Direct Access to Physical Therapy

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

A couple of months ago, a patient called to see if she could get her daughter in for an evaluation on short notice. Her daughter had twisted her knee on the stairs and she had swelling and knee pain that was concerning. This particular family has had experience with PT in the past for multiple acute and chronic musculoskeletal problems, so they have seen firsthand how PTs are helpful in assessing and treating bodies from head to toe, so they thought that it would be best to come straight in for an assessment to see what they should do. Luckily, we were able to get the patient in that day with a PT that she was familiar with for a timely assessment. After a thorough evaluation, the PT concluded that the patient likely had a mild sprain of her knee and with some easy exercises and RICE (rest, ice, compression, elevation) over the next couple of days, the patient would return back to normal function in her knee.

This is a great example of what is commonly referred to as “primary care physical therapy”, which is becoming more and more popular across the nation. In the past, patients have gone to their primary care physician for musculoskeletal injuries and, after a thorough assessment from their trusty doctors, they have usually been referred to PT to further assess and treat the problem. In more serious conditions, the patient gets referred to an orthopedic physician specialist if it seems pretty clear that the patient has a fracture or will require surgery due to a more significant nature of the injury, though this is a more rare situation. Historically, this has resulted in a lag time for initiating treatment, which can potentially lead to slower healing times along with more swelling, stiffness, and pain.

Nowadays, most* insurance companies do not require a physician referral to see a physical therapist, so the situation detailed in the example above is becoming more and more prominent. As the training of physical therapists has elevated to the doctorate level, PTs are specifically trained to assess patients as a direct access provider with the knowledge and skills to be able to treat and/or refer to a physician as needed based on each individual’s situation and injury. The best part is, regardless of the body part (or parts) injured, you can count on the PT for an honest, informed opinion on the best treatment plan to get you back to moving and feeling normally without having to spend a couple of days waiting for the process of multiple appointments and referrals to be completed. The faster you can get in to be assessed for a musculoskeletal injury, the more likely you are to begin to recover quickly versus waiting days (or, sometimes months) to get a professional evaluation performed. The next time you or a family member experiences pain or injury, make sure to call our office and we will get you in quickly to see one of our specialized physical therapists to get you back on the road to recovery as soon as possible!

Working hard to make folks feel and move better

*Please call our office to verify your insurance to see whether or not your policy requires a physician referral to PT

Recap of AAOMPT Conference

By: Dr. Laura Wenger, PT, OCS

One thing that we feel passionately about within our professional staff is a strong commitment to supporting our professional organizations, not only because they are our advocates for legislation that supports PT, but also because they provide great opportunities for education and growth within the profession of physical therapy. Ellen has been involved in one such organization, the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT), for over 20 years and she has instilled the importance of this involvement within all of us PTs here.

Recently, four of our therapists, including Ellen, were able to attend the yearly AAOMPT conference in Salt Lake City in October. Laura, Jeff, and Ted were excited to attend the conference for the first time, especially after hearing raving reviews about this conference from Ellen who has attended many conferences (including an international conference in 2016 in Scotland!) in years past. The conference offered up many benefits, including educational courses and discussions as well as the chance to network and connect with PTs from all over the nation whom are passionate about getting their patients better with manual therapy as a strong focus of their treatment.

Jeff, Ellen, Ted, and Laura enjoying filling their brains at the AAOMPT 2017 Conference!

We were able to learn about topics across the spectrum of treatment, such as preventative PT, the importance of strengthening the alliance with our patients, pain science, sleep hygiene and how it relates to pain, knee osteoarthritis, treatments for irritable nerves, and diagnosis as well as treatment for issues related to the upper ribs, shoulder and arm, core and trunk, and feet. Needless to say, our brains were very full after four days of learning from some of the best and brightest in our field, and we came back to the clinic ready to put some of our new thoughts and skills to use with our patients, present and future!

