Andrew has been my PT mentor for almost a year now and has been very generous with his time mentoring me online. Andrew graduated from VCU’s Medical College of Virginia with DPT in 2006. Since then, he has been a physical therapist for ten years working in a variety of outpatient orthopedic clinics. He went on to complete Manual Therapy Residency and Fellowship training through the Ola Grimsby institute in 2011 and 2012, and became a Fellow of the American Academy of Orthopedic Manual Physical Therapists in 2013. He has served as adjunct faculty and a guest lecturer in the Department of Physical Therapy at Virginia Commonwealth University and has also provided lectures at the UT Medical Center in Memphis, TN. He is also currently an instructor with the Institute for Advanced Musculoskeletal Treatments (IAMT), as well as a mentor for a manual therapy fellowship program. Now he is also co-hosting Healthcare DisruPTion podcast with Jerry Durham.
How did you end up in this awesome PT profession?
This is somewhat of a long backstory but I’ll try to keep it relatively short. My undergraduate degree at Mary Washington College (now the University of Mary Washington) in Fredericksburg, VA, was in Geography, I don’t recommend this as the ideal path to take to physical therapy but I did was necessary for me as I originally thought I would be a teacher. I played soccer for two years in college and then got into weight training. I’ve been active all my life, playing both competitive soccer and basketball, but never considered a career in the health/fitness industry. However, after I graduated college in 1999, and getting a desk job, I began having persistent low back pain. I recalled having intermittent low back pain and “catching” while in high school and college while playing soccer- I felt like I couldn’t bend forward, but it would last for a week and disappear. However, now that I was sitting 8-10 hours a day, the low back pain started increasing and becoming more persistent. I recall tweaking at the gym and then symptoms began spreading into my left leg. Then one morning after an indoor soccer game, I could barely get out of bed. The symptoms had progressed down my leg to below my knee. To make a long story short, a year later I ended up undergoing a laminectomy/fusion at L4/5 for spondylolisthesis. I had two experiences with PT, both pre and post-op, neither of which were remarkable, other than the fact that it exposed to something that I thought I could be good at and would enjoy. In fact, it was my mediocre experience with physical therapy that made me think, “I can do better.”
What are your top 3 areas of expertise? (for example, chronic pain, being a mentor for the fellows, teaching, etc).
As for "expertise," I would refrain from calling myself an "expert" in anything. In my opinion, once people refer to themselves as that, they stop learning and growing. I sometimes feel as clueless as I did right out of school! But the areas I probably have the most knowledge in would be manual therapy, mentoring/teaching, and pain science.
What are you up to these days professionally?
I am treating patients in the clinic 40 hours/week. I am heavily involved in marketing for the clinic, some with physicians, but mostly through community involvement and on social media. Virginia has good direct access and since I returned to the clinic in July 2015, I have helped grow our direct access referral base from 5% to 14% in the past year. A colleague of mine and I are also considering whether or not to try to buy in to the practice we work in or start our own thing. There are positives and negatives to both so we’re in the process of doing our due diligence and figuring things out.
In the meantime, I’m also a contributor to blog on themanualtherapist.com and I co-host a new podcast called the “Healthcare DisruPTion podcast.” It is up on ITunes and as I’m writing this, the first three episodes have been released. The regular release day is Thursday,and I do a Periscope broadcast the Monday following the episode release discussing my takeaways. I also am working on building my first con-ed course, which I am hoping to start teaching, at least locally, by the end of the year.
What kind of course is it and what motivates you about doing it?
The course I’m creating is an exercise/movement course. I’ve been teaching for the past couple of years with another con-ed company but it’s been their material, some of which I don’t enjoy teaching. I wanted to do something that was uniquely my own. I feel like a lot of exercise courses out there are predominantly on the performance spectrum, involving higher level functionality, but that is not necessarily a true representation of what most of our patient populations are comprised of. I wanted to do something that would beneficial for patients at any level, and would incorporate pain science with basic concepts that could be applied right away into clinical practice. I am also a student of personal development and consumer behavior and I have incorporated some of these concepts into the course, because how we communicate with patients, build rapport, and establish the therapeutic alliance will have a significant determination on the outcome.
