Tell us a little about your background and how you first got interested in the physical therapy profession. What was your first exposure to Postural Restoration®?
That’s a good question, with kind of an involved answer because Physical Therapy is actually a second career for me. I became interested when I was about 16 years old. I was playing a game of backyard football and crunched something in my knee. I went to an orthopod but nothing significant was found so I was sent to PT for a few weeks. My therapist was fresh out of school, very attractive and I had a total crush. This was a case where quad sets and hamstring curls got the job done, but that experience turned me on to PT. I mean, how cool would it be to work with athletes and return them to activity? I went to college with every intention of becoming a Physical Therapist. The problem was that I was a 17-year old kid, at a party school, with no idea yet how my brain learns or how to properly apply myself. As a result, I bombed my first semester freshman year. I think I had a 2.1 GPA. When I went to see my advisor (he was just a general class advisor in a huge university), his “advice” was that I’d never get into PT school and that I should consider a different path. I was an impressionable kid and I took his advice. To this day, the anger I have as a result of that conversation still drives me to prove that guy more and more wrong.
I fell into Economics. It came very easily for me. I didn’t have to study much and I seemed to excel on the tests. After finishing my Bachelors, I was recruited to go through the graduate program, which was only 15 months longer so I did. Because of that, I was able to land a job in the School of Public Health at the University of North Carolina working as a research assistant. Actually, my title was “Applications Analyst”, which is a fancy name for data programmer. This was a great place to be because I was working closely with very critical and analytical thinkers on new and original research topics. The environment was a great learning opportunity because the nature of the work was to break down complex problems into smaller components, fix, understand or alter those components, and then put them back together so that the complex problem became solvable. Not too different from an integrated Postural Restoration® program.
It was a great learning experience, but something was still calling me toward PT. I began taking an anatomy course through the University for fun. About mid-way through the semester I realized my grade average was over 100. When I finished the semester with a 106 average I started thinking, why not try to finish up my PT school pre-reqs and take a chance?
Elon, as a PT program, had three attributes that drew me towards it. First, it was one of three schools in North Carolina that was offering the DPT degree when I began looking. Second, they had a modular setup rather than a semester set up. They could spend variable amounts of time on each topic with longer timeframes for highly important subjects like anatomy, and shorter timeframes for things like modalities. But the biggest appeal was that they were accepting students with varying backgrounds, not just the standard 2 chem classes, 2 bio classes, 2 physics classes. I fit in very well with their program.
I met Dr. Boyle (Kyndy) in my first month there. I had her for a 4-week class on “Intro to Mechanics” or something like that. We got along very well and I can remember some things she taught that are PRI concepts, but they were presented more along the lines of looking at general asymmetry, which I had an interest in. I say that because at the time I was working out a lot and I noticed little things like: no matter how many extra repetitions I did with my left, my right arm could always curl more weight for more reps. The same was true for my left arm with triceps extensions. At any rate, Kyndy went on sabbatical to finish her dissertation for her PhD after that module and I didn’t really cross paths with her again formally as a teacher until my third year.
You began taking PRI courses as a student. What was your reaction to being exposed to Postural Restoration® while still a student? What advice would you give to others who have or are interested in taking PRI courses as a student?
Thanks to Kyndy Boyle and Sangini Rane (my first clinical instructor), I was exposed to PRI ideology at an early stage. I mentioned before that I met Kyndy in my first month of PT school, but that PRI was not taught per se. We read articles that are current PRI reference articles. We talked about PNF concepts, and a little known muscle called the triangularis sterni. She came into our anatomy lab to point out some eccentricities with the diaphragm, but it wasn’t until I met Sangini that I was challenged with a (now seemingly simple) concept of a ZOA, or lumbo-pelvic asymmetry, or officially introduced to Postural Restoration®. Three weeks after starting my “clinical” with Sangini I was sitting in a Postural Respiration course that Ron was teaching. Timing was perfect because I had just finished my anatomy and orthopedics courses. The information was still very fresh, but to me, nothing I heard was surprising (but I can’t say that I fully understood it all). I soaked up as much as I could at the time.
The challenge I ran into was getting back to campus after our clinical affiliations. My friends and I would spend time in the skills labs “showing off” what we’d learned. I wasn’t able to defend or explain what I had learned at the time, but I did learn just how much I didn’t understand. I was able to continue progressing through the PRI theory and concepts while in school through courses and individual study, but I wasn’t really able to clinically apply concepts for rehabilitation.