The Skinny on Climbing Injuries

By: Dr. Laura Wenger, PT, OCS

I recently got an email from a Durangoan that is living overseas to partake in amazing rock climbing adventures. She asked for some tips regarding keeping her shoulders strong and injury-free while climbing and was curious about what types of injuries climbers encountered the most. Climbing is a tough sport that requires a lot from our upper extremities and core, so making sure that you are adequately strong and progressively increasing your climbing is a must in order to prevent injury from overuse of a muscle that wasn’t ready for pushing (and pulling) that hard.

A study just came out this year regarding the results of a survey that assessed the types of upper extremity injuries that are sustained by rock climbers.1 Approximately 400 climbers of all types- including bouldering, trad, sport, ice, and indoor- responded, and the results of the study highlighted a few things from the sample of participants:1

  • 90% of the participants reported sustaining an upper extremity injury
  • The most common area injured was the fingers (41%) followed by the shoulder/arm (20%) and the elbow/forearm (19%).
  • As the level of experience increases- from beginners to professionals- the odds of finger injury also increases.
  • Females were significantly more likely to report a shoulder/upper arm injury than males- in fact, females were twice as likely to sustain an injury here versus their male counterparts
  • On that same note, females were significantly more likely to have surgery related to their shoulder/upper arm injury (21%) than males (11%)
That’s Nicole, one of our techs, way up there!

So, what’s the deal with the shoulder getting hurt with climbing? Shoulder injuries, such as impingement, rotator cuff strains, and sometimes subluxation/dislocation because of the range of motion required, occur commonly because of overuse injuries where somebody is a desk jockey during the week and then gets out and climbs hard all weekend. This “weekend-warrior” climbing can sometimes create excess stress and inflammation to the muscles and tendons surrounding the shoulder.

It is not always possible to completely avoid injury with rock climbing. But, if you are going to climb a lot, having a “regular” climbing program and not doing it so sporadically can set you up to not have these overuse-type injuries. Or, if you can’t get out and climb more often during the week because of work or life obligations, then doing some rotator cuff and shoulder strengthening every other day is a way to keep your shoulders conditions so that you can climb hard over the weekend with less risk for injury. If you need more tips or advice from a PT on how to prevent shoulder (or other upper extremity) injuries with climbing, or need to figure out what to do about an injury that you may already have, call us to schedule an appointment with one of our specialized physical therapists to get you back on the rock (or ice!) injury-free!

  1. Nelson CE, Rayan GM, Judd DI, Ding K, Stoner JA. Survey of Hand and Upper Extremity Injuries Among Rock Climbers. Hand. 2017;12:4):389=394.

The Therapeutic Alliance

By: Dr. Laura Wenger, PT, OCS

Sometimes, life doesn’t go how you’ve planned. We get it. A pain in your knee limits your summer hiking plans. A torn rotator cuff leads to a surgery and time off you haven’t planned for. Sometimes your aches and pains don’t necessarily limit your participation in an activity, but they don’t allow you to do things the way you would like to do them. Pain and discomfort come in all shapes and sizes. And not only that, but it happens to the best of us!

Take my case, for example. I was clicking along, training for a trail-running half marathon that is happening this October- the Durango Double that begins and finishes right behind our clinic that we love to sponsor and volunteer for! But, there were a few bumps and snafus that happened with my busy life schedule that happened to derail my training, which led me down a bumpy road to injuring myself due to poor training habits coupled with a pre-existing condition that I was not addressing the way I should have been. You may think, “But, you’re a PT- you should know better!!!” So, in the end, I’m taking a time-out from running to focus on my body in the way it needs to be focused on. What better way to do that then by surrounding myself with smart, caring and trustworthy PTs (AKA my colleagues here at Tomsic PT!) that can help guide me along my path to rehabilitation so that I can keep up in participation of trail-running endeavors for many years to come!

