Tag Archives: sports physical therapy

Private Pay Physical Therapy

I’ve been meaning to write an article about this for awhile now, and since the New Year and the many changes in the insurance industry it’s prompted some action on my part.

The current trend in the health insurance industry is to increase the patient’s responsibility for their health care.  This shows up in rising co-pays that are as much as $60 per visit or deductibles that can be as high as $10,000.  This pretty much means you pay the first $10,000 of your medical expenses before the insurance company starts kicking in anything.  On top of that you max have an ‘out-of-pocket’ max to reach so that you may still have a co-pay or a co-insurance until you reach that magic number.

I’ve had this type of insurance myself so I know full well how it works.  To be able to afford the monthly premiums anymore, some folks are forced to go this route and then pray that nothing bad happens to them or their family.

I’ve always offered what I think is a rather fair private pay rate since many people didn’t have insurance prior to the Affordable (laugh) Care Act.  Everyone is required to have insurance from this point forward or pay a fine.  Many younger folks are choosing to pay the fine for now since it is much cheaper than paying for insurance they probably will not use. In this case private pay for physical therapy is a no-brainer.

Now what about for those of you that do have insurance?  This is where is can be a little tricky.

The private pay rate here at Elite Physical Therapy is $75 per visit.  This was the lower end of what insurance companies would typically pay for a physical therapy session, although with cost cutting more companies are hovering around this point.  There are still companies that do pay significantly more than that depending on what is billed.

The typical session at Elite is 45 minutes (60 minutes day 1 with the evaluation), and is one on one with the physical therapist.  You have 45 minutes of my undivided attention plus access to me by phone or email with questions.  The typical frequency of visits is 2x per week, and in some cases 1x if cost, schedule, or distance are issues.

That being said, for a person who is private paying for physical therapy, that would come to $150 weekly.

Most clinics are going to see you at least 2-3x per week so if you have a $50 co-pay you’re already up to $100-150.  Not only that but most other clinics in this area will allow you 15 minutes with your therapist and the rest of the session is spent exercising on your own or with a tech.  You may save a little, but the quality of care may not be the same.

Here are a few other scenarios I have run into where someone chooses private pay over insurance:

  • They do not anticipate meeting their deductible and choose to pay the $75 private pay rate rather than what they would be charged if it were billed through the insurance.  Going through insurance can cost as much as $225 for the first visit and $90-120 for subsequent visits.
  • Some people would just rather keep their health information between them and their doctors so they request to private pay versus going through their insurance.  I’ve heard a number of valid reasons for this but the big one being concerns over the deductibles going up (much like claims against auto or home insurance).

Here are a couple other points to consider when choosing between private pay and insurance, or even which PT clinic is right for you:

  • My thought process with many injuries/conditions is that you should see substantial improvement within 4-6 sessions.  I tell my patients this right up front.  You may not be 100% that quickly but you should be well on your way.  I don’t want to waste your time and money so if things are not improving in that time frame its time to go back to your physician.  I hate to say this but I’ve had patients come to me with 20-30+ visits to PT under their belt already and no results.
  • Many clinics in this area do not give discounts for private pay physical therapy!  PT services, just like physician or hospital services, are billed out at a much higher rate than what would actually be paid out.  It’s a game we all have to play with the insurance companies unfortunately, but to bill a patient that same rate to me is ridiculous.  At a minimum you’re probably talking $150 for a 30-45 minute session.
  • This goes along with the point above – I’ve done some checking and as far as I know I have the cheapest private pay rate around.  I’ve even had a couple referrals from other PT’s because their ‘friend’ didn’t have insurance and I had the best rates.

The point of this article is to let you know that you have options!  Great care for a fair price is what it’s all about here.  If you have any questions at all feel free to contact me at 231 421-5805 or shoot me an email:  joe@elitepttc.com

 

 

 

 

Elite PT and Sports Performance Exercise of the Week – The Whip Snatch

I wrote this article for my SportsRehabExpert.com site a few weeks back, and figured it would be good to share here as well just to give you an idea of some of the more advanced strength and power methods we use here at Elite Physical Therapy and Sports Performance.

 

I picked up this exercise from strength coach Paul Longo at Central Michigan University about 8 years ago (and now at Notre Dame). This was one of his favorites since it was so simple to teach and really hard to do incorrectly. I’ve used this exercise over the years with my more advanced athletes, and they’ve really like it so thought I would share.

