Masters in the USA- Are you confused? Part 1

Hey readers,

In the last few weeks I have received numerous requests asking me about various masters programs available here in the USA. Are you confused about making the right decision?  Don’t know the difference between the masters in exercise science and masters in physical therapy? I have been down that road myself. Read on, this blog post series is for you.  Let me begin by saying this first, for the most part the US has done away with bachelors and masters program. Most of the schools now offer a single Doctor of Physical therapy 3 yr program (DPT). Only a handful of schools offer Masters in physical therapy. Now would you want to come to the US and do your bachelors all over again only to become a DPT. I would presume not (at least not initially, but getting a T-DPT eventually might actually be a good idea). I didn’t pursue my masters in PT so it wouldn’t be correct for me write about it.  So this blog post is dedicated upon throwing some light on my Masters program- Exercise science.

Alright, first off,  EXERCISE SCIENCE IS NOT A PART OF PHYSICAL THERAPY. It’s a totally different field here. It elaborates upon exercise not rehab. Understanding this is crucial. In my school it had three tracks-  Exercise Physiology, athletic training and strength and conditioning and you can choose any one. To oversimplify,  let me briefly describe the three-

1. Exercise Physiology– this track will gear you toward becoming an exercise physiologist learning things like EKG’s/ECG’s, exercise testing, exercise prescription etc. Your target population could be anyone from a regular Joe to working with  cardiac rehab patients doing exercise stress testing (Bruce, modified Bruce) to exercise delivery. You do not have to be licensed to practice as an exercise physiologist but if you wish to be taken seriously you would want to give the ACSM examination.

Pros-

  • Excellent for people interested in Cardio-Pulmonary and inpatient setting with great focus on research.
  • This concentration is easier for us physios.You could pass the classes easily as you studied a lot of the stuff in your bachelors.
  • Having stated the above point there is more to this course than just passing and getting a degree behind your name. If you really wish to have a fulfilling experience and are not content with  mediocrity (which is understandable as you pay a few thousand dollars, ouch!!) feel free to delve into the course and you would be amazed with all the great stuff you learn. Every school has a ton of research going on and good thing come out of being a part of them.

Cons- There are no real cons to learning but relatively speaking

  • I found some of the classes in this track  to be repetitive from what we learnt in our bachelors especially for those who have a strong base in cardio pulmonary rehab.

2. Athletic training– ever wanted to be that cool person who travels with a sports team and along with the team physician is the first line of care should an athlete be injured?  This is the track these cool people chose in school. Their job entails doing stuff on both ends of the spectrum from simple icing, taping, strapping, using electrical modalities, assessment and diagnosis (similar to what we do) to getting an athlete with potential serious injuries (think spinal cord and concussions etc) off the field safely. They often work closely with PT’s and refer out to us when needed. Yes, you must be licensed to be a AT.

Pros-

  • Since we do not have athletic training as a profession in India, this is a great elective for immediate care on or off field for aspiring sports therapists. The sheer practicality and on field experience can be invaluable.

Cons-

  • Well honestly speaking the PT program  is more extensive and in-depth and I don’t see many PT’s opting for this course while I see a lot of AT’s enrolling for physical therapy school after a few years of experience (which is often a natural progression here).
  • Your base earning and scope of practice is more as a PT. So unless you plan to take this knowledge  back home and use it as a sports physio, you might find yourself reconsidering this option.

3.  Strength and conditioning –  I wish I knew about this track  sooner than I did cause its my favorite (and among the three tracks this is the one we will find ourselves least familiar with). A strength coach takes the  role of ensuring that the athletes are at the peak of their performance at any given time during the season, they are able to meet the physical and metabolic demands of the sport but above all else, like my school’s head S and C coach would say “Its injury prevention goddammit, prehab.” (Sorry for the blasphemy but I quote). To be recognized as a strength coach and be able to train athletes one must pass the gold standards license, the certified strength and conditioning specialist (CSCS) test.

Pros-

  • Can’t say enough good things about this track. Great entry point if you want to work in the sports physiotherapy field.
  • Not content with just a rehab role? If you wish to be involved more extensively with training a team during off-season, this track is for you.
  • My favorite part of this track was finally being able to see how american college athletes train. This part is not touched anywhere in our physiotherapy curriculum (maybe in masters in sports physiotherapy. Any sports PT’s out there, feel free to comment). Remember how we all wondered about the great athletic abilities and sheer physical prowess of western athletes? There is a reason they are bigger, faster, stronger- they have strength and conditioning coaches. (luckily, its now being offered in India also but not during my time. This is BIG). More info on this soon.