Sneaking in some exercises between patients

The neat thing about that concept is that there is research that has shown the powerful effect on the relationship between patients and physical therapists on treatment outcome in patients with low back pain.1 Sure, a well-trained PT is worth their weight in gold when they can recognize what is happening in your body that is contributing to your pain and, even more importantly, what needs to be done to help reduce your pain and discomfort in order to meet your goals. But, beyond having the ability to identify and treat your problems appropriately, the relationship- or therapeutic alliance- that is built between you and your PT may predict how much better you will get.1 Specifically, the therapeutic alliance depends on three things: (1) the therapist-patient agreement on goals, (2) the therapist-patient agreement on interventions (AKA treatment choices), and (3) the affective bond between patient and therapist, which refers to the trust and confidence that the treatments will bring the patient closer to their goals.1

Research has demonstrated that higher levels of therapeutic alliance were associated with greater improvements in perceived effect of treatment, function, and reductions in pain and disability.1 I just find it fascinating that the relationship we love building with our patients is not only fun in our small community, but it actually helps our patients get even better than they would have if we didn’t have a strong alliance built during our time together! Getting on the same page with your goals, the treatments we are offering, and how confident we are in how those treatments can improve your conditions is integral to having a successful rehabilitation of your problem. Even though this research focused specifically on low back pain, my hunch is that we can extrapolate this information to other areas of pain and discomfort as well. I feel fortunate that I am surrounded by empathetic and knowledgeable PTs to help guide me through my own issues, and I hope that each and every one of our patients realizes the importance in creating these relationships with each other!


  1. Ferreira PH, Ferreira ML, et al. The Therapeutic Alliance Between Clinicians and Patients Predicts Outcome in Chronic Low Back Pain. Phys Ther. 2013; 93:470-478.

Running and its Impact on Our Joints

By: Dr. Laura Wenger, PT, OCS

I always love finding out new information regarding the impact of running on our bodies. As a runner, I know the love-hate relationship that I have with running as sometimes it feels like the thing that can cure my ailments and other times it feels like it may cause them. From some of my older patients, I have heard everything from, “Running is the best activity for my heart that has kept me strong throughout my life,” to, “I wish that I never started running because it ruined my knees.” With so many varied experiences, the question often comes up about whether or not running is beneficial or detrimental long-term. As it turns out, not only me and my patients are asking this question, but researchers are as well.

Enjoying the beautiful flowers and mountain views on a July trail run- not a bad backdrop for a run!

A recent systematic review and meta-analysis, which are quality ways to assess all of the available data regarding a specific question, sought to find out if there was any association between running and hip and knee osteoarthritis, which is a condition where your joints undergo degenerative changes that may cause pain and dysfunction.1 And even beyond that, the researchers wanted to find out if the running intensity and history of years running had any influence on this association.1 The researchers ended up being able to analyze 25 studies, which gave them a good sample of information to help them answer their questions.1

Overall, this analysis of studies found that running was not necessarily associated with osteoarthritis and, in fact, recreational runners had lower odds of hip and/or knee arthritis when compared to competitive runners and sedentary non-runners.1 In terms of years running, the people that ran less than 15 years had a lower association with osteoarthritis than those who ran more than 15 years.1 That being said, most of the studies that looked at running for more than 15 years were focused on competitive runners, who already had higher odds of developing arthritis, and they were unable to find conclusive information on recreational runners that ran for more than 15 years.1 The definition of competitive runners were runners that were reported as professional, elite, or ex-elite athletes, but the amount of miles of running was not necessarily described.1

Getting out for a run in the high country surrounding Durango!

So, what’s the take-away? It seems that recreational runners may be better off for having lower odds of developing hip or knee osteoarthritis than those who run competitively and those who don’t run at all and are more sedentary in general, especially if they run for less than 15 years total.1 As far as knowing about the impact of running recreationally for more than 15 years, there is not quite enough information to tell!1 There are more factors that go into running that can potentially affect your joints and pain, which are factors that PTs are specifically trained to identify and treat. If you have questions about how running might be impacting your joints, make sure to see a PT to have your running form and strengths/weaknesses analyzed to find an individualized approach to your issues.

  1. Alentorn-Geli E, Samuelsson K, et al. The Association of Recreational and Competitive Running with Hip and Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Journal Ortho Sports Phys Ther. 2017;47(6):373-390.