Couple prerequisites here:

1) Deadlift is first and foremost. As you’ll see in the video, a great hip hinge is a requirement so the athlete must be technically sound in the deadlift.

2) Swings are a favorite of mine and I really just see them as deadlifts for speed and power. The athlete must demonstrate a perfect hip hinge, good power as they drive the hips into extension, and also must be able to stop the kettlebell on a dime and throw it back down. The last point here just shows me that the athlete has the ability to coordinate and stabilize through the entire body in an instant. This is important to me now that they will be going overhead with a bar.

3) Hard Style Overhead Presses are also important, not just for upper body strength, but also for that ability to learn how to stabilize the entire body while driving a weight overhead. It’s one thing to press a weight, and an entirely different thing to catch a weight overhead. I want to know my athletes are rock sold with their arms overhead.

Now on to the Whip Snatch:

Teaching Tips:

1) I don’t get real technical with measuring for grip on the bar for this lift. Have the athlete get their hands at just the right width that the bar sits at the level of their hip crease.

2) Push the hips back with the bar as far as possible. I will have them just do reps of this hip hinge initially.

3) Jump and shrug!

4) Catch overhead.

I find that if we have the start position correct and we’ve worked through the progressions, the rest of the lift usually falls in place. The only other cue I find I need at times is ‘elbows to the ceiling’ after the jump shrug to keep the bar close to the body.

The whip snatch is a great power move and one that falls in line with many of the other lifts we talk about here on the site. Definitely one to give a try!

Shoulder Rehab Part II

In Part I, I discussed how physical therapy of the shoulder using traditional rotator cuff exercises really gets me fired up.  Traditional methods of shoulder rehab often train the muscles of the shoulder in a way that they are not really used in normal everyday function.  If you haven’t caught that article yet, I suggest you read that one first.

In this article I want to address a couple other pieces of the puzzle:  motor control and regional interdependence.

There are many cases in which a certain movement may look dysfunctional in a standing position, but may actually be completely functional in other positions where the patient is more unloaded like lying on their back or stomach, side lying, on hands and knees, or even in kneeling.  In these positions there are fewer joints and segments to control and in most of these cases less gravity to deal with.

Unless the movement pattern is tested in multiple positions, it is not possible to know with any certainty that the movement is limited because of a true mobility issue (think joint restriction or ‘tight’ muscle) or if it is because of a lack of motor control.

Here is a great example looking at a functional reaching pattern behind the back.  In standing, you should be able to reach up behind your back and touch the bottom of the opposite shoulder blade as in the picture below:

So this past week I had a patient come in that could only reach to just below her belt line.  She had been given stretches to increase that movement but they really hurt her shoulder to perform.  If you’ve ever had a shoulder problem or therapy after a shoulder surgery then this exercise will look very familiar:

Shoulder Internal Rotation Stretch

When I had her lie down on her left side, she could reach all the way up her back and touch the opposite shoulder blade!  So why could she not do it in standing but had no pain and no difficulty lying on her side?

By going to a more unloaded position in side lying, the other joints of the body are taken out of the equation, and there is much less to have to control.  In this position she could be successful.  This is a great example of poor motor control, not a loss of shoulder range of motion.  So of course the first question she asked me is why did she spend the last 4 weeks in therapy and at home trying to stretch out her shoulder?

During the evaluation is was also discovered that she had some loss of mobility in her neck.  Because the neck movements were not painful, these were addressed first using cervical manipulation and then I followed that up with some soft tissue work using the Graston Technique through her upper trapezius, levator, and rhomboids.

C1-2 Thrust Manipulation

GT to the Upper Trapezius

Here is where that term – Regional Interdependence – comes into play.  In simple terms, regional interdependence is the interplay between different regions of the body.  In this case its easy to see how limitations in the neck can affect the shoulder since there are a number of muscles that run between the spine and shoulder girdle.  In other cases it could be dysfunction even further down the spine, the pelvis, hip, and beyond that could affect alignment and function at the shoulder.  Without the proper evaluation, it would be nearly impossible to find these relationships.

Once her cervical mobility was restored, we immediately went to corrective exercises to improve motor control of the neck and shoulder girdle.  These were fairly simple non-painful exercises that allowed her to successfully work through her neck limitations in a more unloaded position (hands and knees in this case).

Following that first treatment she could reach behind her back and nearly touch her opposite shoulder blade!

