Students in the Clinic

Dr. Laura Wenger, PT, DPT, OCS, FAAOMPT

It’s no surprise that we love learning based on the advanced certifications that many of our clinicians have undertaken, are currently involved in, or plan to be involved in! Along the way, we have realized that part of being a good learner is also being a good educator, and we love having opportunities to educate students across multiple levels. At least three times a year, we act as clinical instructors for students undergoing Doctor of Physical Therapy training in universities from across the country. You may also notice that we have student interns from Fort Lewis College or other undergraduate programs participating in “shadow” internships where they get to learn more about the field and decide if they want to move into the physical therapy profession in the future. We also enjoy opportunities to share the love for our profession with even younger students in high school and middle school as they are starting to think about college and what types of educational tracks they want to go into. We even get opportunities to mentor each other in the clinic, with both myself and Dr. Ellen Tomsic, PT, OCS, FAAOMPT currently serving as mentors to our colleagues on weekly basis.

Maybe it really does take a village? We love the opportunity to work with DPT students to improve their hands-on and clinical reasoning skills

As the unofficial clinic director of all things educational, I recently had a great opportunity to share my love for the profession with 9th Grade Students at Animas High School through Durango’s Business Education Connection program. I always get invigorated about my profession and how lucky I am that I get to work with our community of patients every day when I participate in events such as this, especially when students ask great questions such as “What do you love most about your job?” and the path that I took to get to where I am today (which, admittedly, was a long and winding one). We look forward to more visits and opportunities with students at all levels in our clinic and community!

I had a lot of fun at the 9th Grade Explore Career Fair at Animas High School where I got to chat about all things Physical Therapy

The Importance of Expectations and Communication

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

As physical therapists, we are deeply invested in creating relationships with our patients not only as a side effect of the amount of time we are able to spend one-on-one with you but also to ensure your success in meeting your goals. So much of this relationship-development occurs on your first visit with us, where we do a deep dive into the history of the problem that is bringing you PT and getting a better understanding of who you are as a person and what kinds of factors may impact your rehabilitation both positively and negatively. Many professionals in PT and other healthcare fields are also interested in this topic, as there have been many research studies developed- especially in the past 20 years- aimed at understanding the relationship between expectations of both the patients and providers and a person’s ability to improve. 

One such research article was just published by some of my colleagues as part of their work in the Bellin Doctor of Science of Physical Therapy program, where the research team wanted to get a better qualitative understanding of the expectations that patients have before they come to PT.1 Overall there were five main themes that emerged in terms of the questions that patients expected to have answered when meeting their PT for the first time:1

  • “What is wrong with me?
  • “How long will it take me to feel better?“ 
  • “What can I do as the patient?“
  • “What can you (the physical therapist) do for the pain?”
  • “What is the expected outcome of physical therapy?”

 

The answers to these questions can be formulated after a thorough history and physical examination by the physical therapist to understand your specific condition and all potential contributing factors. And, the answer to these questions also may evolve over time, which is why we continued to focus attention and detail to your response to treatment and activity progression along the course of your rehabilitation, making the appropriate adjustments as needed. At Tomsic PT, we work to take the time to know you and your problem to help you reach your end goals. There may be additional questions or expectations that arise for you either before or during your course of PT, and it’s important to feel comfortable bringing these to your physical therapist so that we can best understand how to help you throughout the course of your treatment. 

  1. Subialka JA, Smith K, Signorino JA, Young JL, Rhon DI, Rentmeester C. What do patients referred to physical therapy for a musculoskeletal condition expect? A qualitative assessment. Musculoskeletal Science and Practice. 2022. 59;102543.

Answering the Question “How Much is Too Much?”

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

Spring is peeking its head around the corner here in Durango. With the coming of warmer months, we here at Tomsic PT are also starting to see a rise in patients coming in with injuries related to ramping up their training for varying activities including endurance running and cycling. When working with these patients, we often hear the question, “how much is too much?” when it comes to managing training progression and the risk of injury. Dr. Nathan Dailey and Tyrone Deel recently dove into this topic on one of the recent episodes of The Daily Note podcast. Because it is such an important topic and a question that most patients would like guidance with, I wanted to address some of the key principles here.

