Home Exercise Programs for Low Back Pain

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

Low back pain is a common condition that we see daily in our clinic and something we are always seeking new research on as physical therapists to make sure that our treatment approach is up-to-date. One of our integral components of treatment for patients with low back pain is giving an individualized home exercise program to make sure that you can perform movements and exercises that will help to accelerate and maintain the improvements you make with treatment. Though our treatment will sometimes involve a manual therapy (hands-on) component, we will more often than not work to find a complementary exercise so that you can essentially “self-treat” yourself between sessions and beyond your time in physical therapy.

An example of a manual therapy technique for low back pain that we use often in combination with a home exercise program unique to each patient.

A recent scoping review was published by some of our colleagues that sought to understand the use of home exercise programs in research on low back pain.(1) What this review found was that, out of the 292 studies that they looked at, only 94 of them (32%) included some type of home exercise program in their research.(1) Now, we know that research is not perfect and there are many variables that need to be factored in when designing a research project. However, one thing that we as Doctors of Physical Therapy (DPTs) are taught to look out for when assessing research is how well we can apply the outcomes of the research to the decisions we make on a daily basis when working with you, our patients. In this situation, it is interesting to note that the treatments the researchers are studying are not quite in line with our own, as we (dare I say) always emphasize a home exercise program as part of our successful treatment plan.

So what does this mean for you as our patient? Well, ultimately, I wanted to give you a little insight into our thought processes and allow you to see how we can (or sometimes cannot fully) use the latest research studies to influence the decisions we make to help you on a daily basis. What I hope you can realize is that we are taking the information gathered from research to inform- but not dictate- our clinical decisions, as we know that research conditions are not exactly the same as what we see and do every day in the clinic. Ultimately, factoring in your specific situation along with the research and our own experiences is what leads to the decisions we make every session that we are with you. Here at Tomsic PT we are passionate about giving you the most individualized and best evidence-based treatment that you deserve to help you get back to your goals as soon as possible!

1. Lee GT, Himler P, Rhon DI, Young JL. Home exercise programs are infrequently prescribed in trials of supervised exercise for individuals with low back pain: a scoping review of 292 randomized controlled trials. J Orthop Sports Phys Ther. Published online January 16, 2023. https://www.jospt.org/doi/10.2519/jospt.2023.11448.

Strength Training for Endurance Activities

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

As we have rounded out 2022 and look forward to a bright 2023, we are loving all of the new snow on the ground in and around Durango! The fresh snow has allowed for more accessible terrain and we know that snow sliders of all types are excited to get out there. Seeing as Durango is home to many endurance athletes- professional and weekend-warriors alike- we love to find out information that helps serve members of our community. With many people choosing cross-country skiing as their endurance sport of choice when the snow allows for it, I was eager to find info on how to help our patients improve their performance on skinny skis.

The beautiful snow outside of our clinic this morning!

One article that I came across in my literature review focused on the effect of strength training on middle- and long-distance athletic performance.(1) Cross-country skiing was one of the sports included in the 28 articles evaluated in this meta-analysis, along with running, cycling, and swimming.(1) In this article, performance was defined using tests to assess maximal force, maximal power, and submaximal force along with other tests to measure such markers as maximal oxygen uptake (VO2Max), the energy cost of location (EC), and aerobic endurance.(1) In the exercise physiology world, these tests are used as acceptable measures of an individual’s performance.

Nathan deadlifting 500lb at Fort Sill, Oklahoma in 2020. Though we are not typically lifting this much, this is a prime example of a strengthening exercise that could contribute to your performance in endurance activities!

After analyzing the results of the 28 included articles, the researchers of this meta-analysis found that the implementation of strength training from 1 to 3 sessions a week, and especially maximal-force training including sets of 1 to 5 repetitions at a high load (80% or more of the person’s 1-repetition maximum), lended toward moderate improvements in middle- and long-distance performance.(1) This finding was true for all of the sports assessed, including cross-country skiing. This meta-analysis is another example of a tick in the box supporting strength training for multiple reasons, and something that we love being able to help our patients understand and implement. If you are an endurance athlete and hoping to maximize your performance this winter season and beyond, make sure you ask about how strength training can benefit you at your next session with one of our Doctors of Physical Therapy!