Biking Position and Low Back Pain

By: Dr. Laura Wenger, PT, OCS

It’s May in Durango, which means cycling season is officially in full throttle! With these month’s races such as 12 hours of Mesa Verde and the Iron Horse Bicycle Classic road and mountain bike races, there are a lot of locals hitting the pavement and the dirt to start getting their miles in. As PTs, we see a lot of folks whose main goal is to be able to bike without any issues. There are always discussions on bike posture and what is the “right” position for each body, for which there is not a carte blanche answer. That being said, there are some general guidelines that may be undertaken for cycling that may help you have a more successful season.

John showing off his bike position at 12 Hours of Mesa Verde

As it turns out, a slim majority (51.5%) of cycling-related injuries are related to overuse, and low back pain is the most common of these types of injuries.1 These injuries can cause lost time on the saddle and require medical intervention, so they are important to pay attention to and, more importantly, to figure out how to prevent. For road cyclists especially, a flexed (or bent over) spine position is used in an attempt to create proper aerodynamics which might translate toward increased speed and efficiency, which are both desired goals for racers and non-racers alike.1 A recent systematic review, which is an analysis of multiple studies, sought to determine if there is any relationship between body positioning and spine muscle activity in cyclists with low back pain that wasn’t brought on by trauma.1 The researchers also wanted to find out if bike fit affects these factors, so that cyclists can have more guidance on how they should be set up on their bike in order to feel their best.1

After reviewing eight studies, the researchers found that there is evidence that supports the idea that muscle activation imbalances in your core muscle group are risk factors for low back pain in cyclists.1 The studies also support the idea that there is some relation that sitting in a prolonged, flexed position during cycling is related to low back pain.1 Changes such as a well-balanced core muscle activation program as well as changing your positioning on your bike to one that is less bent-over may very well decrease your risk of developing low back pain.1 Specifically, a lower handlebar position that requires your back to flex more may set you up for further issues.1 Physical therapists are specially equipped to assess and help you refine your ability to activate the muscles in your body and especially in the core muscle group. We also love to assess bike positioning in order to find the best position for your body and recommend changes that will either prevent or reduce low back pain. If you are a cyclist and you are currently experiencing back pain or would like to know if you are at risk for developing back pain and what to do about it, call us to schedule an appointment with one of our specialized PTs.

  1. Streisfeld GM, Bartoszek C, et al. Relationship Between Body Positioning, Muscle Activity, and Spinal Kinematics in Cyclists With and Without Low Back Pain: A Systematic Review. Sports Health. 2016;9(1):75-79.

Why We Host Students

By: Dr. Laura Wenger, PT, OCS

You may notice that we usually have one or two students around the clinic at any time. As a physical therapy clinic, we get the opportunity to host Doctorate of Physical Therapy (DPT) program students from all over the nation as well as undergraduate interns mostly coming to us from Fort Lewis College.

The staff with our 2016 Regis University DPT student, Vickie
The staff with our 2016 Regis University DPT student, Vickie

The DPT students come here seeking an enriching, hands-on experience in order to put the skills they have gained during their didactic curriculum into practice in a real-life setting. Their time with us, whether it be a short 6-week rotation up to a longer 12-week rotation, is supposed to be the time where a lot of the actual learning happens, especially in learning how to treat patients with their hands and communicate effectively, all with the end goal of making you, the patient, feel and function better!

Jeff with our 2016 Idaho State University DPT student, Kevin, working to help a runner after a race
Jeff with our 2016 Idaho State University DPT student, Kevin, working to help a runner after a race

The undergraduate interns, which are mostly exercise physiology majors from Fort Lewis College, are utilizing their time here to learn more about the profession of physical therapy. This helps guide many students to decide if they want to pursue further graduate education in order to become a physical therapist, versus other healthcare professions that they may be interested in. These students are not so much hands-on like the DPT students, but they are in more of an “observation and shadowing” mode so that they can assess the day-to-day of a physical therapist.

