The Guide to Travel Physical Therapy & Psychology – A Randy Bowling Movement Conversation

I recently had the pleasure of talking about all things travel PT and psychology with my dear friend, Randy “The Dolph” Bowling.

Travelin’ fam

Randy has been a traveling physical therapist for almost 10 years now, and has a substantial knowledge base on the traveling process. He also is very much into psychology, and thought me a few things.

You can find Randy on facebook and Instagram.

Here were some of the topics discussed:

  • Why Randy chose to become a traveler
  • How to best interact with travel companies
  • How to network with other travelers
  • The need for negotiation
  • What do travel contracts look like
  • What does the interview process look like
  • What makes a good traveler
  • Randy’s thoughts on psychology
  • How important is focusing on pain?
  • Why Randy is a big fan of Louis Gifford

Here is the video, audio, and scroll down to read the modified transcript.

Enjoy!

 

Here were some of the links mentioned by The Dolph

Fordyce’s Behavioral Methods for Chronic Pain and Illness

Clinical Reasoning for Manual Therapists

Pain-Related Fear: Understanding and Treating the Complex Patient

Aches and Pains

The Seductive Allure of Neuroscience Explanations

Modified Transcripts

 

Zac: Hello you beautiful, sexy, outstanding people. This is Zac Cupples from zaccupples.com, and I’m bringing you another movement conversation with my good friend, the legend himself, quo board extraordinaire, straight out of Arkansas, “The Dolph,” Randy bowling.

Say hi to the people Randy,

Randy:  Hey my name is Randy.

Zac: The reason why I wanted to bring Randy on for this movement conversation is because Randy is incredibly experienced at being a travel PT, and he knows a lot of the ins and outs.

He’s also is into some psychology shit, so wanted to pick his brain on that so those are the two topics for today, and I couldn’t find a better guy than Randy.

Dolph be on that Sigmund Freud shit or somethin’, fam

And also, he’s my bro, and bros be talking about all types of things, so who knows where this is going to go.

As for all these movement conversations, I don’t have specific questions. I never gave Randy anything in advance. We’re just gonna go off the top of the dome like some good freestyling back in the day. Think hip-hop circa 1994.  Maybe some Big L shit.

Randy, tell us a little bit about yourself.

Randy:  I got my physical therapy degree from the University of Central Arkansas, and started traveling October that year.

I meant to do it for two to five years, and now it’s been over 9.

Zac: He’s almost on the decade level for this travel stuff.

Randy:  I should have rounded up, it would sound better.

Why did Randy decide to travel?

Randy: Two reasons:

One, I wanted to see the country a little bit.

Second, I wanted to pay off my loans. So, I wanted to make a little more money, see the country,  and it’s worked.

Zac:  Did you have any other possible options that you were exploring before?

Randy:  I did not. I just started up.  One of my buddies from the year ahead of me had traveled and got me in touch with his company, so I pretty much started.

How Randy Selects a Location

Zac: Where have you all traveled to?

Randy: first job was in Big Spring, TX, then I went to Hobbs, NM, Ruidoso, NM, Tillamook, OR, Carthage MO, South Hill VA, Roma, TX, a couple other small towns in Texas for that same assignment, then back to New Mexico, then Arizona, and Idaho somewhere in there.

Zac: World traveler, or at least US traveler.

Randy: Yes.

Zac: And now Page, America

Randy: Yes sir yes sir.

Yes, be jealous

Zac: So when you’re picking all these places, you’ve been kinda all over the place.. What what is your criteria and process when you are selecting a spot that you want to be, and maybe discuss what that looks like when you’re interacting with the company.

Randy:  What I look for is small town hospital-based outpatient clinics, and I’m sure most of your listeners probably are more geared towards outpatient, so if you want good jobs that give you plenty of time with patients and lets you have freedom to do what you want to do, small town hospitals are the way to go.

As long as you don’t mind being lonely. Sometimes, in small towns, you’re gonna be by yourself a lot—watching movies, eating by yourself.

Zac:  Unless you’re in Page, America, then you’re just gonna do all types of fun stuff.

Randy: Exactly. Page is a great spot.

Zac:  It sounds like that wasn’t always what you were searching for in a travel gig, so what were you searching for before?

Randy: When I first started I just wanted outpatient, but I took a couple of privately owned clinic jobs, and those we’re not so great. I’ve worked home health and some acute care, but preferred outpatient.

Why Randy Likes Outpatient

Randy: I like outpatient because if they don’t want to see you they just don’t show up. In acute care you have to go stick your head in the door, even if they don’t want you to be there.

Zac: Very much so. It gives you a little bit more freedom.

Randy:  The people who are going to go and want to be there. Home health is nice too because they’re usually excited to see you come, so it has some perks too.

Navigating Travel Companies

Zac: Have you always worked with the same company then?

Randy: I have worked for two different companies, Aureus and Delta Health Care Providers.

Zac:  What were your first interactions like when you were interacting with some of these companies? What led you to switching?  What are you looking for when it comes to finding a good company?

Randy:  Initially I didn’t really care about insurance cuz I didn’t have any health issues, so I just was primarily looking for somebody that could get me a job in it either an area I wanted or a job that I thought would be cool and pay well.

That’s the reason I switched the first time because I found out they they could be paying me more and should be paying me more, so I switched, and the company I was with said “hey we can’t match that,” but eventually I switch back to them.

Zac:  What were some of the conversations like that you had with these companies when you were switching back and forth?

Randy: Basically, I explained to my recruiter at the time that this is how much they can pay the job have this is how much they can pay and she said “well, let me see what we can do.”

And she said we can do this much, and it wasn’t quite enough for me to stay with them so I switched the first time.

Zac: So you used a little bit of negotiation tactics?

Randy: Yes and I’m terrible at negotiating,  but you should. You should always talk to two or three recruiters, especially when you’re starting.

And be ruthless

Travel Therapy Contracts

Randy: The main thing for me is that I should have negotiated more earlier on,  and I wouldn’t have taken those private clinic jobs.

Zac: Let’s talk a little bit more about the negotiation side of things.

Randy, in terms of things that you may have negotiated now, or in terms of your contract structure, is there anything that you would have done differently knowing what you know now?

Randy:  Well, the thing that led me to the biggest amount of change that I saw in pay was talking to other therapists, and as a traveler sometimes you’re on a job and you’re the only traveler, so you can’t talk to other people.

So if you do find yourself in a position where there are three or four other travelers, you get to be good friends with them, start talking to them about money. They’re usually pretty cool about telling me what they’re making and then you can find out “am I where I should be.”

Also your boss says sometimes will tell you if you get to be good enough friends with them. They’ll kind of tell you what the pay rate is, and if you know that and that kind of gives you an idea of what could be out there, that you’re not getting.

Zac: So basically you should probably be a good dude and hang out with your peeps.