1. Berryman N, Mujika I, Arvisais D, Roubeix M, Binet C, Bosquet L. Strength training for middle- and long-distance performance: a meta-analysis. Int J Sports Physiol Perform. 2018 Jan 1;13(1):57-63.

AAOMPT Conference and Diligence with Research and Clinical Practice in Physical Therapy

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

At the end of October, both Dr. Ellen Tomsic and I had the opportunity to attend the annual conference of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT). While the conference was located in beautiful San Diego, I found myself so enthralled by the programming and evening conversations with fellow passionate PTs from across the country that I never left the conference premises for the entire three days that I was there. Ellen has been a member and Fellow of AAOMPT for nearly 30 years, and I feel fortunate that she introduced me to the academy eight years ago where I would eventually follow the academic and clinical journey of becoming a Fellow myself. Attending their yearly conference reaffirms my sentiment every year, as I always find myself surrounded by inspiring clinicians, educators, and researchers in our field.

Laura and Ellen at this year’s AAOMPT Conference in San Diego

This year, amongst the many excellent keynote speeches, our academy was privileged to hear a top researcher and educator in our field discuss challenges in understanding the effects of manual therapy within the current research being published. A specific 2021 systematic review was highlighted during the speech by Dr. Chad Cook, in which the researchers made the following conclusion:

“Manual therapy does not seem to have clinically relevant effect compared with sham treatment. Similar effects were found with no treatment.”1

At first glance, when reading a conclusion like that, one might think that manual therapy is a treatment that provides no benefit to our patients, which is a notion that many of our patients and all of our PTs would have a difficult time believing as we see the positive effects of manual therapy as part of a holistic treatment approach on a daily- or really hourly- basis. However, as Dr. Cook broke down in his keynote speech, we must not rely on our first glance when reading research. While Dr. Cook walked through multiple points of contention with taking the results of this systematic review at face value, one point of note was that the types of manual therapy treatments and sham treatments varied greatly between the 24 trials included in this review and meta-analysis. This point lends to one of the greatest challenges in performing valid and meaningful research on manual therapy as a treatment in that, pragmatically, manual therapy treatments look different trial-to-trial which is much like a clinical level where the treatments may look very different individual-to-individual.

Our therapists work through an individual assessment process to tailor each treatment- whether exercise, manual therapy, educational, or other- to each patient in front of us.

When we look at this clinically, the reason for these differences is that each person is unique, and it is our responsibility as a physical therapist to individualize the treatment approach based on each person in front of us. Furthermore, we use a model where we can test your response to treatment on a session-by-session basis (and oftentimes at multiple points within a session) to make sure we are picking the correct treatment approach for your body. So, while there may not be conclusive evidence in research that manual therapy is an effective addition to treatment of musculoskeletal conditions based on reviews like the one highlighted here, we can prove to you and ourselves that the treatment choices made are beneficial by using the most relevant evidence we have- your actual improvement. To be clear, this is not to say that all research is irrelevant, but rather to highlight the fact that research studies are not perfect in their design and are merely one piece of the puzzle when using evidence-informed care. Our clinicians are all either pursuing or have pursued advanced certification so that we can stay at the top of our game to make the best decisions for you.

1. Lavazza C, Galli M, Abenavoli A, et al. Sham treatment effects in manual therapy trials on back pain patients: a systematic review and pairwise meta-analysis. BMJ Open. 2021;11:e045106. doi:10.1136/ bmjopen-2020-045106

Winter Sports Readiness Program

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

As soon as the temperature starts dropping at night and there are rumors of light snow up in the high country, many of our minds turn to winter activities. We have already had a few patients comment on the desire to feel strong and prepared to enter this winter season to enjoy their favorite sports- skiing, snowboarding, cross-country skiing, and snowshoeing to name a few. Due to this high demand in interest, we have come up with a Winter Sports Readiness Program to serve our patients and communities. This entails an individualized, sport-specific assessment to come up with a program to address your strength and conditioning coming into the winter sports season.