What excites you to get out of the bed every morning during work days?
It sounds cliche, but being able to help people feel better and get back to their lives. I also work with a great group and for a good owner who allows us plenty of autonomy so there’s very little “workplace stress” that often comes with certain environments. I enjoy the people I work with as well as (most) of my patients, so going to work is something I actually look forward to.
If you’re dreading going to work the next day on Sunday night, you need to think long and hard about 1) where you work and if it’s the right place for you, and 2), are you actually doing what you want to be doing?
Let’s talk a little about manual therapy. Due to our limited time with patients, the residents are taught to use manual therapy only to increase patient buy-in, to decrease pain, and to improve range with impingement signs (posterior knee pain with knee flexion, anterior hip pain with hip flexion, etc). Do you have your own indications for doing manual therapy?
I think manual therapy is indicated in a variety of situations. As a fellow in the American Academy, I certainly have a bias or preference towards utilizing manual therapy, especially early within an episode of care. I would argue, however, that the effects of manual therapy are most often due to neurophysiological changes, not true alterations in biomechanics, especially in the short term. Any rapid improvements in range of motion, for example, are more likely due to a reduction in pain, altered proprioception, reduction in tone/guarding, reduced fear of movement, motor pattern disinhibition, among others. Manual therapy is not truly “releasing” tissue or breaking adhesions. A true capsular or intra-articular lesion is not quickly resolved and requires stress over time. The only exception may be a capsular entrapment in a facet joint, but I have found those to be very rare.
There are times, however, where using manual therapy may not be appropriate or beneficial. For example. patients with high levels of allodynia or hyperalgesia may be too sensitive for manual therapy and often are better treated with “safe” movement to help calm down the system and later they may tolerate and benefit from manual therapy.
I do have beliefs similar to yours about manual therapy. Is it possible or do we even want to “stretch” a joint capsule?
To my understanding, the only tissue that responds to “stretch” is muscle. We do. however, want to stress collagen (the tissue comprising the capsule), in order to stimulate fibroblast synthesis and repair, as well as increase lubrication to the tissue. Collagen has a relatively fixed length but it’s overall elastic range is due to a combination of the dry weight and the lubrication, which adds to the “crimp” zone of the tissue. An immobilized tissue will lose lubrication and the amount of “crimp” it has and therefore will lose relative length before trauma and ultimate failure . In a situation like an adhesive capsulitis or stiff posterior knee capsule, regular stress over time is the best way to induce the needed stimulus for tissue adaptation as well as improving lubrication. Initially, I think this is best achieved through manual therapy, partially due to the other benefits including reduction in pain, muscle tone/guarding, as well as helping reduce fear and demonstrating that the motion is safe. But ultimately, the patient performing regular movement/mobility over time will be what is needed.
Do you give stretches (muscle or joint) to the patients to do at home? If so, what’s your reasoning behind how it helps the patient?
I rarely give patients “stretching” in the classic sense. I have found that muscle LENGTH is very rarely the limiting factor in a person’s mobility. On top of that, when you put a sustained stretch through a muscle, we also have to consider the other tissues that are being affected that do not respond to stretch. However, I do often give MOVEMENT, repeated motions, and self-mobilization exercises to patients. Protective muscle guarding is often a limiting factor in motion, so trying to remove the painful stimulus, and then getting the “tight” area moving is often sufficient.
Tissues respond to stress over time, not force. So I have found dosing consistent, regular movement the way to go. But, if patients report liking stretching, I recommend only short-duration holds of 5-10 seconds at most, which let’s be honest, that’s what most patients are doing anyway even if you prescribe 30-60 seconds.
Will you agree that we are no longer using our hands to “fix” patients? For example, sacral nutations, counter nutations, bones being out of place, amongst many others. If so, are you using more of biopsychosocial (BPS) in your interventions?
I would certainly agree that we should be moving past the belief that we are “fixing” pts and certainly beyond the notion that we can put things “back in place,” especially joints like the SIJ, in which the joint line cannot even be appreciated until after a surgeon works 30 minutes with a scalpel. One problem is, is that this mindset shift is not only slow going through physical therapy, but has become an accepted thought among patients as well. I often find that I have to help patients understand that they are much more robust than they think, and things don’t really slip, “out of place” so easily. And if they did, we’d be a whole lot worse off.