Randy: Yes.

Zac: You know this is one of the reasons why I want this conversation with you is because you’ve done this so much longer, that you know how some of these ins and outs in this in this field work in travel PT.

Now what about in terms of the specifics of contracts. Now I know in early in your career you elected to have them find your housing. For those of you people who don’t know, with travel PT, you have a few options in terms of how you can structure your contract.

It’s not just the the total lump sum. There are some other benefits you could potentially have or not have. Randy, you’ve been on both sides of that coin, so why don’t you go ahead and talk to us a little bit about stipends versus having the companies search for your housing.

Randy: Usually if the company searches for housing they’ll put you in a nicer place. Well, they definitely put me in a nicer place then I would find for myself sometimes because they want to keep you working for them and they will make sure you have a place that’s ready for you. They’ll cover internet, cable, things like that. It’s less of a hassle. That way you can just show up and it’s usually ready to go.

Sometimes there might be a day or two delay. If they can’t find something furnished, then they’ll furnish it for you and it’s it’s simpler.

You don’t take home quite as much money, but it’s also much easier just to show up, move into the place and you don’t have to set anything up.

Zac: How much of a difference would you say there is in terms of take-home pay, and mind you people, that the stipends that you get for traveling are tax-free, so you’re gross to take home is very similar.

There’s a slight difference in terms of taxes just based on your hourly pay. Depending on how you structure your contract versus the situation that Randy is talking about if you find your own housing.

You don’t have to mention specific numbers, but I mean would you say?

Randy:  I think initially the first time I switched they paid me $10 more an hour I think that was tax-free. But since then I we’ve made some different changes and I started getting a bigger chunk of that tax-free.

Zac:  In that amending, you’re saying that that’s in terms of some of the negotiation stuff you’ve done?

Randy: it’s kind of evolves when you’re with a company for a little while. You’ll find yourself either staying the same slowly losing a little money, and sometimes it works the other way to where you take a job that pays you a little more and just based on kind of how that works.

They know you’re not gonna want to take much less than that, so they try to find you something close to that.

But I’ve had a couple of years where it seemed like where I was losing a little bit of money.

Zac: Why do you think that is?

Randy: Because I’m a poor negotiator.

Zac: Way to talk ownership, Dolph!

Randy: Hey I’ve learned a little something from living with you.

Zac: It’s not me, it’s Jocko Willink. #disciplineequalsfreedom

Deciding on a Travel Clinic

Zac: What kind of questions are you asking the clinic you are potentially working at for your travel assignment? You obviously had some not-so-great experiences, so where did you error in that process?

Randy: I think it’s just I ignored the signs. I knew they probably weren’t gonna be the best jobs and I just took them anyways.

Clearly, Randy is not a fan of Ace of Base.

Zac: So what what signs did you see?

Randy: Usually they will be pretty upfront with you and tell you how busy or not busy you’re gonna be, so if you ask “how many patients am I gonna see in a day” and “how much time will I have with them” they’ll answer.

Earlier on sometimes I took jobs just cuz I maybe wanted to go somewhere or for other reasons, and then you get a job when you’re seeing three or four people at a time, and they’re just miserable.

Zac: So there’s a lot of times with some of the selection in these jobs there’s kind of a trade-off between location versus pay versus quality of care that you could potentially give or not.

Randy:  That’s correct.

Now in outpatient it seems like rural areas you generally can give a better quality of care and have more time with patients.

Zac: What about with the home health and other jobs that you’ve worked that weren’t outpatient? Would you say that that was the same as well?

Randy: I only took one job that was strictly home health and one job that was strictly acute care. Most of my other jobs have been sort of a combination like here in Page; a little bit of acute care, a little bit of outpatient, or strictly outpatient

Zac: Was the home health also rural area?

Randy:  Yeah it was. It was Tillamook, OR.  It was a very good setup for home health. They only expect I a full day versus five patients a day. The only bad thing was that I had to fill out the Oasis. So if you take home health, you should try to negotiate that you don’t have to do the Oasis.

Zac: You can negotiate that?!?!

Randy: I think my buddy did. He’s not as a traveler, just doing PRN work in Texas.

Zac: Really?!?!

Randy: Yeah.

Zac: Because I thought the Oasis was a mandatory thing you have to do.

Randy: Well, the nurse that admits can do that so if it’s somebody that’s just coming off of a total hip or a total knee, and they don’t really need nursing care, then they may say PT can see them. Or if it’s just generalized weakness coming out from the hospital they may say nursing is going to be involved.

But in the home health situation the nurse can go in and do the admit.

Zac: The Oasis is the worst documentation I’ve seen.

I saw one patient in home health once.  And the reason why it was only one patient was because the company didn’t put anyone on my schedule after that, and I’m like “well, this is silly. Why am i doing this job?” and I quit and they were upset that I quit.

I don’t know. Maybe there was poor communication or something like that but it was bizarre.

Other Contract Pieces to Consider Negotiating

 

Randy: You can negotiate sometimes with the traveling company and get continuing education money or if you’re going to extend you’ll need this much time off, and maybe negotiate getting something paid for.

Back to home health someone who is not a traveler would get paid more for an eval compared to a regular visit. Same thing with the Oasis. I think you could get paid a little more. You could say you’ll do the Oasis but you need to pay me more for that because it’s gonna be much more time-consuming.

Zac: So have you negotiated for some of those things yourself?

Randy: That’s just kinda what I’ve heard other people get.

Zac: On the more days off side of things. Obviously we’re very #blessed in Page, America, where we can kind of take off as much time or as little time as needed because Kai is awesome. I’m going to have her on here one of these times because she’s got some good stuff, but do you feel like other clinics that you’ve worked at or other places have that same flexibility?

Randy: Not quite as much flexibility as we have here because Kai will pretty much let you off whenever you want. If I know that I’m gonna need time off I just put it in the contract and I generally don’t like to take that many days off unless something comes up. So, if I know I need to leave or go home and visit family or take care of things, then I’ll try to write it up into the contract where I have this week off or these two days.

Zac: Have you ever done it where like you can get just have two weeks of

flexible time off?

Randy: I’ve not.  I think some people have done that probably in the past.

Zac: The big crux of this you beautiful, sexy, people is that you you have a lot of wiggle room in terms of your negotiations with things, and it’s not just travel pt but that’s all PT jobs, so don’t be afraid to ask for what you want and what you need in order to be successful.

Any other travelling pearls or like any other things that you wish you would have known going into this?

Randy: Just don’t take his job if it doesn’t sound good to you. Don’t feel the pressure to take a job because there’s always gonna be more. The worst case scenario is you just take a few extra weeks off.

Dealing with the Potential Loneliness of Travel PT

Zac: Lonely is probably not the word, but you get a lot of alone time as a travel PT. How do you recommend someone who’s in that potential scenario deal with it? What do you do to make sure you don’t go crazy?