A lot of the answer comes down to how we define “Training Load”. There are two main types of training load that need to be considered here: internal and external.1 External training loads are more often what we think of- “physical work” being performed such as a distance ran or biked, an amount of weight lifted, and reps performed in a high intensity exercise, to name a few examples.1 Internal training loads include such things as ratings of perceived exertion (RPE) and heart rate, measures of how challenging or tasking an activity was to your body both physiologically and mentally.1

Nathan deadlifting 500lb at Fort Sill, Oklahoma in 2020- a solid external training load, and probably internal, too!

To determine the training outcome, an equation of sorts can be used: Outcome = Individual characteristics of the athlete + external training load + internal training load.1 Individual characteristics include things like age, baseline fitness level, and previous or current injuries.1 This highlights the importance of an individualized training program and accounts for the fact that two individuals training for the same race on the same “training schedule” may have very different outcomes, such as one sustaining an injury and the other not (I speak from experience as the injured person here).

Enjoying some trail running in our beautiful San Juans!

There are guidelines for how to safely progress training in order to achieve an optimal outcome- performing at your desired level/goal and being injury-free usually the target here. As physical therapists, we are trained to help you look at these individualized factors, especially in the context of past or current injury, to help guide you toward doing what you love without limitation as much as possible. If you’re currently training for a certain activity or event and desire more guidance to doing this without unnecessary aches and pains, be sure to reach out to schedule an appointment with one of our PTs so we can discuss your optimal training progression based on your individual needs.

1. Gabbett TJ. The training-injury prevention paradox: should athletes train smarter and harder? Br J Sports Med. 2016; 50:273-280.

Classifications of Pain Discussed on “The Daily Note” Podcast

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

We have been keeping busy here at Tomsic PT and are, as usual, excited about all of the fun things going on outdoors and in the clinic these days. One thing that many of you may not know about is that our very own Tyrone Deel, marketing coordinator extraordinaire, and Dr. Nathan Dailey, PT, OCS, CSCS, resident strength and conditioning specialist, started a podcast in the fall of 2021. They use their podcast, “The Daily Note”, to touch on a wide variety of topics related to physical therapy, health, and human performance, including strength training, technique, and home exercise programs. It’s very fun to listen to these two chat about these topics in an evidence-based and patient-centered manner.

The most recent episode of the “The Daily Note” from January 2022 touched on an important topic that we have to speak with our patients about frequently- pain. Take a listen if you’ve ever wondered about pain, what it is, and how to manage it. I’ll give you a brief rundown of an important thing that Nathan touched on during this discuss relating to the three types of pain and how they differ1:

  • Nociceptive– this could be thought of as a “tissue issue”, such as when you sprain a ligament, strain a muscle, or have joint pain related to a condition such as osteoarthritis.
  • Peripheral Neuropathic– this describes “nerve pain”, such as burning or electrical pain caused by a nerve irritation that may also be accompanied with things like tingling, numbness, and weakness.
  • Central Sensitization– the most vague of all of the pains, as instead of being caused by a specific tissue injury or nerve irritation, it is driven by your nervous system and brain’s response.

The reality of these classifications of pain, as Nathan describes in the podcast, is that all three types of pain may be present in any individual’s situation but there is usually one that will be the predominant cause of the issue. It is up to us as physical therapists to be able to identify which type of pain is most relevant in your situation in order to best treat you and help you get back toward higher levels of function and tolerance to activity, and that is why our detailed and thorough exam and follow ups help us guide you as best as possible.

Nathan and Tyrone go into the science of pain in much more detail in their conversation. If you’re looking for a knowledge snack in 20 minute or less to learn more about your body and various concepts related to your function and mobility, take some time to check out “The Daily Note”. You can find the episode on Google Podcasts, Stitcher, and Spotify to hear more!

1. Smart KM, Blake C, Staines A, Doody C. Clinical indicators of ‘nociceptive’, ‘peripheral neuropathic’ and ‘central’ mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians. Man Ther 2010;15:80-7.

