Back to the Future: Your imagination is the only limitation; Mike Ukoha, DPT
When you graduate from physical therapy school, life comes at you fast. Bills are hitting your inbox. Student loans are crashing down from cloud 9 where you left them for 3 years. But above all, you’re starting the career you’ve been looking forward to for years. For me particularly, I enjoy the moment while thinking 5 to 10 years in the future. Staying inspired is key for me. In the frame of 5 to 10 years from now, I always speak on opening a practice of my own. A practice with the energy of Greg Todd (@GregToddPT), the patient experience of Jerry Durham (@Jerry_DurhamPT), and the depth of knowledge of Roy Film (@RoyFilmDPT). With that being said, the Maryland Student Special Interest Group was able to present a clinic with those qualities in our Clinic Spotlight series.
On Monday, I had the pleasure of visiting one of the most innovative practices that the state and country has to offer. This practice is known as PhysioFitness (http://physiofitnesspt.com/) located in Rockville, MD managed by president Marc Sickel and CEO Dr. Jan Dommerholt, a world renowned physical therapist. The visit duration was 3 hours and my mind truly was blown. The conversation and gems of knowledge were sprinkled throughout the day. I’ll try to condense the visit to the best of my ability. The best way to describe what I experienced is simply put: If it’s 2017, in PhysioFitness it feels like 2050. Hop in the Deloran, lets ride.
*I’ll be paraphrasing some perspective for length purposes
We started the visit with a brief chat on the background and history of his partnership with Marc regarding PhysioFitness. Prior to his current partnership, Dr. Dommerholt practiced at his Bethesda office. Since his partnership, he continues to work at the Rockville and Bethesda offices, respectively. Essentially, the partnership began 3 years ago after an experience where Dr. Dommerholt was working with a patient diagnosed with Ehlers Danlos Syndrome. He worked with this patient and tried various treatment techniques. The patient’s progress in strength and functional outcomes wasn’t optimal over time. However, with suggestion from a parent and one referral to PhysioFitness he saw this patient return the strongest he’d seen in 4-6 weeks. So the secret question everyone is thinking: How did this patient get better?
Patient treatment insight:
Dr. Dommerholt expressed “ research shows 40% of patients who had cardiac surgery did not show up for PT that was recommended by their doctor". A sentiment we could agree certainly could have you feeling under appreciated as a healthcare professional. So in that space again how do we help patients? The MAJOR KEY is external focus. Each and everyone of us went through PT school being taught to give verbal cues and tactile cues to patients for various reasons using an internal focus. Whether it was activating the transverse abdominus for low back pain or appropriate quadriceps activation for stair management training. But research shows that our verbal commands focusing on internal focus (controls muscles, stance, etc) inhibit people from learning the motor task. Instead we can effectively impact patients by having them focus on an external activity ie balance on a foam roll to activate the transverse abdominus. Learn more on motor learning using external focus from Gabriele Wulf’s Research: (http://www.sportwissenschaft.de/fileadmin/pdf/BuT/hossner_wulf.pdf)
“Very little you can’t accomplish having fun”
So with external focus comes FUN. Could you imagine a place that gave you a completely different session every treatment? Well yea it’s here. No question. Dr. Dommerholt emphasized “people only cancel at PhysioFitness only when they’re sick. It’s NEVER NOT fun for the patient and therapist alike” I soon saw what he meant by that. He brought the “toys” (equipment) out and didn’t disappoint. They had toys to train anyone from a 5 year old on the autistic spectrum to a professional athlete. The world of PhysioFitness is special. Let’s tour.
I came in a bow tie, dress shirt, dress pants and my comfortable OTW vans. I should have come in my Adidas gear and Adidas alphaboost. Everything had you on the move. A thirty foot long trampoline, rock climbing wall, and a track are the first things you see upon entry. Just the tip of the ice berg. I won’t delve into each piece of equipment but will point out a few common features. Each piece of equipment presented customized planning, increased variability, increased opportunity for dual tasking and most importantly durability. In my mind, I always think of technology as frail and expensive. However, as you can see below you can hit everything full force as children and professional athletes often do haha.
Larger than Life
So after the tour, we chatted about various concepts within the profession and Dr. Dommerholt’s experiences. Here were some takeaways:
Diagnostic Ultrasound/ autonomous practitioners:
MU: Diagnostic ultrasound is a good mechanism to further our abilities as independent practitioners diagnosing musculosketelal injuries such as tendon tears. Do you believe more physical therapist should advocate for diagnostic ultrasound use in a clinical setting?
JD: No reason not to. However, ultrasound can be challenging. We need to be further educated to effectively manage that. The thing missing from us being autonomous practitioners is simply being convinced as a profession that we CAN be autonomous practitioners. Do all new practitioners believe they have the skill set to practice independently? You have to believe you’re worth it.
MU: Evidence-based practice is important to optimally treat patients. What do you believe is a barrier to more clinical research being done?
JD: The biggest problem with completing research in the clinic is MONEY. A case study is easier since you just need to valid outcome measures and data over time. However, for the average clinic it is difficult to make enough money where the billable revenue lost to research can be lost for you individually or for that respective company.
MU: What are two of your favorite experiences working internationally in the field of physical therapy and why?
JD:Meeting physical therapists all over the world and share a common love for our profession
Realizing the impact of teaching dry needling to physical therapists worldwide. If each PT in our course uses dry needling 5 times per day, for example, thousands of patients benefit every day from our efforts. IN 2016, we taught almost 100 dry needling courses. Let's assume that there were 25 students on average per course who each use dry needling 5 times per day. That would mean that by the end of the year, more than 10,000 patients per day would benefit from having dry needling included in their PT program!