I don’t know that I really had to worry much about “putting PRI aside” to prepare for boards. I think the test is designed to make sure aspiring clinicians know how to not hurt someone, or if a patient is appropriate for PT or requires outside referral. I would suggest that students who have been exposed to PRI understand that each and every thing they are taught in school is a progression and could be beneficial to their patients on some level. It is worth learning and it may help them immensely someday.
The other thing to keep in mind is that for every test and every technique, there is a time and place. Keeping an analytical head is continually necessary. What I mean by that is that you wouldn’t perform a Lachman’s test on someone with shoulder complaints. That is not what the test was designed for, and it is not what it is validated for. As a therapist, there are times when I may not want treat a patient, for instance in the case of an undiagnosed ACL tear that is confirmed by a compendium of tests learned in school.
You are one of a handful of therapists to complete the Postural Restoration Certification (PRC) program within a few years of graduating. How has this decision and process helped you as you reflect on your short career at this point?
To be honest, I think becoming so involved with PRI so early has pigeon holed me as a Physical Therapist. I can’t work with “an ankle problem” any more. I can’t work with “shoulder pain”. The science of Postural Restoration® has afforded me the knowledge and insight to realize that, and the PRC process reinforced it. Some folks come in with certain expectations. They want a neck massage, or ultrasound and I can’t do that for them. I believe that those methods do not empower a patient. The patient does not have to take ownership of their situation. I have had many patients over my very short career whose issue is something very different than what they believe it is. Working with the patient so that they can understand their own body is one of the biggest challenges (and biggest rewards) that I have.
As a clinical thinker, the PRC process was validating. I think one of the biggest things I learned is confidence. That, there really isn’t a wrong answer clinically if you can logically justify your reasoning. This is a concept that has been huge for me in developing as a clinician, especially with the types of patients I get to work with these days.
You recently opened your own private practice with your wife in Cary, NC. Tell us a little about that adventure and your practice, STEPS for Recovery. How has this decision set the path for your future?
STEPS for Recovery opened its doors in 2012, but the practice has been in the planning and development stages since 2008. When I first graduated from PT school, I worked in an Inpatient Rehabilitation facility (with my now wife), mostly with patients who’d had a stroke. Our treatment approach worked to facilitate and restore normal motion. The idea is that normal motion cannot be restored if only compensations are taught (i.e. using the unaffected leg to lift the affected onto a bed). One of the things we noticed early on is that we’d do what we could while the patients were in Rehab, but once they were discharged our methods were lost at follow up. Our idea was to open an outpatient neuro PT clinic specializing in rehabilitation for patients with stroke and brain injury outside of a hospital system. I don’t want to discount hospital systems, but as a private clinic we would not have the same rules and constraints to follow. If we wanted to see patients for hour (or longer) individual sessions, we could and that was a big desire.
In 2008, a few wrenches got thrown in the gears of that plan. One of those was running into James Anderson for a Myokinematic Restoration course. The only Myokinematic Restoration course I had taken up to that point was given the year before, but was truncated to one day due to air travel issues. So when it was being taught locally in ’08, I wanted to take it again to get the full course. When I was there, I really felt at home. Not to sound more weird than normal, but it was pretty much an instant thing – “this is where I am supposed to be”. So, the clinic was put on hold while I pursued that feeling for the next few years.
Shortly after returning from Vermont, where I was working with Jen & Chris Poulin, an opportunity arose for us to revisit the idea of STEPS for Recovery. As it turned out, this was a bit of a now or never endeavor. A very well respected mobility DME vendor had some space next door for sale. We jumped on it for the potential collaboration and proximity.
In its current form, STEPS for Recovery’s caseload is mostly traditionally neurologically involved patients. We see patients affected by stroke/brain injury, and we’ve started a SCI program and a wheelchair seating clinic. I consult with some of those patients, and I have a small caseload of more traditional PRI-type patients. The variety in this patient population is unbelievably complex. It isn’t realistic to expect that someone with ataxia, hemiparesis or paraplegia can do a 90-90 Hemibridge, or a Knee Toward Knee PRI Non-Manual Technique. For that matter, I can’t expect PRI tests to be valid due to altered tone and spasticity (I see that all the time with HGIR and Should Horizontal Abduction testing).