When the patient returned for her next visit, she had maintained her neck mobility and behind the back reach without shoulder pain.  We progressed to kneeling and standing motor control exercises, and by the end of the treatment she could touch her opposite shoulder blade without difficulty.

Half kneeling chops and lifts are a great way to improve stability and motor control through the spine and hips.

Needless to say, this patient was quite happy with the results.  Sometimes it is as simple as being in the right place at the right time with your treatment.  We’ll see how the rest of her treatment goes but for now we’ve knocked out a major limitation in her shoulder function without directly targeting her sore shoulder.

Part III coming soon

If you have any questions, feel free to contact me:  joe@elitepttc.com

 

 

Shoulder Rehab Part I

Physical therapy of the shoulder using traditional rotator cuff exercises really gets me fired up, so I should probably warn any physical therapists, chiropractors, or physicians reading this to buckle up!  Actually I’m not going to try to offend anyone, I just like to challenge conventional thinking and ask questions – especially when it comes to dogma like rotator cuff exercises.

If you’ve ever been to physical therapy for a shoulder rehab then you’ve probably seen this one:

Shoulder External Rotation

and this:

Shoulder Internal Rotation

These are just 2 of many exercises that supposedly target the rotator cuff that are commonly provided by your health care provider.  In fact, many of you have probably been handed 2-3 pages of these and told to do 3 sets of 15 up to 3x daily.  Ever heard of the shotgun approach?  Your health care provider is hoping and praying that one of these might just work and make you feel better.

Now here is the reality of the rotator cuff:  It’s job is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket)

The 4 Muscles of the Rotator Cuff

What most health care providers are going on are EMG studies that measure how hard a muscle can fire in isolation during a specific activity.  There is certainly great evidence that the rotator cuff muscles are firing during these exercises.  The problem as I alluded to before is that these muscles do not function in this way in real life.

These smaller rotator cuff muscles are stabilizers, not movers (like the larger deltoids, pecs, lats, etc).  The traditional rotator cuff exercises train the muscles like ‘movers’ which is not their true function.  I’m not going to argue that someone can’t show increased strength over time within these exercises, but I will argue is that there is no transfer to improved function (i.e. lifting, reaching, carrying, pushing/pulling, etc).

The reality of the rotator cuff again is to stabilize the humeral head (the ‘ball’ of the shoulder) in the glenoid fossa (the socket).  It performs this task reflexively meaning it happens without you having to think about it.  All four muscles quickly fire and relax in a specific sequence (depending on the activity) to stabilize the shoulder joint.  They never work in isolation like you have been trained in the past.

So what are the best ways to fire the rotator cuff reflexively?

  • Compression – this means putting weight through the arm.  Examples would include exercises that involve hands or forearms on the ground holding your body weight, any type of pressing, holding a weight (on your back with the shoulder flexed 90 deg. – think top of a bench press position; or with a weight overhead) just to name a few.
  • Distraction – this would include anything that pulls downward or outward on the shoulder (think traction).  This would include carrying weight by your side, pull-ups, horizontal rows, lifting from the floor, etc.

In any of the above activities, the brain immediately recognizes the need for stability and reflexively fires the cuff to prevent bad things from happening like dislocating your shoulder or falling on your face.  Now obviously I’m not trying to actually do these things to you, but forcing muscles to fire reflexively always works better when there is some sense of urgency.

I’ll leave you with a few of my favorites below, and in part 2 I’ll tackle more of the dogma of shoulder rehab.

Arm/Leg Diagonals – a.k.a. the Bird Dog – Shoulder Compression for Reflex Stabilization

Farmer’s Walk – Shoulder Distraction to elicit reflex stabilization

 

Kettlebell Arm Bar – The goal is reflex stabilization of the glenohumeral joint through compression (using a kettlebell) while performing thoracic rotation.  Lots of great things happening here!

Feel free to email any comments or questions to me:  joe@elitepttc.com

 

 

Ankle Rehab Update

So last week I posted this message on Facebook:  “Limited ankle mobility is a very common reason for nagging foot, knee, hip, and back pain in runners. Unfortunately not too many PTs or doctors are looking there. Maybe it’s time to call us and rid yourself of that pain for good!”

In the past week I have been asked 3 separate times about what is the best way to check your own ankle mobility and then how to improve it.  So to bring you up to speed on why it is so important to have great ankle mobility I refer you to a previous blog post title “Movement Proficiency and the Ankle” which you can find here:  http://www.elitepttc.com/blog/?p=20

Now for the measuring and correcting!