Ski Injury Prevention

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

It’s always refreshing to wake up to inches of snow on the ground and know that winter is approaching! For those of us Durangoans who love to ski, it’s even more exciting to hear about the 2+ feet of snow that fell in the last 24 hours at the resort. If you’re like me, this news got me looking around for my skis and gear this morning to make sure everything is ready to go to hit the slopes this weekend. As I prepare to get on my skis for the first time in many months, as a PT I also think about whether my body is ready to go in order to set my self up for success for injury prevention this winter. Cue the literature search…

Unfortunately, when digging into the research, there is little information on ski injury prevention for the recreational skier like me. However, I found an interesting review study discussion ski injury prevention specific to alpine racers, so- while not perfect- I’m taking some of the information from this review to extrapolate into my own skiing and the ability of my patients to think of certain methods to reduce their ski injury risk this upcoming season.1

In this review of the existing data, the researchers found that the majority of alpine ski racing injuries occurred while turning (80%) or landing (19%).The researchers also found that there were four athlete-related risk factors that have been identify with statistical evidence, including:1

  1. Insufficient core strength/core strength imbalance– something we can work on!
  2. Female/male sex– in this study, males were found to be at higher risk of injury than females
  3. High skill level– higher ranking athletes were found to be at higher risk of injury than lower ranking athletes, which could be related to many factors such as increased on-snow time
  4. Unfavorable genetic predisposition– one recent study showed that ACL injury risk of alpine skiers may be related to their parent’s history of injury

In addition to athlete-related risk factors, the researchers outlined their findings on equipment, course, and snow-related injury risk factors as well.1

Ellen’s husband, Brad, enjoying fresh powder in the Canadian backcountry

When assessing the findings of this article, my next question becomes: “Is there anything I can do or change for myself or my patients given this information?”. Given the information above, the one thing we can address in the physical therapy realm is core strength and muscle imbalance. Something that we are offering at Tomsic PT is our Winter Readiness Program, which gives you the opportunity to work with a PT one-on-one for an hour for an individualized assessment and program development to help you be successful in having an injury-free season. Although we can’t modify all of the factors related to ski, and other snow sport, injuries, we can focus on the modifiable risk factors and help you to reduce the impact of those those in a sound manner. If you’re like me and itching to get out on the snow while making sure you are as ready as you can be, make sure to call our office to schedule a Winter Readiness assessment soon. And, keep doing your snow dances!

One of my days out on skis enjoying our beautiful San Juan mountains
  1. Spo¨rri J, Kro¨ll J, Gilgien M, Mu¨ller E. How to prevent injuries in alpine ski racing: what do we know and where do we go from here?  Sports Med. 2017;47:599-614.

 

Introducing Dr. Daven Valdez, PT

Back in August, we welcomed a new member to our team- Dr. Daven Valdez, PT! Well, he wasn’t completely new, as Daven was a student here from January to March 2020 when he was undergoing his Doctorate education, so we were happy to welcome him back. Here is some information about Daven:

  • How did you end up in Durango and where did you live previously?
    I was born in Durango and grew up in Durango and Dolores. Southwest Colorado has been my home for most of my life and I always knew I wanted to end up back here after pursuing my professional degree. After graduating high school from Dolores I went to Grand Junction to obtain my Bachelors at Colorado Mesa University and then moved to Denver where I obtained my Doctorate of Physical Therapy degree from University of Colorado.

  • What do you love about working in Durango/at Tomsic?
    What I love most about working in Durango is being able to give back to the community that raised me. Once I decided to pursue Physical Therapy as my profession, I always knew I wanted to make my way back to Durango to provide high quality care for the active community members that call this amazing town home. What I love most about working at Tomsic is being able to learn from and work alongside some of the best and most knowledgeable therapists around. I was a student at Tomsic my second year of PT school and the PT’s here left such a great impression on me that I knew I had to work in that environment to help me grow as a clinician and person.

 

  • What are your special interests in PT and how do you incorporate them into your clinical time at Tomsic?
    A special interest I have in PT and one that I try to incorporate into my practice is resistance training. Utilizing the principles of progressive overload to build strength and stability for my patients is a big part of my treatment style when indicated. Being creative with my exercise prescription to replicate and build to my patient’s hobby or activity of choice is something I strive to implement and improve on each day in the clinic.