Patterned asymmetry still exists however, but this population also has less predictable forced compensatory movement. So I get a lot of practice taking PRI concepts and improvising. I continually ask myself, “if the patient can’t use their left side at all what do I do? If I take the arms and legs off, what does this patient need, and how can we help them get it?” Of course, just because we are able to make a change in one position (supine, for instance), it doesn’t mean that the patient will be able to generalize that motor skill to another position or situation, so there is a lot of refining that goes on for one muscle activation pattern. It is really challenging and also pretty exciting because we are seeing patients make changes. That being said, it is also nice to get a grand slam (one or two visits and you’re done) knee pain patient every once in a while.
The verdict is still out as to whether STEPS was a good idea or not. We’ve only been open for a year, which means the work-day usually starts between 7-8a, and lasts till 9:30 or 10p (weekends are fair game too). As an owner and manager it can be really difficult to get much done during the day so there is always some sort of “homework”. Plus, being a new clinic, the caseload is still somewhat volatile. It’s like planting a garden, a lot of hard work and not much return in the beginning. But I believe the freedoms that private practice has allowed are well worth it.
As a Postural Restoration Certified (PRC) therapist, what types of patients continue to challenge you the most? What advice would you give to other therapists (who may be newer to PRI) who are struggling with some challenging cases?
Aside from some of what I described above, I think some of the more challenging patients are those who “know about their bodies.” These are the folks who “do yoga”, or take Pilates, or have seen 10 other professionals and have been told different things, or heaven forbid, someone who has medical training. These patients “know what is wrong” with them when they walk in the door, and it takes a lot of energy, politics and patience to invite them to think a little differently. It is a continual struggle to educate patients and oftentimes I feel like I go overboard in that sense. But I feel like my job is an educator. Folks that are looking for a manual therapist to push them around aren’t going to get that from me. I’m not good at it. I find knowledge to be more empowering and I think it develops a greater level of trust with the patient.
Probably the thing I find most helpful in working with the chronic and complicated patients is simplicity. Keeping things basic. What I see is that most patients will find a way to compensate with a lot of the PRI activities. I think that is because body awareness is a developed trait and the average Joe hasn’t developed that trait. Sometimes, I’ll spend half an hour teaching someone how to perform a 90-90 Hip Lift, and it might take another 10 minutes to get a balloon in the mix. But usually when I put that kind of effort in, my patients benefit better than if I fly through four or five activities and send them on their way.
Another thing I try to do when struggling with difficult cases is to take a step back and ask, “Why am I recommending this activity? Why is this person unable to maintain neutral? What are they doing through their day that is pulling them away from a good position?” I’m not a “pull an exercise out of the book” type of clinician. Every activity I give has a reason and I really try to understand the tri-planar components involved before handing it over. That’s because (for example) some activities may have a sagittal inhibition component, but a larger frontal plane facilitation component. If I am working with a strongly extended patient, they may not be able to handle the frontal component without also losing the sagittal component, and thus they may not be able to use that activity to inhibit their Left AIC pattern. Understanding that from a “why” perspective allows me to hone in on more appropriate activities.
Who have been your mentors over the years (PRI and non-PRI related)?
I’m interpreting your meaning of “mentor” as people who have helped me get to today, not necessarily people who have stood at the front of a class room.
- My parents always allowed a long leash, which gave me plenty of room to find my way. It took me a long time to “find my stride” in life. They never judged or pushed me towards something they wanted for me. They did have high expectations and instilled a strong work ethic. That inspired a lot of creativity and adaptability in how I work cognitively.
- My Aunt has been a driving force in many aspects of my life. She is such a free spirit that it is hard not to want to be more like her. She spent most of her 20s living on a beach. Somewhere along the way she wanted to get into “our” field, but her college degree was a little dated by then and PT schools turned her away. So she went to Chiropractic school, became an ART (Active Release Techniques) instructor, and became the most referred to clinician (for sport injuries) in the San Francisco Bay area for a time. And when it was time for all of that to be over, she sold that business and moved on. Even knowing what I know about PRI, there is not a clinician I trust more on this earth.
- Slash – This one might be reaching for it and I am not endorsing the early “rock & roll lifestyle” days. But there is a certain element of “going with your gut” that we as clinicians must entertain. I’ve always been a fan of the guitarist, but from a career perspective, I think there is a lot to learn from that renegade spirit. When something feels right and you know it, then work for it tirelessly, follow that gut feeling, do things your way and make it happen.