Randy: Well, it usually doesn’t bother me. I’ll just go to the movies and watch a movie by myself or go out to eat by myself, but there are certain people that don’t handle being alone very well.

You should still travel or at least give it a shot. You may do two or three assignments, and decide is not for you.

Zac: Or maybe you just go to a location where there’s people.

Randy: Yeah, but even when you are at a location where there’s people, you’re still in a new place by yourself, and not everybody is great about going out, making friends, and that sort of thing. That’s some people don’t handle the isolation so well. Or miss family, miss friends.

Zac: You plan on sticking around this travel gig for a minute?

Randy:  I said two to five years and I should at least get to ten right?

Zac: At least! What keeps you going?

Randy:  That feeling of knowing there is some place else to see that I haven’t been.

Zac: You’re quite the adventurer.

Randy: I try to be.

Zac: Dolph and I go on some great hikes, fam. That’s one of the added benefits about being a traveler. You can see a lot of cool places, cool things, and meet cool people.

How Did Randy Get into Psychology

 

Randy: I’m trying to think exactly when I first really got into that. It might have been when I went to the first San Diego Pain Summit. There was a guy named Eric Krueger who gave a presentation, and he was I think in school at the University of New Mexico, and he gave a really good presentation.

I didn’t know who he was, didn’t know anything about him, but one of the presentations stood out to me and it was more from a “how do you approach people from a psychological standpoint.” and so that got me into reading a few more things.

Then you realize that sometimes you might be doing somebody a disservice if your primary objective is just to eliminate their pain. If you’re focused only on their pain they may never get better. They may never get back to actually living life, and it kind of frees you up a little bit when you know I don’t have to change the pain before I get them doing something.

If this was a game, Dolph just Scrabbled the fahhhk out of that last paragraph.

 

Zac:  So then what what was the crux of the talk? What was the lightbulb thing for you during that talk that made you switch to the shift of focus on, I hate to say function, but function, and purpose, and movement, versus focused on pain?

Randy:  I don’t know if just the talk did that. It was just the other stuff that I read and books that I found. Realizing that at a certain point sometimes with people with chronic pain, another test, finding something that’s wrong with them, isn’t really going to help them.

But if you can get them to realize that they can begin to do some of the things that they’re either afraid to do, or just haven’t done because they quit doing it two, three, four, or five years ago and hasn’t made it into their head that it’s a possibility for them.

It doesn’t mean that you tell them the pain is unimportant, or that it’s just imagined, or any of those things. That there’s some things that are tossed out that come across the wrong way to people.

But if I can get you to do an hour of something that before you could only do for minutes, and your pain is still the same level, you got better even though your pain didn’t improve. If you can play with your grandkids, and you still have the same level of pain that you had just sitting on the couch.

And I guess it goes back even farther than that talk by Eric Krueger. I bought this book Clinical Reasoning for the Manual Therapists. There was something written by Louis Gifford and I had two patients around that time after I read the little essay that he had in there, and one of them was a school teacher who felt guilty because she was overweight, and was so scared to do things. Told me she was scared to go shopping, scared to clean her house, and I just told her I just said hey it’s okay to go shopping. Go shop! She’s like “I’m gonna get mad at you if I have pain.” I’m like “go shopping and get mad at me.”She went shopping, she was happy, and she did fairly well.

Then a couple months later I was on a new job, and there was a lady, she wasn’t my patient, she was low 40’s, probably 41, and I just saw her for one visit after somebody else had started with her. I didn’t get to work with her again after that, but she started listing off all the stuff she didn’t do anymore. She said I don’t even bend over to tie my own shoes anymore, and so I just kind of asked her I said “hey did that help you?” And she said “no it didn’t,” and I said “well maybe you should start doing some of those things.”

Kind of forgot about her and didn’t think too much about it.

Couple weeks later, I walked by her when she was working with the other therapists, and she said “hey that helped me more than anything else.”

Zac: So then what were you like before Louis Gifford changed your life?

Randy:  Well sometimes you’re a little scared of the pain for them. Not just them being scared of it. You think you’re doing something wrong if they hurt, and you can be, but not always.

Sometimes, you have pain, you’ve had it for a while, getting back to life, just doing general activities around your house, and just living life, having fun with friends and family sometimes is not gonna be the most comfortable. But if you remove yourself from life, you don’t get better. Your pain rarely improves because you start staying at home, not hanging out with friends and family, not going bowling, not playing basketball, lifting weights, and all the things you used to do that were fun for you.

Zac: If you can get your people to understand that pain and tissue damage aren’t the same thing, it’s groundbreaking. That’s groundbreaking for a lot of people, and it’s unfortunate.

I mean this was true when I was in PT school, and I’m sure because you’re so much older than I am when you were in PT school, but they don’t really teach you that concept.

Randy: No, and it’s been around for a while.

Zac: Yeah definitely pain fibers. I never heard of nociception in PT school, not once.

Randy: Seems like they might have mentioned.

Zac: Yeah, maybe at UCA they were a little bit more up in that regard. Not that St. Ambrose wasn’t. I thought they had a wonderful manual therapy program, and I learned a lot of good things, don’t get angry. And actually, Adriaan Louw was there, but he didn’t really speak as much when I was there as he does now. So I feel cheated (I’m just kidding).

So then what is in terms of some of the resources you had mentioned after you heard Eric Krueger talking, after you got some exposure to Louis Gifford, what are your top three resources that were most salient for you?

Randy: I think you can’t go wrong with Fordyce’s Behavioral Methods for Chronic Pain and Illness it’s really good read.

Zac: You got to say the the one story.

Randy: In the intro?

Zac: Yeah! that still sticks out with me a little bit.

Randy:  So Fordyce was going to treat this patient in an acute care setting, and before he went in to see them, he had a consultation with the doctors and the other medical providers that were gonna go in, and he said “anytime this guy mentions his pain, we’re just gonna look out the window because he wouldn’t get up out of bed, wouldn’t do anything.” So he said “every time he brings up pain, we’re just gonna ignore him, turn, look out the window.”

So they do that a few times and the guy catches on pretty quickly because it’s obvious. And he’s like “I know what you guys are doing,” but it still didn’t matter. He started getting dressed and getting out of bed.

Zac: Well it’s amazing how much you can develop cognitive associations that can perpetuate pain, you know? And maybe it’s “I am feeling this” and therefore when I see you doing this activity reinforces that response. It’s Pavlov’s dogs essentially. It’s the same thing. That type of conditioning is still relevant in in pain, and it’s one of the factors that can lead to chronic pain, which I’m going to be talking about in my talk! Just a heads up!

What were the other couple books?

Randy: Pain-Related Fear is what I’m reading now.

Zac: What are you getting out of that?