Cons-

  • Does not offer much to those not interested in sports setting.
  • Just attending the classes in school, learning from books, passing the test and getting the title doesn’t make you good S and C specialist, especially with our limited knowledge in the field. You must volunteer with the coaches and spend time in the trenches. This is not a true negative point about the track, its just holds true for almost everything we ever do.

A blog cannot do justice to two years of higher education but this is the closest I can describe the curriculum of the masters in exercise science program especially in my university- Long Island University, Brooklyn Campus. Remember, if you are looking for a pure physical therapy experience for your masters this course might not be for you (there will be no manual therapy class offered). In the future posts in this series, I would have some of my fellow PT’s who attended masters in PT program (the few that are left) describe their experiences in a guest blog post article. Reading them will hopefully help you make a better decision when deciding to study abroad. Until next time,

Pursue Excellence

Abhijit Minhas PT

(BPT, MS, CMP, FMT)

 

LETS TALK SHOULDER PART 2

Holla , Rehab studs. This weekly blog happens to be my first video blog ever (on the downside I paid a decent buck to upload these videos so feel free to share if you like)!!! You may see only four videos here but I had to re-take them multiple times as I didn’t want to upload YouTube videos here and I am clearly not a natural in front of the camera as you will see shortly (apologies, however I will get better). The reason for uploading my own videos is that physios are great observers and I wanted to have some of your expert feedback on my techniques, cues etc. Quick disclaimer – I made these drills on common patterns I often find and the correctives I use for them as a continuation of the first part. These are not the only interventions and their selection depends upon a thorough evaluation ( this disclaimer was for any trolls out there, a prudent therapist knows this all to well).

1. Mobility drills for that gnarly exaggerated thoracic kyphosis- I find most of my patients love these drill after the initial discomfort they feel when their poor upper back is moved into the extended position. Some patients also report feeling more upright and a little taller after the intervention. Important point to remember is discomfort is acceptable but this intervention should not be painful. Progress slowly.

 

Lets not neglect  rotation-

 

 

2. The ‘W’ exercise for rotator cuff weakness- though there are a number of exercises for strengthening the rotator cuff  this one is my favorite. As mentioned in the video, I don’t like to knock out 3 sets X 10 reps. I would rather train the rotator cuff for endurance with longer holds in the externally rotated shoulder position ( actually depending upon patient tolerance I might do both). Lets not forget the primary goal of the RC is supporting the head of the humerus into the glenoid and secondary action is IR/ER. What is your one favorite ‘go-to’ exercise for RC training?

 

 

3. The ‘Y’ exercise for lower traps- I have seen big guys benching close to 200 lbs struggle during this exercise with a tiny pink 5lbs dumbbell attempting full shoulder scaption ; hence give this exercise it’s due respect.

 

 

 

Remember that we only scratched the surface with this blog posts. We also must think about other big players like the serratus anterior, lat dorsi, Levator scapula etc. To work on the pec minor I use different manual therapy techniques which is a blog post for another day. I would love to hear some of the exercises you commonly use during your rehab. Feel free to post links of videos if you can. I envision this blog not just as a medium for me to express my thoughts but a common ground to exchange ideas. Until next time.

Pursue excellence
Abhijit Minhas PT
(BPT,MS,CMP,FMT)
(Ps- I wear my physical therapy shirt with pride).

LETS TALK SHOULDER PART 1

As discussed in my last post, I treat my shoulder patients differently now compared to a few years ago. When I say ‘shoulder problem’, let’s get specific. There can be a ton of things happening in the shoulder and discussing every possibility is way beyond the scope of this blog post. In my practice the most common shoulder problem I have seen so far is shoulder impingement with a gradual and insidious onset of symptoms rather than traumatic episodes (also very common- rotator cuff issues in overhead athletes). Let’s discuss shoulder impingement briefly. It is simply pinching of the rotator cuff muscles, tendons and bursa between the upper end of the arm bone (head of humerus) and the tip of shoulder blade called acromion especially with arm elevation or overhead activity.  

If you haven't heard of JANDA yet, you should look into his work ASAP.

 

 

Common patterns I find in these patients-

1. The typical upper crossed posture– I place this on my número uno common pattern for shoulder dysfunction because I see this all to often and I have ignored this in the past. Now who doesn’t have a rounded upper back with shoulders rolled in and forward neck posture. After all we live in this posture, sitting in our chairs in front of the computers, TV’s etc. Now over a period of time the thoracic spine gets quite stiff and you will observe lack of thoracic spine extension. So a stiff thoracic spine will affect the scapulo-thoracic joint causing the scapula to be stuck in a more protracted, downward rotated and anteriorly tilted position causing compression of the sub acromion space as your patient moves his arm up causing impingement. This brings me to my favorite point, Often the cause of pain might be away from the site of pain and needs to be worked on equally or more even though the patient has no complains there. While they might question your actions initially (patient education), we should know better than to run after symptoms.