Laura posing with her alma mater's 2016 University of Utah DPT student along with Scott Ward, the dean of the Physical Therapy program
Laura posing with her alma mater’s 2016 University of Utah DPT student along with Scott Ward, the dean of the Physical Therapy program

Regardless of which type of student we are hosting, the benefits to the clinicians are immense. Not only does hosting a DPT student end up in higher productivity levels for the provider1, the clinical instructor that is assigned to the student gets to refine their clinical reasoning skills by being challenged to teach and explain why they are doing what they are doing. As new research and evidence regarding best physical therapy assessment and treatment comes out and is taught in professional-level DPT programs across the nations, we get to keep our pulse on the latest and greatest research that may change the way we practice for the better in order to ultimately get each patient better, faster. Also, the patient gets to become much more of a learner as to the “why” of PT, as they get to take part in the learning experience that is very much reciprocal between each clinical instructor and their student. All in all, it is a “win-win-win” situation for the three people involved!

Carmen, our 2017 Regis University DPT student, refining her manual therapy skills
Carmen, our 2017 Regis University DPT student, refining her manual therapy skills

Next time you are in the clinic and you get to meet one of our students, make sure to take time to appreciate the learning and benefits involved in their presence in our clinic!

  1. Pivko SE, Abbruzzese LD, et al. Effect of Physical Therapy Students’ Clinical Experiences on Clinician Productivity. Journal of Allied Health. 2016;45(1):33-40.

Exercising in the Snow- Snowshoeing

By: Dr. Laura Wenger, PT, OCS

It may feel like has Spring has already sprung here in town, but up in the high-country there are still plenty of days left to participate in one of our area’s favorite wintertime activities: snowshoeing. For those who may not necessarily like to ski or snowboard, snowshoeing is a great way to get into the great outdoors in the winter as well as a great way to get your heart rate up. Whether it’s a gently paced walk on a traversing trail, a more steep incline and decline (with a couple bouts of sliding on the way down!), or a running race on snowshoes (yes, those do exist!), folks of all levels can participate in this activity. In fact, a survey in 2006 found that approximately 5 million people participate in snowshoeing, and they estimate that this number is growing.1

Snowshoeing for any age!
Snowshoeing for any age!

A fairly recent study from researchers at CSU in Ft. Collins and a university in Australia wanted to get down to the nitty gritty of “how we move” in snowshoes AKA the biomechanics of it.1 I won’t engage you in all of the intricate details, but in general we tend to stand in a more flexed, or bent, position of our hips and knees, pull our hips into more of a bend while swinging our legs forward, and start to point our toes a little sooner as we are about to put our foot on the ground while stepping forward.1 These changes in the way we move while snowshoeing, namely the semi-“crouch” position we end up in, are likely the main reason that we expend more energy versus overground walking as it requires more use of our leg muscles and is less efficient than the normal heel-to-toe walking that we usually do.1 For something that expends your energy twice as much as walking a level ground, snowshoeing turns out to be a great way to exercise during those winter months when you’re feeling a little more cooped up!1 So, hopefully you are able to get out there and enjoy a little bit more of the high-country snowshoe trails before the snow melts this spring and don’t hesitate to talk to your physical therapist about the value of snowshoeing.

  1. Browning RC, Kurtz RN, Kerherve H. Biomechanics of walking with snowshoes. Sports Biomechanics. 2012;11(1):73-84.

Soreness versus Pain

By: Dr. Laura Wenger, PT, OCS

One of my first days in the backcountry this year. It sure was fun, but I was sore!
One of my first days in the backcountry this year. It sure was fun, but I was sore!