Randy:  I’ll let you know when I finish.

Zac: You mean you don’t have any insights now fam? You’re about halfway through ain’t you?

Randy: Well, one of the things that I thought, and I sort of started the process with a lady today,they had people rank activities based on how much fear they had to do them. And it was fear all of harm, not fear of pain. Because it’s hard to have somebody disprove that it causes pain.

But if you set them up and they think that they’re paralyzed or that they just their backs gonna fall into or something, then you can set up an experiment. Have them try the activity. Even if it hurts they’re like “oh, I’m ok.”

He’s OK!!!!

Zac: That’s interesting. So really, this book and it sounds like some of the approaches that you’re mentioning, are not necessarily geared at addressing the pain component of chronic pain or persistent pain, but it would be addressing all the other factors that could potentially perpetuate that—be it fear, be it anxiety, be it whatever.

When you’re approaching a patient, you’re trying to address a lot of those other areas in hopes that I can reduce the threat of pain, which is in the central focus.

Randy: Yeah pretty much. If you took somebody that’s really fearful, really anxious, and you get them to do something, then they get to see that the bad, negative result they were so concerned about didn’t happen, that’s much more likely to create a long-term change then you’re just telling them that “hey you can go pick up that 50-pound kettlebell.”

But if they go do it and they’re expecting something catastrophic to happen and it doesn’t, then they’ve just learned “hey, I’m not as fragile as I thought I was.”

Zac: So then how do you handle a situation where you have them try the activity in question and they do get a negative result? Maybe not paralysis or something like that, but maybe their fear matches the result that happened. How do you navigate that type of scenario?

Randy: It’s tricky. You either try to figure out another way to show them that they’re still okay, that they can do something, or you just may have to say “hey, I started you out a little too far. Let’s back off a little bit. Reapproach it again. Start with a lower load. Start with a different task, and just say “hey that was my fault.”

Take ownership!

Zac: Love it! So essentially, you’re still trying to keep the movement in question as a focus of the treatment, but maybe you’re changing something contextually, or something that reduces the potential of getting into that situation or that scenario; whether that’s load, whether that’s positioning, whether, that’s body mechanics whether that’s…

Randy: Yeah. You can take them out of the position if standing and bending hurts get them in quadruped and have them bend. Let them see that “hey my back can bend; maybe bending putting all my weight on it right now is a little painful, is a little too sensitive, is something I’m not ready to tolerate yet,” but get them to do the activity. Figure out a way.

And sometimes, you can’t. Sometimes, people are just not going to get better.

Zac: That’s very true. That’s a hard thing to swallow. That you’re not gonna get everyone better, but it sometimes happens.

It makes me think a lot of the patients who I’ve worked worked with over my experiences where it just wasn’t happening in it for a multitude of reasons.

Randy: Yeah. It’s extremely frustrating. It’s gonna happen.

Zac: It’s gonna happen. But it doesn’t mean you can’t be satisfied. You got to keep getting better. That’s the key.

What’s book number three?

Randy: Aches and Pains by Louis Gifford.

Zac: Nice plug! Nice plug! So what is it? Because I know you love Louis. He’s your boy. And I like his books. I read Topical Issues in Pain Volume 1, and I thought was phenomenal, and I look forward to reading Aches and Pains, which thank you again for getting me that.

What is it about his messages that resonates with you so much?

Randy: I think it’s that he got them to do stuff and he didn’t spend a whole lot of time explaining things in detail. Maybe I’m misinterpreting what I read, but just letting them know that it’s okay to try things, and giving people permission to do things.

Zac:  So he didn’t discuss ion channels much?

Randy:  I don’t believe so. Maybe he did. I’ll have to read it again.

Zac: Well you know what though? I think when we first dive into some of the pain science stuff, that you go all in, and you’re talking about the brain and the anterior cingulate cortex, and the ion channels, and the emergent properties of bioplastic blah blah blah blah blah.

And although there is some research suggesting that if you incorporate neuroscience into your explanations, regardless of accuracy, you actually are a little bit more believable; more credible. But sometimes, having a simple explanation is much more warranted, and you don’t have to go that in-depth into some of these things.

Randy: I think the patients need you to have a basic understanding of that, but I don’t know that they need to know that. My eyes would gloss over if somebody started talking about that to me. But if you can just tell them and get them to understand, however you need to do it. That it’s okay to move. It’s okay to try this.

I had a guy not too long ago that, after his back surgery in 2010,  didn’t lift legs ever again until a couple weeks ago, and all he had done was run. And when I told him it was okay to do some squats with a kettlebell—some goblet squats or some deadlifts—he’s really excited and happy about life, and knew that he could go out and try something again.

Zac: That’s awesome. So what’s that conversation like when you have someone who’s afraid of, let’s take this case, afraid of lifting something up or squatting, and it sounds as though maybe you’re not going with the ion channel talk. So, what is the talk like?

Randy: Well, with him, he came in not for his low back. He came in for his neck pain. Well, his neck was getting better, and because something had improved he’s more willing to listen to me. So when I say “hey, why don’t we work on your back a little bit?”

I know some people hate manual therapy, but if you can find something that feels good, why not spend a little bit of your time doing something that feels good, and then get them to do your exercise or vice versa; exercising, then doing something that feels good.

So we had found a few things that actually felt good to him, it gave him a little bit of pain relief. So then when I’m like “hey, let’s try to do this goblet squat,” and he’s like “I haven’t worked my legs in a long time,” and I’m telling him “it’s been seven years, I promise you, you can handle it.” He’s willing to try it.

So it just depends. It’s different with every patient.

Zac: For sure. It sounds like the biggest thing is just getting buy in. Buy in and building the relationship with the patient and that trust so then you can test the waters of activities that are potentially threatening to that individual right.

Randy: If you can get them to buy in, and just get them to try it.

Even if they don’t completely buy into it, if they’re willing to give it a shot. If they’ll try something and then you hope you don’t pick something that’s too heavy or pick the wrong activity that just really flares the pain up, because then they’re not gonna trust you again.

Give it a shot!

Zac: Man, when you have that wonderful southern accent though it helps.

Randy: it helps when you sound like Joel Osteen

Zac: Yeah it does.

What’s next for Randy

Randy: I’m gonna stay working for Kai and go to Susanville, CA after a three week break.

Zac: Got any big plans for your three week break?

Randy: I’m gonna take mom on a road trip back home to Arkansas.

Zac: Nice! Another nice benefit to being a travel PT is when you get to the point you can you can take a lot of time off,  which is really, really cool.

Where is the learning brigade taking you right now? What direction are you taking your continuing education from from here on out would you say? What do you need to get better at?