If you haven't heard of JANDA yet, pleasae go ahead and do so now.
If you haven’t heard of JANDA yet, please go ahead and familiarize yourself with his work ASAP.

2. Posterior rotator cuff weakness– think teres minor and infraspinatus vs deltoid, think small vs big, David vs Goliath (may be an exaggeration in some cases or may not). One of the actions of the deltoid apart from abduction is superior translation of the humeral head. To counter that the primary action of the rotator cuff muscles is holding the head of the humerus into the glenoid cavity. If the posterior cuff is weak and is already small it will not be able to counteract the superior pull of the bigger deltoid on the humerus head causing it to jam into the sub acromiom space causing – impingement. Ever had novice bodybuilding enthusiasts come to you complaining of pain in the shoulder with overhead press. Ask  them their shoulder routine and you will tend to find a lot of military press and side flies for deltoid hypertrophy with very little or no external rotation exercises for teres minor and infraspinatus. So while they might feel they are working on shoulder strengthening, it might be feeding into the dysfunction. This picture sums the force vector of the above muscles well. (While the figure shows only supraspinatus, we know the force vector is same for the rotator cuff. Remember primary action is not rotation at the shoulder but holding the humeral head in the cavity)

deltoid_pull
The bigger deltoid will bully the smaller rotator cuff if you do not intervene!!

 

    3. Upper to lower trap imbalances– as we all know most of us have this dysfunction where the upper trap is over active and the lower trap lies in dormant hibernation. What results is inability to posteriorly tilt the scapula during elevation (blame weak lower trap) leading to the anteriorly tipped acromion (blame overactive upper trap) compressing the sub acromion space causing – impingement. Take the example of the body builder again, does he do shoulder shrugs on “shoulder day”. Hell ya he does and can you blame him? The ladies love it!! Incorporating a lower trap corrective exercise drill is paramount in these cases.

 

 

4. The evil Pec. Minor– pec minor tightness and upper crossed syndrome often go hand in hand like peanut butter and jelly or ‘Vikram-Betaal’ (this weird analogy may or may not resonate with you, but I write this after a long day at work and late into the night). A tight pec minor exerts a medial pull on the long head of the bicep tendon sometimes pulling it out of the bicipital groove. Now going back to anatomy, the long head of the bicep attaches to the glenoid labrum and a positional dysfunction in this muscle can most definitely cause shoulder discomfort. Those who know me from my college days know I was a very big proponent of the MULLIGAN CONCEPT (still am) and the posterio-lateral MWM’s glide to the shoulder has provided me excellent results in the past. However, those familiar with Brian Mulligan’s work know that his concept does not explain very well why the therapy works the way it does sometimes giving the impression of ‘voodoo witchcraft’ which is great; but I have had some of my patients return after a week with reoccurrence of some discomfort and pain. I am no longer contend with this explanation and I feel we might not just be placing the shoulder in a retracted position but also might be unintentional placing the tendon back in the groove with the lateral push (think of the hand grip, it’s very close to the tendon. Thoughts??). While this approach is downright awesome to perform it makes me wonder; am I chasing symptoms again?? Hence, pectoralis minor soft tissue release is always on my agenda (so common in geriatric patients!!).

While there are a lot of other issues that could cause the dysfunction and this is not the complete picture, these are some of the very common patterns that I find and address with my impingement patients. Part 2 of the blog will be my first video blog where I will perform some corrective exercises mentioned above and post the videos. I will make this into a social experiment partly on myself as I find myself often falling into the dreaded excessive thoracic flexion.

 

For those already doing this, I’m sure their patients are thanking them, for those who haven’t, I urge you to think out of the box. My days of only ultrasound, ESTIM, coddman’s exercises (yawn), finger ladder and that gigantic wheel on the clinic wall(can’t even remember it’s name) are long over. Treating pain and not the underlying cause is a great disservice in my opinion and I will be the first to admit on this blog that I was guilty of it. Like my mentor said in one of the courses I took a few months ago, “If you did it unintentional and did not know better you are excused, but from this day onwards if you still do the same thing, you are only pretending to help”!! Let’s not be that person. Comments are welcome.

