talked about that too, how that was important. So, my niece and nephew got some hands-on work too. And then everyone wanted me to work on them. So, everyone liked me being here.
Dr. David
Yeah, what she's referencing to is just how you have to adapt your body size, your hand, your body shape as well, to the person that you're working with. Which is obviously going to probably be a different size and shaping you. And like she mentioned a while back, about how I'm a big guy. I'm 6’2, over 200 pounds and Lilly is 5’2 or 5’3?
Lilly
Yeah, 5’3
Dr. David
She is a lot smaller than me and getting her to do a lumbar technique or a thoracic technique is pretty challenging to kind of wrap your arms around me. It's a big deal for her to find adaptations trying it on different people because she felt like she was failing all the time around me. Trying to do like a thoracic manipulation or something but she could probably go knock it out easy on somebody her size.
Lilly
Or my niece and nephew, they loved it. They're like pop my back.
Dr. David
How old are they?
Lilly
One is 15 and one is 13.
Dr. David
So, they are on their way to being an adult. They're little mini adults.
Lilly
But I did have that click. I think I even mentioned to you, how I had been practicing and practicing, and then one day I was practicing on my husband and it was like my hands were just doing it automatically. It was like an epiphany because I finally had that psychomotor score. I was like, I got it finally, I think it was on the neck. Because that was one of the parts that I felt comfortable early on. And I was like, I just know how to do it now. And I felt so happy and it wasn't right away. It wasn't even like after a week, it was like maybe after three weeks. It just clicked where it's like, I finally got that manual skill down.
Dr. David
That's definitely how it works out where it needs to come on with multiple reps, you have to just keep going. That's why I tell people practice at home. Even while you're here, practice at home before, and then even when you're here. Practice at home when you're not here. Just that you're heavily involved in it. You're thinking about it. I mean, you should literally be dreaming about doing manual therapy.
Lilly
Yeah, for sure.
Dr. David
So, we talked about the hardest thing. What do you think was easiest thing about being here?
Lilly
The easiest thing for me personally, since I have a massage background was the soft tissue mobilizations. I always felt pretty comfortable whenever a patient came in. And they're like, Oh, it's over here in this area. And after I had done the usual mobilizations, or even the soft tissue work, that you had showed me, I was able to implement strategies that I do, and I was able to treat them and help them in a way that I felt was pretty effective.
Soft tissue work, for me has always been pretty easy. And then just talking to people, that's a big thing here. As PTs we have to establish a relationship, but in order for them to want to come in, something that you taught me was, make it fun for them. Engage them and start talking about stuff so that they get their mind off of you literally grabbing their bone and moving it so you're able to work freely.
So that was pretty easy for me just having that connection with patients and I really enjoy that. I love talking to my patients and talking about their dogs or their work, or whatever is going on. That was nice. It wasn't too hard.
Dr. David
I love that part about this, the way that we do things. Because we see clients completely one on one, for an hour most of the time. And you really do develop almost like a family type relationship with clients. I mean, you were just telling me before this, how you had one client who had a death in the family and then, as we record this, we're in the middle of the Coronavirus lockdown so everybody's gone through that as well.
So, it's been stressful for patients coming in here. And they come to you, I haven't even talked to some of these patients so barely talked to them. The ones that you're working with just at the introduction, and then when they walk in and for the subsequent visits, they barely Say hi to me, and they are ready to go work with you.
Lilly
Yeah, they're my patients for sure.
Dr. David
I think that's pretty cool. You develop that relationship.
Lilly
We've been through a lot together, and I think I was there emotional support. Whenever this happened, like the Coronavirus and people shutting down, I think they were kind of emotional support for me too. Some type of normality. So, it worked both ways.
Dr. David
What would you say was your favorite part of this clinical rotation?
Lilly
My favorite part, aside from learning all these advanced techniques was for sure getting treatment. Dr. David would have to show me the techniques and I actually had a sacral shift, and I didn't know. I had low back pain, but I'm a mother of a three-year-old, so I always thought like, Oh, it's just because I had a kid and it comes and goes, I just have a little back pain for the rest of my life.