Randy:  I really want to get better at medical screening; just making sure that I’m not missing stuff that I should send to another provider. And I’d like to refine my evaluation skills a little bit know. I think I’m gonna head back there. And I’m more into strength and conditioning stuff to review instead of just going on what I’ve learned from doing it myself over the years. Probably good to actually read some stuff.

Zac:  Oh for sure for sure. If there’s one thing that PTs don’t read enough of, and that’s not just outpatient but that’s anyone because a lot of these principles are important, is the S&C side of things. Because they don’t teach you how to squat, deadlift, or do many of these things.

Randy: Well, people are doing rowing with a yellow theraband with their 30 year old patient.

Zac: Yeah, yeah. Homie don’t play that. We lift everything in Page, America. Just an FYI.

Sum Up

Dolph was a tremendous source of knowledge for travel PT and psychology, and I hope you got a lot out of this interview.

To summarize:

  • Travel PT is a great way to explore the world and pay off student loans
  • Don’t be afraid to negotiate with your recruiter
  • Take the assignments you feel comfortable with
  • Focus on function, not pain
  • Remove limiters of fear, anxiety, etc

Are you a traveler? Are you into psychology? Comment below if you wish to offer any insights.

Photo Credits

Max Halberstadt

Flickr

CrushNush

Nick Youngson

S8an

 

Genu Recurvatum, Geriatric Power Training , the Problem of PT School, and Professional Communication – Movement Debrief Episode 25

Movement Debrief Episode 25 is in the books. Here is a copy of the video and audio for your listening pleasure.

Here were all the topics:

  • How do I treat someone with genu recurvatum
  • What activities I select to improve power in geriatric clients, and where I’m thinking of going
  • Why PT school hasn’t been fixed
  • What the real problem is with bettering the physical therapy profession
  • How to effectively communicate with professionals who don’t speak the same language or have the same thought process as you

If you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 7:30pm CST.

Enjoy.

Zac Cupples iTunes                

Here were the links I mentioned tonight

Enhancing Life

Method Strength

Andy Mccloy 

Here’s a signup for my newsletter to get a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies:

 

Check out the mentor program

My Feature on Mike Robertson’s Physical Preparation Podcast

I was recently featured on my boi Mike Robertson’s Physical Preparation Podcast.

It was quite surreal to be interviewed by a guy who I have tremendous respect for, and who has been a huge influence on me.

MR was one of the people who I was initially exposed to when I got into this field. After reading all the cool things he wrote on t-nation, I bought most of his products, became a huge reader of his blog, and applied many of his teachings to my own training.

Zac = fanboy.

Can you imagine what it was like the first time I met him and Bill at IFAST? Like meeting rockstars, fam. Then he we are, having a conversation as peers.

Point being with this story, if there was no Mike Robertson, we wouldn’t be having this conversation right now.

The Life of A Mercenary PT

All types of mercenary shit

Here were some of the things we discussed in this podcast:

  • How I got started in the world of physical prep.
  • What life is really like in the NBA/D-League, and what it’s like to transition from therapy to performance at the highest level.
  • What skills I was comfortable with, and how he grew and evolved to take his coaching skills to the next level.
  • My biggest struggles in pro sports.
  • Movement Variability: What it is, and why you probably need more of it.
  • What it’s like to transition from the biggest stages in sport, to working in a smaller setting with a more general population.
  • How I get it all done – from working as a mercenary PT, to writing, to public speaking, etc.
  • The BIG Question.
  • A really fun lightning round where we discuss pops Daddy-o Bill Hartman, his favorite hip hop groups, why I started the Movement Debrief, and what’s up next for me.

Click here to listen to the podcast.

ZAC CUPPLES ON THE LIFE OF A MERCENARY PT

 

Knee Pain & Modalities – Movement Debrief Episode 24

Movement Debrief Episode 24 is in the books. Here is a copy of the video and audio for your listening pleasure.

Here were all the topics:

  • What ACL graft should you get?
  • What does the systemic process look like for knee pain?
  • What local factors are important for knee pain?
  • the importance of plyometrics for knee pain
  • Is there a place for modalities?
  • What modalities I incorporate into my practice

If you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 7:30pm CST.

Enjoy.

 

Zac Cupples iTunes                

Here were the links I mentioned tonight

Enhancing Life

Darkside Strength

Adam Bryant

PRI Impingement and Instability Course Notes

Here is the Active Midstance Test

Here’s the Copenhagen Adduction Test

Bill Hartman

A Randomised Controlled Trial of ‘Clockwise’ Ultrasound for Low Back Pain

E-Stim and BFR

Here’s a signup for my newsletter to get a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies:

 

Check out the mentor program

October Links and Review

Every week, my newsletter subscribers get links to some of the goodies that I’ve come across on the internets.

Here were the goodies that my peeps got their learn on from this past August.

If you want to get a copy of my weekend learning goodies every Friday, fill out the form below.  That way you can brag to all your friends about the cool things you’ve learned over the weekend.

Biggest Lesson of the Month

Life ought to focus on creating value, for the people you work with, for others, for the world, for yourself. When you create value, rewards will come.

Quote of the Month

“Common 99% thinking won’t get you uncommon 100% results” ~ MJ Demarco

MJ Demarco is becoming one of my favorite authors, and he inspired the biggest lesson above.

Hike of the Month

A great park in the land of China

I didn’t get much hiking in this past month, namely because I was prepping for my talks in the land of China. However, while in China, my hotel was right next to this really cool park that I walked through frequently. Amazing amalgamation of architecture, flora, and people.

Training

The Trick to a Perfect Rear Foot Elevated Split Squat

My son, Trevor Rappa, gave us a great cue on nailing the rear foot elevated split squat. Perfect for those people who sag into the back leg.

Weight Position During the Squat

Want to more effectively load the legs when you are squatting? Here is one of the most impactful changes I’ve made when coaching squats.

Rehab

Blog: Should We Delay Range of Motion After a Total Shoulder Replacement?

Mike Reinold is a guy who I look to on a lot to influence my post-operative care. In this post, he makes a salient point regarding the early range of motion controversy. The devil is in the details.

Blog: All Gain, No Pain Knee Pain Solution for Lunges and Split Squats

Daddy-O Pops Bill Hartman just killing it with the content, fam. This time around, he discusses how he approaches individuals who get knee pain during split stance activities; a common problem I’ve struggled with in the past. Thank you for helping a son out, pops.

Infographic: Early versus Delayed Rehabilitation After Acute Muscle Injury: No Time to Waste

Yann again killing it with these graphics. Here this time he brings us a study which shows how drastic an impact recovery from an injury can be the sooner you start moving.

Health & Wellness

App: Insight Timer

Want to get into mediation but don’t want to spend the buck on Headspace or Calm? Then Insight Timer is your answer. There are several different styles of meditation available in this completely free app.

I will admit, you have to sift through a lot of crap to find the particular meditations that work for you, but once you find one’s that work, you are golden.