- Ron – I’m pretty sure everyone who has done one of these has named Ron, James, Mike, Lori, or Jen. I think they are all fantastic teachers and the Institute is changing rehabilitation in this country. But aside from all of that, I really get a lot out of spending time (outside of a course) with Ron. I just get tickled by the things he notices and finds interesting. The first time he visited STEPS for Recovery, he literally spent half an hour looking our portable mirror. He was mesmerized by the slight variability in the glass, which causes a slight stretch of the reflected image. I think the Buddhist concept of the infant mind applies ~ observe things as if it is the first time you see them. As a fairly creative person, it is good to be reminded by seeing that implemented.
- Kyndy – my first exposure to PRI, without realizing. As a third year student, I had a 5 week selectives class that Kyndy instructed. This is where our balloon article (The Value of Blowing Up a Balloon) was born. I believe it was roughly 3 years after that class when we finally got around to sending that in for publication.
- Sangini – my first clinical instructor. I think I was her second student and we met at a time when she was pretty new to PRI. I think we both got a lot out of those early discussions. Sangini has a commitment to her patients that I have not seen anywhere else.
- When we met, Katie (my wife) was an instructor for the Neuro-IFRAH organization. This is a treatment approach developed for the management of patients with lesions at the level of the brainstem or above. I think what I want to say here is that working with Katie and learning about this approach taught me to look at how movement occurs “normally” (asymmetry aside), the variability in what is “normal”, and how things change with neurologic insult. This lesson still drives me, I find myself watching people walk on a brick sidewalk (different than in a lab), or how people get out of cars (it’s a sit – stand transfer, but entirely different than one that might be documented by a therapist). The list literally could go on for days.
- Jen & Chris Poulin & Josh Wellenstein – I spent about 13 months at Poulin Performance in Vermont, which was an unbelievable experience. This was when Jen was preparing to become a faculty member for the Institute. Jen and Chris are both really passionate about PRI and helping others to learn and understand these concepts. We’d have weekly clinical development meetings to discuss concepts, cases, or techniques. And Josh is a fantastic clinician with loads of outpatient orthopedic experience and was a great resource. In fact, I still call on him when I run into difficult situations with patients.
What types of activities and hobbies do you like to do outside of work?
Since opening STEPS for Recovery there really hasn’t been much of an “outside of work”. But I am lucky because a lot of my hobbies coincide with work. I’m a pretty introverted guy. Working as a PT where I have to interact with a lot of people can drain me. Most of my hobbies are things that I can do by myself. There are three that immediately come to mind.
I’ve been into running since high school. That happened by accident really. I was always a “jumper”. One day in gym class we were playing basketball. I had an opportunity for a dunk so I took it. I broke the rim (which surprised me more than anyone else). The track coach was in the gym at the time. Instead of being in trouble or having to pay for it with cash, I had to pay for it by joining the track team. I don’t know that I have ever really stopped running since then. But being out gives me ample opportunity to observe other people’s form and mechanics. More recently, I’ve started competing in bike racing too. I suppose these things help me to set goals now, which keeps me moving forward.
I got my first guitar when I was 9-years old. I took lessons for about a month. The teacher I had was teaching me bluegrass and gospel type tunes. I wasn’t at all into that so I quit for a few years. When I was 12 or 13, I pulled it back out of the closet and taught myself from listening to the radio. I still play pretty often. I’d say I’m pretty bad. But sometimes turning the volume up to eleven helps even out the day.
Wood-working is the same type of vibe - high volume with a myopic cognitive focus to task. My first project was one that my uncle and I threw together. I had gotten a chunk of birds eye maple and wanted to make a head board for my bed. My uncle realized that I didn’t have enough wood to make it happen, so he donated a piece of Hawiian Koa and we made a coffee table. My first individual projects were making cutting boards using salvage wood that I’d get out of a flooring company’s dumpster. One day I thought, “why not try to do a PRI logo (the polyarticular chain)?”. The first time I tried, I made three at once. I wasn’t sure how badly I’d mess up so I wanted some insurance. The first one (which now resides at the Institute) turned out the best of all of them. It’s made from Peruvian walnut with a curly maple inlay. It may be my favorite one to date. Since then, I’ve made about 8 for different clinics around the country. I’m hoping to continue doing so. Each new one that I make is more unique and interesting.