Then he's showing me this how you assess, with leg length discrepancy, you look here and he's like, you got a sacral shift. And I was like, wow, fix it. He definitely put his hands on me a few times. I even had a knee problem, and you helped me out with that, and I think even a neck problem. So that was cool. It was like getting some treatment out of it.
Dr. David
Yeah, for me, it's needed because well, obviously, so that you feel good while you're working with patients. Last thing I want, is for you to be in pain doing that. But you also learn a lot from getting the treatment to see, and to be the recipient today to get a therapy. Somebody who knows what they're doing, putting their hands on you. Compared to somebody who's learning how to do this stuff, to see what it should feel like to feel the joint move to because you have a different mind going into this.
Unlike somebody who's not in the medical field or isn't familiar with the type of mental therapy stuff that we do. They're not really paying attention to what to look for, but you've been living and breathing this stuff for years now. Being inserted in PT school. So, you're very aware of what joint we're on, how we're moving it, what muscles influence, and all the surrounding topics regarding rehabilitating it.
I see it as like, even if you didn't have a problem going on, and you do some of these techniques to use so that you can feel it. That's pretty much how we progress through things. Whenever I'd show you a manual therapy technique, I'd say I do it to you, and then you do it to me, or somebody else, so that you can know what it's supposed to feel like.
Lilly
And it helped me out. Because since I had the experience of feeling it. First off knowing what the pain was like, and then knowing what the treatment was like, and feeling better afterwards, I was able to explain it to my patients better. That way they know what to expect. And I could even just have a story to relate to and say, Hey, I started working out here.
I started doing some deadlifts, and I was always scared of using the bar, it's so heavy and I've never been a gym rat personally. I'm more of like, let's go around and dance or do an activity, more cardio stuff. And here I had to learn the importance of strengthening. And I mean, obviously, we know that in PT, but it was at a different level, it was more, I think you have a CrossFit background. It was like Olympic style lifts, and I started doing deadlifts here and my pelvic shift, it shifted again, even though he had fixed it.
We went through treatment, he helped me out with it, and then I had a story to tell my patients like, hey, look, this is what happened to me, and we could relate on a different level. It was cool having that experience and it was a tool for me to use with my patients.
Dr. David
I hadn't mentioned this to you, but yesterday, when we ended the day, we were covering an ankle technique. And we covered a few techniques. One of those was an ankle technique, and I hadn't reviewed that technique for myself, for probably a year or more. We went to the technique and my ankle felt looser. You only did it on my right and as the evening progressed, and even this morning, I didn't realize how stiff my ankles were, until I've had my ankle loosened on the right. Because of my left ankle feels stiff now and I didn't realize how stiff it was. If I move my dorsi flex, I can feel my right ankle move up better here and walking down the hall here in our building.
I'm like, man, my left ankle feels way stiffer than my right! So even for me it reminds me of how life is, like how we forget that we have all these little issues and we live like that. I've been running. Since all the Coronavirus stuff, I've been running more. I think since I've been running, I probably missed 5 or 10 degrees of dorsiflexion. I'm a little angry now. So, we have to get you to fix me. Since it's your last week here.
Lilly
Yeah, it's important to maintain your body. Right? I think that's the reminder. We all have to take care of ourselves.
Dr. David
Yep. All right, we're almost done here. I’m going to ask you one more question for wrap up. So, what would you say to a PT student that's thinking about doing a clinical rotation at a manual therapy focused clinic, or a private pay clinic? One of the two, or combination the two, like we are here? What advice would you give, or what kind of heads up would you give them?
Lilly
So definitely, be confident, especially at this setting, and then just own your knowledge. I think I was telling you earlier. No, your (bleep)
As a student, just know your stuff. I think coming in here, we all feel like we know anatomy. But Dr. David would put me on the hot seat, and he'd be like, so what's the insertion here? And what's the nerve here? How does it move here? And I really had to just think and say my answer. And he's like, are you sure? Are you sure? Then I would second guess myself. And he's telling me to look it up. And I was right.