  • What’s one fun fact about yourself that you’d like to share?
    One fun fact about me is that I try to learn to the best of my ability all the activities that my patient’s enjoy. Being a great clinician in health care to me means being able to connect with each patient on a professional as well as a personal level. If I am seeing a patient that enjoys pilates or yoga for example, I will take classes to learn how to incorporate elements of that activity into their plan of care to better connect with them. It is something that also keeps me busy and ensures that I am always learning.

Make sure to say hi to Daven the next time you see him in the clinic!

Returning to Sports after an ACL-Reconstruction

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

When I was completing my initial doctorate degree at the University of Utah, I focused the efforts of my doctoral project on identifying risk factors for individuals to sustain a repeat or opposite-leg knee anterior cruciate ligament (ACL) injury after undergoing an ACL-reconstruction surgery. Nearly 10 years later, researchers are still working to identify risk factors for a second ACL injury and to either validate or invalidate previously identified factors. One such recent research article by Beischer et al.(1) sought to further understand the factors that may impact the likelihood of somebody sustaining a second ACL injury after going through surgery and returning back to sport.

The main reason why this topic is so heavily investigated is because the rate of reinjury has been shown to be concerning for young athletes. According to the literature review in the Beischer et al. study, “approximately 1 in 4 patients who are 25 years of age or younger and return to high-risk sport after primary ACL reconstruction sustain a second ACL injury.”(1) For the amount of time and energy it takes to have and recover from this surgery, I don’t like the sounds of those odds and I certainly try to prepare my patients as much as possible to have success when returning to their sport.

This research study focused on three specific factors: 1- the amount of time to return to a knee-strenuous sport after ACL-reconstruction, 2- symmetrical muscle function as assessed by a variety of strength and hopping tests to compare the injured leg to the non-injured leg, and 3- symmetrical quadriceps muscle strength at the time of return to sport.(1) After analyzing data from 159 athletes, this research group found that athletes who returned to knee-strenuous sport earlier than 9 months had an approximately 7-fold higher rate of new ACL injury- of either the same leg or the opposite leg- compared with those who returned at 9 months or later after surgery.(1) They did not find associations with muscle function or symmetry of quadriceps strength in relation to new ACL injury.(1)

The results of this study reinforce the results of many prior studies showing that returning to strenuous sport “too soon” after an ACL-reconstruction is risky. Ultimately, time is on your side when it comes to properly rehabilitating after an ACL-reconstruction surgery, and getting back into play is not to be taken lightly. For those patients of ours who are recovering from an ACL-reconstruction, we will continue to be diligent in educating them about the importance of time throughout the rehab process.

1. Beischer S, Gustavsson L, et al. Young Athletes Who Return to Sport Before 9 Months After Anterior Cruciate Ligament Reconstruction Have a Rate of New Injury 7 Times That of Those Who Delay Return. J Orthop Sports Phys Ther. 2020 Jul;50(7):411.

Return to Work Clinical Practice Guidelines

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

In conducting evidence-based practice, there are three main things that physical therapists rely on to help make the best decisions for how to treat their patient: the patient’s preference, the experience of the practitioner, and the research that is available. Focusing on the research aspect, we rely heavily on high-quality peer-reviewed resources and journals to gather our information. This information gathering is a continual process that is going on behind-the-scenes when we are not working face to face with our patients. One such resource that we use is the Journal of Orthopaedic & Sports Physical Therapy (JOSPT), which provides us with monthly access to new research on a variety of topics within the orthopaedic and sports world of PT. This journal also publishes Clinical Practice Guidelines, which provide an evidence-based overview of specific topics.

Dr. Christine Richards, PT, OCS

Over the past few years, one of our very own PTs, Dr. Christine Richards, PT, OCS, has been working diligently with a group of PTs to author a Clinical Practice Guideline that was just published this summer in JOSPT, titled “Clinical Guidance to Optimize Work Participation after Injury or Illness: The Role of Physical Therapists.”(1) This guideline provides a summary of recommendations for best practice when it comes to physical therapists’ treatment of patients who have been involved in work-related injuries or illness, which is something we see often in the clinic. These recommendations covered all aspects of patient care, including timing and duration of care, evaluation, treatment involving multiple factors, ergonomic assessment and recommendations, and psychologically informed practice.(1) As with every patient that walks in our clinic, we want to use the most well-rounded approach to help workers either stay in their job or return to work after any illness or injury, and this guideline provides an excellent synopsis of the research on this topic over the past 20 years.(1) We are so proud of Christine for her hard work on this valuable project!