In my mind, the BPS model is THE model. People forget, the “B” is still “bio” which is the tissue and mechanics, but instead of that being the ONLY thing, it also takes into account the person, their beliefs, and the context in which the event(s) occurred. Nothing happens in isolation. If you’re a hand model and cut your finger, I am willing to bet that you will experience more pain than if a soccer player cuts their finger.
How do you incorporate pain science, when most everyone else in the health care team (MDs, surgeons, etc) are treating patients with pathoanatomical approach? I find that incorporating pain science into my patient education makes me stand out as an outlier/weird compared to other health care practitioners that the patient has already encountered. This results in losing the patient’s confidence at times...
Losing the patient’s confidence is certainly a risk when talking about pain science, which is definitely a challenging concept not only for health care practitioners, but for patients to grasp as well. Kind of like exercise, we have to know how to dose out education effectively. I often use metaphors, which help take the abstract and complex aspects of pain science and put them into language and visuals that patients can more easily understand. When I first started incorporating pain science into pt discussions, I failed quite often. But over the past year or so, I have had very few outright rebukes. Some patients take longer than others to really embrace, but ultimately, I think people are happy to know that they aren’t really “broken” or “diseased” and what they may be dealing with is not a life sentence.
The biggest change I’ve made is not talking about just the “brain” as people too often jump to the wrong conclusion that “it’s all in my head.” I now use “nervous system” or just simply “you” because it really is the whole person experiencing pain and multiple systems interacting with each other.
One of my philosophies is the good old “Golden Rule-” essentially do unto others. I would want the truth told to me, and I feel that in order to build a relationship, trust must be established. And you can’t have trust without the truth. Pathoanatomical diagnoses and a Cartesian idea of pain are simply no longer the truth. We have to evolve in our understanding and curation of knowledge. It’s what’s right for the person sitting in front of us, and it’s what’s right for our profession and healthcare overall.
Yet, despite our best intentions, the person on the other end may not be willing to receive it. And that’s ok. I’m all about meeting the customer where they’re at, but I’m also not going to let them lead me down a pathoanatomical rabbit hole. I’m happy to refer them to one of my colleagues or even another provider if they don’t want what I’m offering.
What’s a bad advice or two you hear frequently given in our profession?
“If it hurts, don’t do it.”
“It’s because your core is weak”
What’s a bad advice or two you hear frequently given from more experienced PTs to less experience PTs?
I might be fortunate that I haven’t found myself in this situation too often, unless it was me delivering the bad advice, and then of course I don’t remember :) But in all seriousness, most “bad advice” I’ve heard dispensed to less experienced PTs from more experienced ones is anything that has to do with “numbers,” “units,” etc. In my opinion, when decisions are made in the best interest of your patient (customer), the business will ultimately succeed. When decisions are made in the best interest of the business or the insurance company, it’s only a matter of time before failure will catch up with you. You don’t schedule a pt 3x/wk because it’s a company policy if they only need twice or if they can only do twice. The company policy is what is best for the customer! You do right by them, the business will do right as well.
Your top 2 favorite/ most commonly used manual techniques for spine?
Two areas I find that need addressing and that I get a lot of bang for the buck is the OA joint and upper/mid thoracic spine. A simple OA joint distraction mobilization can be great for treating headaches, TMD, and general neck and/or shoulder pain/dysfunction. Thoracic spine techniques are also very valuable because thoracic mobility is lacking in so many patients and can have such an effect on neck/shoulder issues and well as lumbar spine/hip. The most common technique I use is either a simple prone thoracic gapping mobilization or the supine thrust manipulation to the upper or mid thoracic spine. I’m a big fan of manipulation and if I can manip it rather than mobilize, I’d rather do that, if appropriate. Frankly, it’s more fun to do, and saves time.
80/20 Pareto’s principle: 20% of what you do get 80% of your results. What is an 80/20 of being a great PT?
Two things-- the soft skills and the basics. By soft skills I mean your ability to communicate and build relationships with your patients. Everyone wants to learn the newest sexy technique when the reality is we use those much more infrequently than we do our “people skills.”