My favorites so far are “The Warrior” by Michelle DuVal and Franko Heke 5 Min Guided Meditation

Let me meditate, set it straight

Blog: New Neuroscience Reveals 2 Rituals That Will Make You More Mindful

Eric Barker’s “Barking Up the Wrong Tree” blog is hands down one of my favorite blogs on the internet. He spends a great deal of time researching multitudes of topics, getting quotes from others, and writing about damn interesting material. This time, he discusses meditation, multiple “yous,” and so much more.

Podcast: Dr. Brandon Alleman on Direct Primary Healthcare (The Paleo Solution)

I’ve been binge listening to Robb Wolf’s podcast as of late (a great thing about vacations), and I found this one to be particularly fascinating. Here Dr. Alleman discusses how he is saving healthcare by using a subscription-based system for his patients. It’s quite fascinating how this system is saving his clients, including small businesses, money. I’d definitely check this one out.

Blog: Decrease Rumination and Stress with Movement

I’m a big time ruminator on things. Something I’ve been trying to work on. Here, my boi Seth Oberst discusses how movement can help reduce the urge to ruminate, and how it’s a much better alternative than being on your phone.

Personal Development

Blog: Imposter Syndrome and the Fitness Industry

Man this hit home for me on many levels. My man Dean Somerset wrote an awesome post on what it feels like to experience imposter syndrome, and how all of us have to start from the bottom. It’s about the process, and continuing to grow the process.

Blog: Decision Making, After the Fact

Read this when you think about being critical of someone, your favorite athlete, you spouse, your friend, making a poor decision.

Productivity Tip

I made one simple change to the way I schedule things that has led to drastic improvements in my productivity. What is that change? Check out the quick hit to find out, fam.

Blog: Definining Authenticity

Seth Godin keeps his blogs simple, concise, yet effective. Here he gives us what authenticity is not, and his example for what it is really hit home for me.

Blog: How Answering One Simple Question Can Keep You on Track for Success

Daddy-O Pops Bill Hartman provides us with a great technique at helping you stay on task with your goals. I definitely plan on using this one.

Routines and Measuring 

Routines are a great way to reduce stress, as less decisions have to be made. In order to be successful at reaching a goal, it helps to track progress. Here is how I combine the two.

Book: The Millionaire Fastlane

This book has really hit me hard and made me think about the way I am approaching finances, making money, and many other things. This book will challenge all your preconceived notions about what to do with your money.

Miscellaneous

Book: Barking Up the Wrong Tree: The Surprising Science Behind Why Everything You Know About Success Is (Mostly) Wrong

Eric Barker is one of my favorite bloggers and I am enjoying his book quite a bit. Do you want to find out if nice guys finish last? Or maybe you want to learn from prison inmates how important trust is. He has so many great nuggets in this book that I’m certain you won’t be disappointed.

Music

Every Noise at Once

This is probably one of the coolest things I have ever seen. Want to hear every music genre that has ever existed, then get a Spotify playlist having music within that genre? Because That is exactly what this site does. Un…be…lievable.

 Royce Da 5’9″ – “The Bar Exam 4” 

[WARNING, EXPLICIT CONTENT] Good…Lord…Listen to this. Royce is by far one of my favorite rappers. Like, in my top 10, pushing to get into my top 5. Here is a dope mixtape he put together where he just expresses his lyricism; many on some of your favorite beats.

So…freakin’…underrated

Some of my favorite include “C Dolores,” “Still Waiting,” “Gov Ball,” and “Chopping Block”

Side note: got to meet Royce at a concert with like 10 people. He really is 5’9″. And he’s a cool cat.

Freddie Gibbs – You Only Live 2wice

[WARNING, EXPLICIT CONTENT] Some call him the modern day 2pac, Gangsta Gibbs himself takes street rap to a whole new level. This joint gets him talking about his time he was in jail overseas. It’s a great mix of some serious stuff with his typical gangsta fare. Freddie is currently one of my favorite modern rappers, so please give him a listen. Crushed Glass and Homesick are my favorite two.

Which goodies did you find useful? Comment below and let me know what you think.

Photo Credits

Aashishji

Dominik Lippe (Lipstar) und Yannic Lippe

Iliotibial Band Bullshit, Deciding What to Learn, Hip Internal Rotation, and Structure, function, and pathology – Movement Debrief Episode 23

Movement Debrief Episode 23 is in the books. Here is a copy of the video and audio for your listening pleasure.

Here were all the topics (credit Jand80 for the awesome question):

  • Thoughts on the Ober’s test and structures involved
  • Can you stretch the IT band?
  • How to build a thought process
  • The hierarchy of restoring hip motion and where internal rotation fits
  • Do PT’s address structure or function?
  • Are we really testing and seeing pathology?

If you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 7:30pm CST.

Enjoy.

 

Zac Cupples iTunes                

Here were the links I mentioned tonight

IFAST University

An Anatomic Investigation of the Ober’s Test

Three-Dimensional Mathematical Model for Deformation of Human Fascia 

Enhancing Life

Darkside Strength

Here’s a signup for my newsletter to get a free acute:chronic workload calculator, basketball conditioning program, podcasts, and weekend learning goodies:

 

Check out the mentor program

Help Any Client Achieve Their Goals

I recently did a little spot on IFAST University regarding how I approach, assess, and progress people along the physical activity continuum. Read the little intro  below, and if you want to watch the video, click on the picture or the link.

As a bonus, I put together a little PDF outlining how I improve the movement variability side of physical activity. If you sign up for IFAST University, you’ll get access to it.

Without further adieu, here is the post.

The Four Step Process to Address Movement Limitations

I’m in the business of creating change, but — as you know — that stuff is HARD TO DO.

How do you simplify the process?

I like to outline things. When thoughts have a directional flow, it’s easier to keep everything straight. So I have to ask myself questions about each and every situation.

What kind of person is in front of me? And what am I going to do with him or her?

In this post, I’ll outline my process of helping people achieve their health and performance goals. We’ll discuss:The 4 areas where we can start creating change

    • My main area of focus: physical activity
    • The 4 steps physical activity
    • Each step from my physical therapy view
    • Each step from my performance coach view
    • My progression for mobility
    • The 3 active mobility tests I use
    • Testing for arm motion with lower body tests
    • Runners who get pain after they run 5 miles
    • Patients who get back pain after they sit for 4 hours
    • Athletes who can’t play the whole game without pain
    • …and a bunch of other short examples to relate this system to your own clients

Click below to watch the video.


Help Any Client Achieve Their Goals

Continuing Education – The Complete Guide to Mastery Guest Post

Hey all,

Won’t be a debrief this week, as I will be in the land of China giving some talks.

But I wanted to make you aware of a guest post I did on On Target Publications, one of my favorite resources for all things rehab and training.