The first video below shows how I measure ankle mobility in the clinic with the foot on the floor and controlling the ankle to prevent pronation (arch flattening out):

To measure your own ankle mobility, simply assume the kneeling position shown in the video.  Rock your knee over the foot to touch the wall measuring how far your big toe is from the wall with a simple tape measure.  The heel must stay down and arch not allowed to collapse.  The goal is 4 inches!

The next video demonstrates how you can quickly address the soft tissue component of the limitation.  Be sure to measure again as we did in the video as this is the only way you are going to know if it is effective or not.  Always follow the rolling with stretching.

If this does not result in an immediate improvement in ankle mobility, you may have a joint restriction that will not be resolved with rolling or stretching.  Another sure sign of joint restriction is pain or pinching in the front or side of the ankle during the testing.  This can often be resolved quickly with ankle joint manipulation and/or mobilization and certain taping techniques that I employ here at Elite Physical Therapy (in other words it’s time to call the professional).

If you have any further questions feel free to contact me:  joe@elitepttc.com

 

 

 

Does Gaining Range of Motion Really Have to Hurt???

Not all physical therapists are created equal, nor does gaining range of motion have to be extremely painful!  I know there is this idea amongst the public that PT has to hurt to effective, but in most cases nothing could be further than the truth.  Sadly enough there are plenty of PT’s out there who also believe ‘No Pain, No Gain’ to be true.

Here is why it does not have to hurt:

–  When the brain starts feeling ‘stress’ it goes into protection mode.  Pain signals coming in to the brain result in signals back to muscles, fascia, and joint capsule to literally tighten down to protect the painful structure.  So the entire time your PT is cranking on your new Total Knee Replacement, or you are cranking on it at home per their instructions, your brain is busy fighting back.  The result is lots of pain and minimal progress.

– Pain fires up your sympathetic nervous system, the part of the system that handles ‘fight or flight’ situations.   My good friend and physical therapist/strength coach Charlie Weingroff has been consulting with Nike and their athletes on this very topic.  What they have found is that athletes who are in this sympathetic state even at rest exhibit increased stress hormone levels that result in poor sleep patterns and poor recovery from workouts and games.  This elevated level of stress over the long term can have some serious effects not only on athletes, but on the rest of us as well.

Balance is good!

The moral of the story here is that increased pain and stress levels can delay healing and recovery.  Some pain is going to be present when you’re dealing with an injury or surgery, but your therapy should not be making you consistently feel worse  Not what you want when trying to recover from an injury or surgery, and certainly not an ideal situation for someone trying to gain range of motion, strength, and returning to work or athletics.

At Elite Physical Therapy and Sports Performance, we recognize that there are a number of soft tissue and joint mobilization/manipulation techniques that can improve range of motion and quality movement without creating excessive pain.  Some techniques may be a bit uncomfortable at the time of application, but what little pain there is should go away quickly with an obvious increase in joint motion and overall movement quality.

Graston Technique can be used to break up scar tissue and improve range of motion of the knee.

 

Graston Technique is also very effective for treatment of tendinopathies – in this case treating the posterior rotator cuff.

In most cases, there are better ways to gain range of motion and strength than trying to push through restrictions and pain.  If you’ve got any questions concerning our soft tissue and joint manual techniques, feel free to contact us.

C1-2 Thrust Manipulation – this one is money for headaches!

Trigger Point Dry Needling – Coming Soon!

 

The Best Mobility Drill Ever?

I’m into exercises that give you more bang for your buck since I know most athletes are pressed for time, and there are plenty of other training skills they would rather be working on.  The ‘Spiderman’ exercise happens to be one of those exercises that can address everything from hip mobility to thoracic spine mobility to shoulder stability. It is absolutely one of the best warm-up drills you can perform and it’s a staple in our programs.

Check out the video below for a short tutorial on how to perform the exercise, what you should be feeling, and what to watch out for as far as ‘cheating’ through the movement.

Previously posted on SportsRehabExpert.com (the video was originally shot for physical therapists and sports performance professionals so I apologize for all the medical lingo)

Elite Sports Performance

Sports performance training is one of the favorite parts of my job.  We definitely do some unique things here, and I happen to think we get some pretty good results too.

I put together a compilation video that you can check out below.  I doubt you’re going to see anything else like this in Northern Michigan!