Can you explain in more detail how you got started in myofascial trigger point dry needling?
In 1989, I attended a workshop by Dr. Janet Travell who pioneered the myofascial pain concepts. I became very interested in myofascial pain and trigger points. In 1994, I contacted the Maryland Board of Physical Therapy Examiners and asked whether I could use dry needling, which the Board's Executive director confirmed. I called a second time, just to be sure, and was told that indeed I could use dry needling. As there were no formal courses in dry needling offered in the US, I consulted with a physician I worked with to teach me how to do dry needling. I also attended courses in Canada and Switzerland and spent a week with colleagues in Toledo, Spain, to figure out how to use dry needling. In 1996, our organization taught our first dry needling courses in Spain, followed in 1997 in the US. As far as I know we were the first to introduce dry needling to Spain and the USA at that time. For several years, we were the only group offering dry needling courses, until several years later, when some of our former students developed their own course programs.
MU: Generally speaking, dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromuscular pain and movement impairments. However, there are various dry needling techniques in patient care. What are some innovative dry needling treatment techniques that you use at your practice?
JD: Dry needling by itself is an innovative intervention. Not all dry needling approaches have solid scientific backing and sometimes they are based on animal acupuncture studies. We use dry needling for scar tissue adhesions, which is in my humble opinion the most effective way to treat painful and adhered scars.
MU: What are some common diagnosis and impairments you use dry needling for at your practice?
JD: any pain problem
MU: What do you believe is the largest barrier to dry needling being used more commonly in clinical practices across the country?
JD: A few issues:
1. Some state boards of physical therapy have made it difficult to use dry needling due to excessive regulations. The Maryland Board of Physical Therapy Examiners, for example, just released new regulations that contain several demands that will be difficult to meet by any course provider, which will potentially limit the number of PTs who will be able to use dry needling. Even PTs who already use dry needling will need to meet the new rigorous regulations, in spite of using dry needling for prolonged periods of time without ever having caused any significant adverse events. The new regulations require 40 hours of in-person (live) theoretical education, which in the current age of online education is a rather strange requirement. My continuing education company, Myopain Seminars, has very high requirements to become certified in dry needling and includes a challenging theoretical examination. Even when PTs have passed that examination, they will likely need to attend additional live instructional classes to meet the requirement of 40 live hours, which make no sense at all. (More info on dry needling continuing education requirements: http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Dry_Needling/AnalysisCompetenciesforDryNeedlingbyPT.pdf)
Food for thought from the study..
86% of the knowledge requirements needed to be competent in dry needling is acquired during the course of PT entry-level education, including knowledge related to evaluation, assessment, diagnosis and plan of care development, documentation, safety, and professional responsibilities.
14% of the knowledge requirements related to competency in dry needling must be acquired through post-graduate education or specialized training in dry needling.
2. Fear of the unknown. Some folks are worried about needling and its potentially adverse events, even though a study we published showed that the risk of a signifiant adverse events was less than 0.04% (Brady, S, McEvoy, J, Dommerholt, J & Doody, C, 2014. Adverse events following dry needling: A prospective survey of Chartered Physiotherapists. J Manual Manipul Ther, 22, 134-140).
3. Unfounded claims by certain acupuncture groups and individual acupuncturists
4. many clinical dry needling studies do not reflect the clinical practice of dry needling accurately.
What recently published research articles support the efficacy of dry needling?
Espejo-Antúnez L, Fernández-Huertas Tejeda J, Albornoz-Cabello M, Rodríguez-Mansilla J, de la Cruz-Torres B, Ribeiro F, and Silva AG. 2017. Dry needling in the management of myofascial trigger points: A systematic review of randomized controlled trials. Complementary Therapies in Medicine.33:46-57
Gerber LH, Sikdar S, Aredo JV, Armstrong K, Rosenberger WF, Shao H, & Shah JP. 2017. Beneficial effects of dry needling for treatment of chronic myofascial pain persist for 6 weeks after treatment completion. PM&R. 9(2):105-112
Koppenhaver SL, Walker MJ, Rettig C, Davis J, Nelson C, Su J, Fernández-de-las-Peñas C, Hebert JJ, 2017. The association between dry needling-induced twitch response and change in pain and muscle function in patients with low back pain: a quasi-experimental study. Physiotherapy 103(2):131-137
Turo, D, Otto, P, Hossain, M, Gebreab, T, Armstrong, K, Rosenberger, WF, Shao, H, Shah, JP, Gerber, LH & Sikdar, S, 2015. Novel Use of Ultrasound Elastography to Quantify Muscle Tissue Changes After Dry Needling of Myofascial Trigger Points in Patients With Chronic Myofascial Pain. Journal of Ultrasound in Medicine, 34, 2149-2161.
MU: What advice, if any, do you have for students or practicing clinicians interested in becoming certified in dry needling?
JD: compare different course programs, select the best evidence informed program. In other words, study with Myopain Seminars (just kidding, kind of).
After wrapping up, it led me back to the same quote that resonated with me throughout my visit. “Your imagination is your only limitation” Whether you’re in your dream job now or still in a DPT program approach you career with that sentiment and see where it takes you. If you liked what you saw or are interested in dry needling look out for our student day and clinician day at PhysioFitness hosted by the MD SSIG coming soon. Until next time.
Mike Ukoha DPT