This site, run by the incredible Laree Draper, simply puts out a ton of awesome material from many of the big names in the industry. Some of my favorites on this site include the great Stu McGill and Gray Cook debate, and the Lorimer Moseley pain video. 

The post was a print of my continuing education guide, so go ahead, check it out, and support all the great things Laree is doing for the industry.

Continuing Education – The Complete Guide to Mastery

Intro to Hand Therapy Course Review

The hand has always been a weak area of mine, anatomy, treatment, the whole 9 yards. Thus, I was inspired to take an Intro to Hand Therapy Class taught by Patricia Roholt, a certified hand therapist (CHT) with 30+ years of experience.

 The intent of this class was to provide a broad overview of all things hand therapy.  We dove into hand anatomy, evaluation, treatment, splinting, and specific conditions.

My favorites parts were the anatomy, evaluation, and splinting sections. All of these areas were weak points of mine, and I definitely achieved quite a bit of clarity with these concepts. P-Ro is an absolute monster when it comes to splint making, and I loved all the tricks up her sleeve she had to make effective splints. It’s an area I’d like to dive into a bit more.

if the above areas are what you consider to be a hole in your game, I’d consider checking out her online offerings to see if her courses would be right for you.

Check out the full review in the video below. Once you got my final verdict, check out some of the meaningful highlights in the notes below.

Hand Anatomy

Let’s look at some of the fascinating anatomy that accompanies the hand.

The Carpal Bones

Laying your anatomy foundation starts with carpal bone appreciation, and the potential accompanying clinical problems.

‘ppreciate these bones, fam

As you can see, there are two rows of carpals. In the proximal row, the scaphoid and lunate articulate with the radius, and the lunate and triquetrum articulate with the ulna. The pisiform is in this row as well, but doesn’t articulate with any other bones. Its function is to allow for passing of the ulnar nerve and artery, and provide a distal attachment for the flexor carpi ulnaris (FCU).

The big red clinical red flag that can occur in this row is a scaphoid fracture. Because of poor blood supply to this bone, people often needed to be casted for 2-4 months to allow for healing.

Fractures in this region are often not immediately visible on imaging. Thus, a subsequent x-ray ought to be performed 2-3 weeks after the initial injury.

The second row of carpal bones consists of the trapezium, trapezoid, capitate, and hamate.

The trapezium is a bone of interest. In individuals undergoing surgery for thumb carpometacarpal joint (CMCJ) arthritis, part or all of this bone is often removed to increase space. Space is further increased by harvesting the palmaris longus tendon and shaping it into a pseudo-trapezium.

The Hand’s Retinacular System

The retinacular system ensures that tendons stay adhered to the hand while gliding, allowing for optimal hand function.

We can break up the retinacular system into three areas:

  • Extensor retinaculum – made up of six compartments (with first compartment potentially contributing to DeQuervains tenosynovitis)
  • Flexor retinaculum – Contain several synovial sheaths. Fingers II-IV all have their own sheath, whereas fingers I & V share a sheath.
  • Finger retinaculum

The most complex of these systems is the finger retinaculum. There are several pulleys that compose this system to adhere the flexor tendons to the finger: five annular pulleys (A1-A5) and three cruciate bands.

These pulleys are arranged in the following sequence:

Well I’m no Picasso, but do you like it?

For reference, here are the location of the Annular pulleys:

  • A1 – Metacarpophalangeal Joint (MCPJ)
  • A2 – Half the length along the proximal phalanx
  • A3 –Proximal interphalangeal joint (PIPJ)
  • A4 – Middle phalanx
  • A5 – Distal interphalangeal joint (DIPJ)

Trigger finger is a condition implicated within this system. Inflammation and swelling can adhere flexor tendons to the A1 pulley, restricting finger extension. Surgically, the A1 pulley is cut to alleviate this condition.

The Zones of the Hand

There are five zones of the hand to describe portions of the volar surface. It is important to know these zones from a surgical standpoint.

Pink = zone 1; black = zone 2; purple = zone 3; green = zone 4; blue = zone 5

 

  • Zone 1 – Proximal to Flexor digitorum profundus (FDP) insertion
  • Zone 2 – From Zone 1 to A1 (considered no man’s land due to poorest recovery times, as hand intrinsics reside here)
  • Zone 3 – From A1 pulley to volar carpal ligament
  • Zone 4 – Carpal tunnel
  • Zone 5 – Proximal to carpal tunnel up through forearm

Keeping flexor tendons healthy post-surgery involves differentially gliding their tendons. These movements help prevent flexor tendons adhering to the pulleys.

To understanding how to effectively perform these maneuvers, we need to understand flexor tendon muscles.

The big two that we are differentiating are flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP).

FDS primarily flexes the PIPJ…

Don’t stress about the FDS

 

…while FDP flexes the DIPJ.

You down with FDP? Yeah, you know me.

 

Thus, maneuvers must be performed to ensure individual gliding:

It is also important to note that FDP has two separate muscle bellies: one that goes to finger II, and the other that is shared by III-V. Thus, injuries along these particular areas require protection of all fingers, and may require joint blocking exercises to ensure tendon health.

The Extensor Mechanism

Whew, this part is a beast and very complicated structure. Let’s see if we can sift our way through it.

So gangsta that I grew up on that extensor hood, fam!

Here we see all the pieces that make up the extensor mechanism, which combines hand extrinsic and intrinsic muscles.

Let’s start with extensor digitorum communis (EDC), which acts to extend the MCPJ. This guy runs centrally along the finger, and splits off into sagittal bands that surround and stabilize the MPJ. In the picture, these would be a part of the “hood.”

Makes me think of that Wu-tang song every time

The EDC attaches to the middle phalanx, assisting with PIPJ extension. The fibers then split off into lateral bands, which are the criss crossed above past the middle phalanx. These bands are a merging with the hands intrinsic to perform DIPJ extension. The other muscles that would make up the lateral band insertion include the dorsal and palmar interossei, and the lumbricals—all helping to create DIPJ extension.

The Thumb

The big thumb intrinsic muscles are the called the thenar muscles, which help the thumb perform the important opposition movement. These include…

  • Abductor pollicis brevis
  • Flexor pollicis brevis
  • Opponens pollicis
Scalpel not included

These muscles attach proximally at the volar carpal ligament. This attachment is important to consider with someone who has a carpal tunnel release, as this surgery disrupts the thenar muscle attachment, potentially compromising thumb function.

Nerve Supply to the Hand

The big three nerves relevant to the hand are the median, ulnar, and radial nerve.

Yellow = Median; Green = Ulnar; Pink = Radial

The median nerve is the big dog when it comes to thenar muscles and first two lumbricals. Injury to this nerve will impact thumb opposition and sensation.