Assessing symmetry of movement is a large part of the Winter Sports Readiness Program

While a literature review of the role of exercise in winter sports injury prevention is very limited, as highlighted in a systematic review by Hébert-Losier and Holmberg specific to alpine skiing and snowboarding, we have seen anecdotally that increased levels of strength, endurance, and conditioning are indicated to tolerate the demands of winter sports.(1) Although not all sports injuries can be fully prevented due to many outside variables- such as conditions, other sport participants around you, and terrain variations and difficulty in relation to skill level- many factors can go into feeling more confident and prepared to participate in winter sports.

We use plyometric and dynamic movement testing to assess your movement patterns during the Winter Sports Readiness assessment

Our Winter Readiness Program initial assessment includes a battery of testing to assess your overall flexibility, strength, balance, and biomechanics during movement. An example of a test we use is the Star Excursion Balance Test where we assess for side-to-side balance symmetry in a challenging, dynamic reaching movement. This test has been shown in research to be associated with injury status when an asymmetry has been found.(2) This is just one example of a test that we use for our hour-long assessment. We tailor this assessment based on your specific history and goals for winter sports participation so that each assessment is individualized to you. At the end of the assessment, the Doctor of Physical Therapy you work with will explain your results and advise you on a custom program plan based on your performance and goals.

Getting a holistic assessment of your movement patterns and symmetry will allow us to give you recommendations on how to improve your function as you prepare for Winter Sports

So, if you’re looking for more guidance and a plan to make you feel your strongest and best going into this year’s winter season, be sure to call and make an appointment for your Winter Sports Readiness Program assessment as soon as possible to get booked with one of our PTs!

1. Hébert-Losier K, Holmberg HC. What are the exercise-based injury prevention recommendations for recreational alpine skiing and snowboarding?. Sports Med. 2013;43:355–366.
2. Stiffler MR, Bell DR, Sanfilippo JL, et al. Star Excursion Balance Test anterior asymmetry is associated with injury status in division I collegiate athletes. J Ortho Sports Phys Ther. 2017;47(5):339-346.

Take Your “M.E.D.S.”

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

A group of the faculty at South College’s Doctor of Physical Therapy (DPT) program, where our current student Holly is completing her doctorate degree, just published a perspective paper regarding M.E.D.S. and why they are important for your health. M.E.D.S. is a useful acronym for essentials of healthy living- Mindfulness, Exercise, Diet, and Sleep.(1) As practitioners that are helping all of you achieve goals of feeling well in your bodies, we would be remiss not to ask about and address all of these aspects of life that contribute to physical and emotional well-being. Though physical therapists are often thought of as movement and exercise specialists, we are at a point in medicine and research where we are further understanding that musculoskeletal health is multifaceted and a siloed approach to healthcare is not always the best solution.(1) This article by Hughey et al highlights that concept and advocates for a holistic approach physical therapy.

Nathan coaching Christine on strength exercises in the clinic

Coming up on my eighth year as a PT here at Tomsic Physical Therapy allows me to reflect upon the thousands of patient encounters I have had over the years. One of the reasons I love being a physical therapist is that I get to spend so much one-on-one time with my patients- arguably more than any other healthcare practitioner. During the many minutes that I get to spend with each patient through their course of rehabilitation, I have the opportunity to ask about, understand the impact of, and give advice on the aspects of Mindfulness, Exercise, Diet, and Sleep in relation to their current issue at hand. This does not mean that I take the place of other healthcare professionals who are specialists in those areas, as I often refer patients out to mental health specialists, nutritionists, and primary care physicians for more in-depth assessment of these areas when needed.