The American Physical Therapy Association’s (APTA) website for the public, called Move Forward, just came out with a great article about the difference between soreness and pain.1 As PTs, we get questions all the time about how much soreness is “normal” during various exercises. Although you are expected to feel some discomfort either during or after exercises, the old phrase “no pain, no gain” isn’t always true, either. While it is true that you do need to push your body to achieve gains, the push has to be at an appropriate level, which is different for each person depending on their age, current activity level, and strength, among other factors.1 As you continue to push your body in an appropriate fashion, your threshold for activity should increase and increase.1

Think about it like your first day back on skis for the season: for most of us, the first day back is usually a “mellow” one, where you hit up a series of relatively easier runs with interspersed breaks to “warm-up” your legs and get used to the motions required to make it safely and gracefully down the slope. After this first day back, you may experience some delayed muscle soreness for 1-2 days after skiing. Then, on your second and subsequent days back, you may take less breaks between runs and choose more and more challenging runs, with just the same amount of soreness as after the first day (or no soreness) as your body gets used to the challenge that you are providing. However, if you take your first day back on the slopes as a non-stop, quad-crushing day with mogul runs over and over again (and, most importantly, you weren’t prepared for it), you might pay for it later with a higher level of soreness that doesn’t quite go away after a couple days. That would be called pain. The Move Forward website broke it down in an easy-to-read table here:

Soreness Table

For more information on telling the difference between pain and soreness, consult with a physical therapist today to make sure you are playing hard within your body’s limits!

  1. Soreness vs Pain: What’s the Difference? Move Forward. American Physical Therapy Association. Accessed on December 5, 2016.

Mechanisms of Manual Therapy- How does it Work?

Mechanisms of Manual Therapy – How does it Work?

Our goal as physical therapists is to help people feel better, move better, and ultimately live better. One way that we achieve this is through manual therapy (AKA hands-on) treatments, including manipulations (faster, low-amplitude movements) and mobilizations (slower, low- to high-amplitude movements). If you have ever participated in physical therapy, chances are that your PT did some form of manual therapy to work on, or near, the parts of your body where your pain was. You likely walked out of that treatment feeling less pain, as that would have been the goal of the PT’s treatment. Did you ever wonder to yourself, “How did that work to help me feel better???”. You’re not alone.

This is a question that the PT profession as a whole has been working toward answering over many years through the undertaking of extensive research. Although there is no “one” answer for how manual therapy specifically works to reduce pain and improve overall function, the studies have shown that, rather, there are many moving parts that contribute to the effectiveness of manual therapy treatments. A model for this was created by Dr. Joel Bialosky, et. al, back in 2009 with the intent of guiding future studies and serving as a basis of the knowledge we have about how manual therapy works so far.1

Mechanisms Manual Therapy

I’d like to take this opportunity to break down the model above so that it makes more sense to anyone reading this, regardless of your background in health sciences.1

  • When manual therapy (the “stimulus”) is applied to a certain part of your body (the “tissue”), the immediate effect is decreased spasm of the muscles in the area and increased motion.
  • This stimulus being applied sets off a cascade of effects, starting with the “peripheral nervous system” (all of the nerves in your body besides those in your spinal cord and in your brain). An effect of this stimulation is that cells that help attack inflammation are sent to that area (“inflammatory mediators”).
  • Then, the information is sent to the main nerve conduction track between your body and your brain (the “spinal cord”). From here, a whole host of proposed effects occurs, including improved muscle activity of the area that was worked on and decreased pain (“hypoalgesia”).
  • After the information gets to the spinal cord, a feedback loop with the brain begins, which includes changes related to pain, involuntary nervous system (“autonomic”) responses such as changes in stress hormone levels, heart rate, and skin temperature, endorphin and opioid responses (the “feel-good” hormones), and psychological responses to the treatment including expectation and the placebo effect.

All of that boils down to the fact that, after a PT has performed a specific-to-you manual therapy treatment, you typically feel better! This model just demonstrates that there are a lot of factors that play into the why of you feeling better, and research in this subject continues to evolve so that we, as PTs, can better understand how our treatments help you feel better. If you have more questions about how manual therapy works to reduce your pain, make sure to come in and speak to a physical therapist to learn more and benefit from this treatment.

  1. Bialosky JE, Bishop MD, et al. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Man Ther. 2009;14:531-538.