He was just making sure that I knew my stuff. I think that's the biggest thing. Just be confident. Never stop looking at your textbooks, never stop learning, and be open for sure. Because a lot of the things that we've learned that are like common concepts in PT school, were challenged here. And I know that one of the things that we had talked about was like conscious competence, and unconscious competence, and all these other ones. What I felt I knew, coming into this world, this kind of exclusive world of manual therapy and fellowship training, you have to be open to different concepts, or seeing them in a different perspective.
I would say, own your knowledge, but at the same time, be open to looking at it in a different way. Because you never know what you'll be limiting yourself to learning, if you don't open yourself. I just took everything like, Okay, let me just accept it as it is, so I can learn the concept. Then I think we talked about this too, also kind of be able to question it and say, Is this the truth? I would just say, keep those things in mind and you'll do great here.
Dr. David
Yeah, I love it. I think that pretty much sums it up, with the best way to come in is with an open mind. And I ran into that my first clinical rotation. I was always a good student. I learned all the orthopedic stuff really, really well in PT school. I didn't really know about the different schools of thought in PT, because I was oblivious to it. I just didn't know, and I was one of those students. I remember, I'll never forget the first week or two of PT school. One of the professors said who here has had PT? I looked around and almost everybody raised their hand except me.
I had never been in physical therapy, so I didn't really know what it was fully like, besides my volunteer hours. So, I was unaware. I never hung out in the PT clinic for more than I needed to. So anyways, when I went to my first clinical rotation, I was bringing in all this stuff that I learned from PT school in orthopedics, and it was a manual therapy clinic and I almost butted heads with my clinical instructor, that's just kind of my personality.
I was wanting to tell him. I wanted to be right, is what it was, and he was the same. I'm so glad. His name is Paul Payjack. He did a good job of standing his ground against me, and f getting in my face sometimes. I’d be like, this is how it is, I'm telling you. Once I finally said, all right, I'm going to let go of what I think is right, and just trust you fully. Because you're the PT and you're very studied and all this stuff. I was able to start to feel certain joints move that I could never feel before. Or see movement in a way that I hadn't seen.
What I remember telling myself is, even if it's completely wrong with what they're showing me, I'm just going to do it, to at least get a good grade to pass my clinical rotation. But if we know what's the worst, I'll learn what not to do. So, I went into it with that kind of mentality and it changed my life. I still do this to this day, I have an open mind about things because there' are very few things in my opinion, where there's like a hard and fast black and white like this is the right way to do it.
Definitely in physical therapy. There are multiple ways to do things and rehabilitate people and learn and everybody's just unique and different in their learning styles and their body types. So, it needs to be all taken on an individual basis. So, keeping an open mind is a is a huge deal. Thanks for sharing that appreciate it.
Lilly
Yeah, no problem. You guys are welcome.
Dr. David
Any last words before we wrap up? Or do you feel like you got it all out?
Lilly
Yeah, I mean if you guys come here, you guys are definitely not going to regret it, and you guys have been better PTs and I will definitely trust you. Way more if I'm ever your patient. If I know that you had a rotation here.
Dr. David
Oh, thanks a lot. Appreciate your time. Hey guys, thanks for listening. I appreciate you listening and if you're a PT student out there, and you want to do a clinical rotation at our clinic specifically, you can give us a call at 915-503-1314.We are selective with who we take. There's an application process, so heads up on that. And of course, you have to, okay that with your university, with your clinical, whoever's in charge of clinical, at your university. So, get on it soon, it's not something that you can do last minute, on a whim.
You have to plan it ahead and make sure you have all the paperwork lined up, and we do that on our end as well. And then we need enough time to take you through the interview process. We usually have a few applicants as well, and we can only take a select few at a time. So, make sure you're on top of that. But other than that, I wish you the very best day and I hope you are learning a lot. Have a great day Buy bye.
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