Taking a mid-work meditation break on the lawn outside
Christine on a ridge in Denali National Park, Alaska

We are excited to see our colleagues in DPT education promoting “M.E.D.S.” as an essential part of a physical therapist’s breadth of knowledge and responsibility, and are eager to see more programs and clinics engaging in this holistic approach to musculoskeletal and whole body health.(1) Our patients are no strangers to conversations about all of these aspects of optimal health, and we are excited to support our profession in recognizing the importance to a well-balanced approach to wellness and prevention of disease.

1. Hughey L, Flynn TW, Dunaway J, et al. Mindfulness, exercise, diet, and sleep – A necessary and urgently needed skill set of the musculoskeletal practitioner. Musculoskeletal Care. 2022; 1-4. https://doi.org/10.1002/msc.1686

Dry Needling: How does it work?

By Dr. Laura Wenger, PT, OCS, FAAOMPT

As physical therapists, we have many tools that we can use to help patients get better. As part of our dedication to providing quality, evidence-based treatment, we are always seeking to provide individualized, effective, and efficient treatments to help you get back to your desired level of function as quickly as possible. One of the tools that we often use, depending on the patient in front of us, is dry needling. All of our PTs have become certified through training to be able to use this technique to help our patients when we feel it is indicated.

So, what exactly is dry needling?

Dry needling is a term we use to describe the use of a very thin, monofilament needle to penetrate skin through to soft tissue and muscle in a location we have identified as a target. This is the same small type of needle that acupuncturists use- though, even as we are using the same tool, dry needling is very different than acupuncture and the two cannot be confused.

Oftentimes, we will use “trigger points”, or areas of specific tightness and/or pain in a muscle that is related to your problem, as our target. We like to think of dry needling application like a “Control-Alt-Delete” reset to our nervous system. With this treatment, we can target muscles directly that are either too “wound up” or “lazy”, which can happen for a myriad of reasons related to how our brain is connecting dysfunctionally to our body via the nervous system. All of that being said, dry needling is not a standalone treatment, as we want to make sure we can address movement patterns, weakness, and mobility issues in the area around the target muscles to optimize your function with decreased pain. Through a well-rounded assessment, we are able to identify these issues that are contributing to your problem, and then systematically work through a treatment plan to get you back to where you want to be!

What does the research say about dry needling?

There has been much research done on dry needling, especially in the past 20 or so years as it has grown to be a more well-known treatment tool for physical therapists. As I’ve discussed in previous blog posts, no research is perfect and we have to take the information within the context of not only the limitations of the studies we look at but also the relevance to the patient in front of us as we make treatment decisions. But, I want to highlight a recent systematic review and meta-analysis where 42 articles were assessed in an attempt to understand the effectiveness of dry needling in treating musculoskeletal pain.(1) As is typically the case with much research, the review found that there are improvements that could be made in the quality of the research on dry needling. However, from the information they gathered, the authors concluded that dry needling had a larger effect in both timeframes of 72 hours after treatment and 13 to 24 weeks after treatment with reduced pain reported, though the effects were gathered from what was considered “low” quality evidence. There was “moderate” evidence for dry needling having a moderate effect in pain reduction in the 1 to 3 week timeframe after treatment. Overall as a result of this study, dry needling often compared better than no treatment, sham (or fake) dry needling treatments, or other pain-reducing therapies.

When it comes down to it, we see positive effects of dry needling treatment often with our patients both within our session and for days after until our next session. If you are curious about the benefits of dry needling in your case, make sure to ask your physical therapist if you are a current patient or give us a call to find out more if you are not an existing patient!

1. Sánchez-Infante J, Navarro-Santana MJ, Bravo-Sánchez A, Jiménez-Diaz F, Abián-Vicén J. Is dry needling applied by physical therapists effective for pain in musculoskeletal conditions? A systematic review and meta-analysis. Phys Ther. 2021;101:1–15. https://doi.org/10.1093/ptj/pzab070

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.