The ulnar nerve innervates many of the muscles of the hand, including lumbricals 3 and 4, all the interossei, and the hypothenar muscles. Thus, an injury to this nerve can have severe repercussions to hand function. Limitations could include inability to perform a lateral pinch (requires adductor pollicis activity), can’t abduct finger V (need abductor digiti minimi), and will have difficulty utilizing extensor mechanism.

The radial nerve is less of a big dog, predominantly responsible for sensation. There will be alterations in wrist and finger extension, but since hand intrinsics are innervated by the median and ulnar nerve, some finger extension is preserved.

Common Hand Pathologies

Ever seen a swan neck or boutonniere deformity before?

Finger 4 is a swan neck, finger 5 is a boutonniere

With a swan neck deformity, the proximal interphalangeal joint (PIPJ) upwardly displaces secondary to a disrupted  transverse retinacular ligament. These ligaments prevent dorsal displacement of the lateral bands.

With the boutonniere deformity, a PIP extensor tendon defect causes the proximal phalanx to migrate upwardly as the DIPJ extends.

The de facto treatment for the boutonniere is splinting the PIPJ in extension and the DIPJ in flexion.

Evaluation of the Hand

 

Most of this section was your typical evaluation fare: history, range of motion, posture, palpation, etc. But there were a few key pearls I gleaned.

Measuring Thumb Opposition

Measuring opposition according to this grading system is something I am employing much more. We measure opposition via a 10-point grading criteria:

  • Stage 0 – Thumb tip to lateral aspect of proximal phalanx of index finger
  • Stage 1 – Thumb tip to lateral aspect of middle phalanx of index
  • Stage 2 – Thump tip to lateral aspect of distal phalanx of index
  • Stage 3 – Thumb tip to index tip (considered early true opposition)
  • Stage 4 – Thumb tip to middle tip
  • Stage 5 – Thumb tip to ring tip
  • Stage 6 – Thumb tip to small tip
  • Stage 7 – Thumb tip crosses small finger DIPJ
  • Stage 8 – Thumb tip crosses small finger PIPJ
  • Stage 9 – Thumb tip crosser small finger proximal finger crease
  • Stage 10 – Thumb tip crosses distal palmar crease.

With stages 6-10, you want to make sure that the thumb slides down the small finger to ensure accurate opposition, as patients can compensate with thumb adduction, providing a false measure.

Sensation Return After an Injury

There are many ways to assess post-injury nerve function. One test used is tinel’s, in which you tap along the nerve to determine nerve regeneration. If you tap a portion of the nerve, it will produce an electric shock sensation to the point where the nerve has regenerated. This test can also signify potential nerve entrapment.

Based on how the nerve heals, constant and moving touch are some of the first sensations to return. Until these sensations are felt, true sensory re-education cannot be performed.

Wound Classificiations

 A weak spot of mine has always been wound care. Patricia helped stratify decision making for wounds in this class by classifying wound healing types. There are three.

First Intention

This type of wound is a sutured wound, in which range of motion across joints that may compromise the wound ought to be limited for 2 weeks after initial suturing.

Second Intention

This type of wound is an open wound, in which the treatment varies. The intent is to maintain a wound that is not too dry or wet.

Third Intention

This wound is intentionally left open at first to clean and debride, then is sutured and grafted once healed. Treat as a second intention wound until suturing/grafting occurs, then first intention once the wound is closed.

Scar Healing Times

 Scars have a specific healing times as well in the hands, which drive decision making in terms of progressing range of motion.

Coloring can be informative of how well the scar is healing. Typically, the redder the scar, the more immature the tissue is. Whereas white scars are a bit more mature.

Compared to normal skin, scar strength improves according to the following timeline:

  • 2 weeks:3-5%
  • 3 weeks = 15% (tolerates AROM)
  • 4 weeks = 30-50% (safe for most activities)
  • 2 months (70%)
  • 3-6 months (80%).

Splinting the Hand

 The splinting section was one of my favorite aspects of the course and really where Patricia shined.

The overarching goal of splinting is to give the hand what it cannot achieve.

Splints can be classified into three different types, either prefabricated or custom:

  1. Static – These splints lack moving parts, used for rest, protection, positioning, or function in some cases (e.g. nerve injury).
  2. Serial static/static progressive – These splints are used to increase mobility in joints and soft tissues via low load long duration stretching. The former requires therapist-remolding, whereas the latter is changed by modifying components (screw/Velcro)
  3. Dynamic – Splints that contain moving parts to compensate for motor loss, correct for contracture, protect tendons (by pulling in direction they cannot actively contract), or exercise muscles.

There were several different types of splints she suggested, but the real treat was watching her make splints. She had developed some pretty neat tricks to save on cost and maximize function. I don’t necessarily have any specifics, as the splints she makes were quite customized to the individual’s needs.

The Ideal Position to Splint the Hand

To illustrate important components of hand anatomy, it helps to look at how the hand is often splinted after an injury.

I’d rather some more IPJ extension, but like me, this splint is close to ideal, though not perfect #yesimsingleladies

The common position to splint the fingers in is with the MCPJ in flexion, and the PIPJ and DIPJ  in extension.

This position maintains tautness of all the collateral ligaments of each joint: the MPJ collaterals are taut in flexion, and the PIPJ and DIPJ in extension. This position also protects the volar plate, which is a ligamentous structure that limits PIPJ hyperextension. These structures must be preserved at all costs to avoid contracture in these areas.

Sum Up

There is a broad overview of Patricia’s Intro to Hand Therapy course. Though not perfect, it sparked many treatment ideas for me and helped me better appreciate the complexity of the hand.

To summarize:

  • Understanding hand anatomy is important in developing treatment paradigms
  • Flexor tendons must be differentially glided to ensure health post-surgery
  • Splinting acts to give the hand functions it cannot achieve on its own

What tricks do you have up your sleeve for assessing and treating hand complaints? Comment below and let us know!

Photo Credits

Anatomist90

Becguglielmino

Henry Gray

Wikipedia

Anatomist90

Anatomist90

Harrygouvas

Henry Gray

Henry Gray

Grant, John Charles Boileau

Grant, John Charles Boileau

Scoliosis, Morton’s Neuroma, and Just in Time Learning – Movement Debrief Episode 22

Movement Debrief Episode 22 is in the books. Here is a copy of the video and audio for your listening pleasure.

Here were all the topics:

  • Thoughts on Treating Scoliosis
  • Thoughts on Treating Morton’s Neuroma
  • Why I prefer Just in time vs just in case learning

If you want to watch these live, add me on Facebook, Instagram, or Youtube. They air every Wednesday at 8:30pm CST.

Enjoy.

                

Here were the links I mentioned tonight

Advanced Integration Day 4: Curvature of the Spine

PRI Advanced Integration

Ipsilateral Hip Abductor Weakness After Lateral Ankle Sprain

Method Strength – Dave Rascoe

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