1. Daley D, Payne LP, Galper J, et al. Clinical Guidance to Optimize Work Participation after Injury or Illness: The Role of Physical Therapists. J Orthop Sports Phys Ther. 2021; 51(8):CPG1-CPG102. doi:10.2519/jospt.2021.0303.

Strength Training for Low Back Pain in Older Adults

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

To follow up on my blog post from June regarding the importance of strength training, I’ve got another recent research review coming ‘atcha! A group of physical therapists in Spain performed a systematic review- a high quality approach to review multiple research studies- specifically looking at the effectiveness of resistance training programs to help treat older adults (60+) with chronic low back pain.1 Their search results yielded eight high quality research studies that were analyzed to describe the main characteristics of the strength programs used, so that us clinicians can glean the information in order to help us design more effective resistance exercise programs to help our patients over the age of 60 with low back pain that may be affecting their quality of life.1

Ellen taking her shot at perfecting bench press technique

 

Nathan laying down the knowledge on tips and tricks for the bench press

 

Me, working on perfecting my form with Nathan’s guidance

Ultimately, the researchers found that there were a variety of methods used in the strength programs across each of these research studies, but that they all had a positive impact on the patients’ pain, disability, and quality of life.1 The researchers also discuss the reasons why progressive strength programs work: by improving your brain’s ability to connect to the muscles in your body, bone mineral density, muscle function, physical strength, and functional capacity.1 Furthermore, research indicates that strength training programs also help older adults with chronic low back pain see improvements in coordination, balance, and flexibility.1

The three fundamental aspects of strength training programs that was found during this research review include:1

  • Global training of the whole body with emphasis on the large muscle groups
  • Using a traditional periodized program which utilizes the concept of alternating load plans in successive workouts (such as performing 8-10 rep maxes during one workout and 12-15 rep maxes on the next)
  • A gradual increase in volume and intensity initially and further increases in intensity later on in the program

Ultimately, this systematic review provided a big vote for the inclusion of resistance training to help with the treatment of chronic low back pain in adults aged 60 and over.1 A physical therapist will help not only create a program for you but more importantly guide you through proper technique and progression within the context of your individual body’s needs in order to move toward the end result of decreased pain, improved function, and improved quality of life. If you’ve been dealing with chronic back pain and are ready to do something about it, don’t hesitate to reach out to our clinic to schedule an initial evaluation so we can guide you through an individualized plan to help you achieve your goals.

1. Fritz N, Gene-Morales J, Saez-Berlanga A, et al. Resistance training for chronic low back pain in the elderly: a systematic review. J Human Sport and Exercise. 2021;16(3proc):S1492-S1506.

Strength Training in Physical Therapy

By: Dr. Laura Wenger, PT, OCS, FAAOMPT

With the addition of Dr. Nathan Dailey, PT, OCS, CSCS to our team last fall came his strong drive to utilize more strength training within our physical therapy treatment due to his specific background and knowledge as a Certified Strength and Conditioning Specialist. Lucky for Nathan (and all of us!), the remodel that was completed last year provided the perfect space to install a strength training area so that we can meet the needs of our patients. Since the installation of this equipment a few months ago, Nathan has been educating the rest of our team on technique and utilization of strength training within the context of physical therapy.

As it turns out in my investigations of literature, so many of the common issues we see can benefit from the addition of strength training in order to maximize rehabilitation effect. While we have always utilized strength training in other forms in our exercise prescription up to this point- using body weight, bands, and lighter weights- we are now able to further maximize these positive effects using the new strength equipment. For example, take a peek at this recent infographic from the British Journal of Sports Medicine outlining the research that supports strength training for improving running performance.

Infographic from British Journal of Sports Medicine

Regardless of the issue that’s bringing you to physical therapy, make sure to ask your physical therapist about how strength training can be an adjunct to your treatment in helping you move better, feel better, and be stronger and healthier in your life.