Now, don’t get me wrong, I think having a toolbox of wide variety is very helpful, but ultimately you need to get very good at the basics first. In my mind, if you can’t do the basics well, you’re not ready to move on to something more challenging. For example, if you can’t do a mobilization well, you can’t do a thrust manipulation yet. If you can’t move well slow, you’re not going to move well fast. The basics include--confident handling of patients, a variety of general joint mobilizations in different positions, soft tissue mobilization and then some basic spine thrust manipulation.
Don’t worry feel the need to learn EVERY technique that’s out there. Ultimately, you’ll the ones you’re most comfortable with and the ones you use the most often. Get really good at those, and then work on others that you’re less confident with.
I agree about working on the basics first rather than learning new fancy techniques. If you can go back in time and give yourself advice after graduating from PT school, what advice would you give?
#1--Find a mentor early!
#2- Most of what you learn in school (other than anatomy) unfortunately is useless in the real world (at least it was for me), so start reading pain science, consumer psychology, customer service/experience, and business/marketing if you want to better serve your patients, become more valuable to your employer, and get ahead in your career.
18. Name 2-3 PTs who had a huge influence on you and why?
Rick Kring, my Residency and Fellowship instructor at OGI and now CEO of OGI--motivated me through his knowledge and passion to become a better manual therapist
Martin Dominguez, private practice clinic owner and my boss--does things for the right reasons in the right way but also demonstrates that a leader doesn’t need an ego-- they can be humble and confident in what they know what they don’t know; and is willing to hire the people to build a great team.
Jerry Durham- introduced me to the concept of the customer experience and consumer psychology and now I co-host with him on the Healthcare DisruPTion podcast
Who comes to mind as the most successful PT?
Success is hard to quantify. There are many PTs who have made a lot of money and are therefore financially successful, and there are many PTs who are having and will continue to have, a significant impact on the profession. Having the biggest impact might be another way to ask the question, and even then, it’s way too hard to pick just one. Even if we consider just the big names, they are all going to have their acolytes and their detractors. But the main ones that come to mind are Robin McKenzie, Brian Mulligan, Stanley Paris, Robert Maitland, Louis Gifford, and David Butler. “Newer” PTs that I would consider successful include Mike Reinold, Gray Cook, Kelly Starrett, and Chad Cook.
$50-$500 PT related item that you purchased recently that made your life easier.
The item(s) I have most recently purchased are all books. Some are clinical and others are customer/experience and personal development focused. I don’t know if it made my life easier or not, but it’s certainly made me happier. Sometimes the more you learn, the more you realize you don’t know. But even still, you will know more than you did before. My main recommendations would be:
Aches and Pains by Louis Gifford
Mastery by Robert Greene
Mindset by Carol Dweck
The Obstacle Is The Way by Ryan Holiday
The Ten Principles Behind Great Customer Experiences by Matt Watkinson
A Guide To Better Movement by Todd Hargrove
Start With Why- Simon Sinek
To Sell Is Human-- Daniel PInk
Linchpin-- Seth Godin
A Complaint-Free World by Will Bowen
The Talent Code by Daniel Coyle
What is one of your weakest area that you are trying to improve professionally? And how are you working on this area?
One of the main areas I’m trying to work on professionally is the customer experience/sales side of the profession. Regardless of what we want to think, as Daniel Pink says in To Sell is Human, if you work with people, you are in sales. We are trying to get people to come to our clinic, we are trying to get referrals from many sources, we are trying to get our patients to trust us, and we are trying to get our patients to buy in to our plan of care. All of that requires “selling,” which is often perceived (as I did as well) as a dirty word.
How I’ve been working on it is reading several books, many of which are listed above, listening to both physical therapy and business-related podcasts, and with my interactions with people on social media and with a mastermind group that I started locally with some small business leaders.
I have learned so much from this interview. I really appreciate your time! How can people learn more about you?
@ARothschildPT on twitter and instagram
Feel free to Email me as well at email@example.com
Healthcare DisruPTion podcast on tTunes and http://updocmedia.com/podcast/healthcare-disruption-first-episode/