Pursue Excellence-

Abhijit Minhas PT

(BPT,MS,CMP,FMT)

MY EVER EVOLVING CLINICAL PRACTICE

As the title suggests, my thought process when I assess a patient has changed tremendously from when I was a PT student and during my initial months of practice to where I stand now;  a year and a half of experience, a few courses and certifications under my belt and countless hours of studying (for all the physio students out there, sorry to burst the bubble but if you want to stand out in your profession, studying will be a life long endeavor).  Back in Physio school, all my  assessments and therapy were based on treating the site of pain for the most part.  The good old routine of electrical stimulation, some ultrasound, a few strengthening and stretching exercises to the local area along with a sign of hope in my heart that the patient would get up from my treatment table with considerable relief resulting in a  pat on my back from my clinical instructors and general happiness and satisfaction all around. I would jokingly tell my non physio friends that in my OPD, on a regular day I would ultrasound more people than an OB/GYN clinic (obviously both the ultrasounds being different). Unfortunately, this tunnel vision approach left me and my patients with much to be desired. Having realized early that i was missing a piece of the puzzle I have changed my strategy and started investigating globally and so should you. The body does not work in isolated units. So now, my shoulder impingement patients are not just assessed and treated for the site of pain at the shoulder but also screened for posture especially thoracic kyphosis, rotation and extension. My back pain patients will be evaluated not just for the back but for hip ROM, core stability and thoracic mobility. A chronic knee pain patient especially with non-traumatic history of onset of pain will be assessed for the joint above and below (hip and ankle). I have seen far too many patients with over pronated feet and valgus collapse of the knee go under the surgeon’s knife for an investigative arthroscopic procedure without being assessed for foot mechanics to last me a lifetime leaving me looking like this

frustration_cartoon

 

The take away messages is this, while treating the site of pain is a good start, finding out ‘WHY??‘ it hurts and correcting it will bring long term resolution to the problem. In my next few blogs I will discuss some of the above stated examples with mucho details. Please feel free to leave comments. Until next time.

Pursue Excellence

Abhijit Minhas PT

(BPT,MS,CMP,FMT)

My Global Learning

I have had the opportunity to learn rehab, exercise science and physiotherapy in two different countries. I did my bachelors in physiotherapy from India and my masters in exercise science from the US. While I have learnt a good deal from both my experiences, there are certain clear advantages of studying here in the USA that we still lack in India. The teaching styles are absolutely different and our Indian educational system surely has some catching up to do. Here are a few- Here’s how
o Emphasis on evidence based practice– during my bachelors a typical day in College entailed going over a particular topic from our prescribed textbook (sometimes written years ago) where in the professor would talk about it for an hour with some discussion. To me this was a little dry and had me ‘zone out’ in between classes often. What we learnt was often considered the gospel truth which I followed to the T without much question. All that changed as I set foot into my introduction class in my masters program. Here, for every class the professor came in with the latest peer reviewed literature and research papers which constantly challenged some of the archaic information present in books followed by a healthy debate to keep us engaged and thinking. Now I don’t suggest throwing away our required textbooks as the major chunk of the learning still comes from them but my point being this, always challenging or questioning our current knowledge and facts with new findings points to two thing- how little we still know and the fact that we are stepping in the right direction. Like one of my professors used to say- “they call it research for a reason, RE- SEARCH.” It must be a never ending process.

o Flawed testing– To add to this was our examination process which tested us on all we could memorize and how many pages we could write about the shoulder joint, disc prolapse, best rehab exercises etc in a long answer pattern. In my humble opinion, this does not test or train our thinking skills and this thinking-on-the-fly is what we will eventually do for the rest of our professional lives. It will be similar to detective work. Do you think this analogy is far fetched? After all every patient stepping in our clinic will be different and not everyone will have pain due to a bulging disc and external rotation theraband exercises are not a panacea for all shoulder problems. The American testing system from my masters to the NPTE board examination for physical therapy is all based on MCQ’s that will present itself with a situation and will have you critically analyze and come up with the most appropriate solution based on that unique situation. Sounds similar to the real world? If you plan to study in the US or take the board, understanding this now will work in your favor later.

o Experience- the average age of a 1st year BPT student in India is around 18 years. We are fresh of high school and frankly a little distracted because of our newly gained freedom and excitement and promise of a fun college life. Well!! It was at least for me. We are young and have no experience. Here it’s a different story. An entry level DPT student (yes they have done away with bachelors and masters) has to first clear prerequisite which means a lot of them go through a bachelors in exercise science and have worked as personal trainers, strength and conditioning coaches and exercise physiologists. One of the prerequisite also requires you to volunteer in a physical therapy clinic as a aide to get some perspective. They have been in the trenches for a few years, have trained clients and athletes. So the people who make it to PT school are highly motivated, more experienced and wiser than a fresh high school graduate.

I write these points not to demoralize or trash talk about our education system as it has got me where I am today but with the hope that it brings to you an epiphany moment like it did to me or a deeper realization of how we square off with the rest of the world and raise our bar.

Pursue excellence

Abhijit minhas