 

Michael Phelps talks Graston Technique and Training

This article was sent to me yesterday, and I found it not only very interesting, but also validating what I do at the same time.

http://on.details.com/PLYA8S

Michael discusses the benefits of Graston Technique (GT) on relieving pain and freeing up his shoulders and back for swimming.  This is only his subjective report but who is more in tune with how they are performing and functioning than an elite Olympic athlete?  There is plenty of research being done on GT with great evidence based outcomes so I’m very confident that the benefits are real.

One more thing I do want to mention concerning the use of GT in the article, and Phelps’ comments on the pain and bruising that go along with treatment:  the research indicates that GT is just as effective without the pain and bruising.  Of course there will be some pain as you are trying to break up scar tissue, but there is no need to be ultra-aggressive and bruise.  The majority of my patients will tell you they have some mild to moderate discomfort during the treatment, but are rarely all that sore afterward.  The pain relief and improved motion following the treatment is well worth it.

On the subject of training, Michael talks about how his focus this time around has been on developing more power.  He specifically mentions performing the Olympic lifts and pulling/pushing sleds, both of which are mainstays in our sports performance programs.

At first glance you may wonder why in the world a swimmer would need to do power cleans and run with a sled?  Especially when he’s not even on his feet more than a split second to push off the platform.  Many of the benefits of this type of training are for the nervous system and the speed at which muscles can contract.  Training for power means moving a certain weight as quickly as possible.  The faster you can move it, the more powerful you are.  Strength is different in that time doesn’t matter, only how much weight can you move.  Strength is very important, but in swimming and pretty much every other sport out there, its the speed at which you can generate that force that is most important!

Here is a great example of a power clean (one of the Olympic Lifts – this from my buddy Cal Dietz at the University of Minnesota)

Aaron Studt Cleans 400lbs

Anyway, I hope you enjoy the article.  I can’t wait to see how he does this summer.

Plank Exercise Progressions

If you’ve mastered the front and side plank basics that I’ve discussed on here previously, now you’re ready for some challenging progressions that I feel really carry over to athletics and can get you closer to your training goals.

Each of the following plank progressions add hip motion to the equation so you will be supported on one limb for a period of time.  It’s the support leg that is most important for stability and will be working the hardest.  With all of these exercises, you must maintain a stable core.  So in other words, when you lift a leg your trunk should remain motionless.  If you have to lift your butt up or it sags down then either it is too much for you or you are getting fatigued and need a break.  Perfect reps, nothing less.

The other great thing about these exercises is that they give you a chance to look at symmetry.  By this I mean how does your right leg compare to your left leg when doing a front plank, or how about right and left sides when performing a side plank?  It should be just as easy or difficult on both sides.  Right-Left asymmetries are a huge predictor of injury so work to limit these.  Typically I will have patients or athletes perform an extra set on the weaker side to bring that side up to par.

Alright, done with the lecture.  Check out the plank progressions below.

Prone Plank with Hip Extension -alternate lifting legs about 4-6 inches off the floor.  Nothing moves but the hips.  Shoot for 10 solid reps each leg without losing form.  And if you’ve been paying attention in previous posts, hold the leg up long enough to cycle a breath, then set it back down.  That will be the true test of your inner and outer core working together.

Plank with Hip Extension

Side Plank with Hip Abduction – I really like the side planks as they test your entire lateral kinetic chain for stability.  Post up through the forearm by pressing it ‘through the floor’.  Now lift the top leg keeping the hips high.  Shoot for 10 quality reps with proper diaphragmatic (belly) breathing throughout.  When you can achieve that, now hold the leg at the top and cycle a breath before bringing it back down. 

Side Plank with Hip Abduction

Side Plank with Hip Adduction –this is another great variation that I think gets overlooked.  The bottom leg will be off the ground in this case so the adductors (inner thigh muscles) of the top leg will be carrying more of the load.  Breathing is crucial again so get it right.  Start with 10 second intervals if necessary shooting for 30 second holds ultimately.  If you’ve achieved that, then progress the exercise by moving that bottom leg back and forth.  It should look like a running stride – flex the hip up and then extend it back.  Adding the front to back movement will make your core have to work that much harder to remain stable.  I’ll shoot for 10 reps here again as well.

Side Plank – Hip Adduction

Three great ways to challenge yourself!  Remember to play close attention to those side-to-side differences.  Cleaning those up will bring the greatest benefits.