This post is for everyone. Technique Tuesday 8 explores hip hinging. Learn to move and lift correctly from the hips to avoid excessive pressure on the low back. I do want to mention that arching from the lower back to bend forward is not going to blow out your back, this is a natural movement. However, if you do it repeatedly, over and over again (due to work or any other reason) or you lift heavy weights with that posture, you could increase the chances of injuring your lower back. Here you go-
My last two blogs focused on things to consider when moving abroad for masters. You can find it HERE and HERE. This blog post will feature things to consider when moving abroad to start practicing as a licensed physiotherapist. When I say abroad, I am referring to the countries I have worked in – The US and Canada. Ok, here we go-
One needs to be a licensed physiotherapist to be able to work in both USA and Canada. The US has a 250 question MCQ based written test with a passing of 75% called the NPTE. Canada has two tests- the written and the practical. The written component has 200 MCQ questions and the practical exam has 16 practical stations which covers cases of all aspects of entry level physiotherapy. It’s called the PCE.
If you plan to move to North America, prepare to start the process early as there are a lot of steps before you will be permitted to sit for the examination. This can easily take up a few months.
To sum these steps in a nutshell, US and Canada would like to assess our foreign degrees and make sure its equivalent to their standard entry level programs (DPT in the US and Masters in physiotherapy in Canada). If they find it to be at par with their respective standard, then one is allowed to sit for the test. If not, recommendations for courses are given that must be done by the foreign trained physiotherapist to be able to sit for the exam. All of this can take some time hence start early.
For the US please refer to the FCCPT and FSBPT websites (in that order) for more information which is unfortunately out of scope of this blog post. You can find that information HERE and HERE. For Canada, please go to the website Canadian alliance of physiotherapy regulators for more information. It can be found HERE.
Make sure you have enough copies of your mark sheets and graduation certificates (multiple copies, sealed and stamped by your college or university). You will need more than one.
In my opinion, to pass these tests, foreign trained physiotherapist must devote at least 2-3 months of full time study. Students graduating from american and canadian programs are trained to pass these board exams. I cannot speak for other countries but in India a lot of our tests are essay format written tests. It does not prepare us for the MCQ based examination that we need to pass to practice here.
Most of the exam questions require analytical thinking and problem solving to deduce the right answer. There are some questions that test factual knowledge and our memory as well but predominately a lot of questions focus on different scenarios and our ability to chose the best response with the information presented. Sometimes the answers might be easy to pick and sometimes more than one answer might seem correct.
Passing the american NPTE is quite straightforward, score 75% or more to pass. The Canadian exam is more complex, the passing score is not fixed and is set by the board of examiners and one must score more than the fixed score to pass. The candidates do not know the passing score that is fixed. You can read more about it at the CARP website HERE.
After one successfully passes the board exams, there are many different work settings to chose from. One could chose to work in outpatient offices, hospitals, skilled nursing facilities, long term care facilities, schools as pediatric physios or provide home physio.
Average salary for a new graduate in outpatient care varies state to state (USA), province to province (Canada) but to give you a ball park estimate, can start around mid $30’s/hour. Travelling home care Physios or pediatric physios have slightly higher rates.
I have a few more points coming in the final part 4 of this blog post. Stay tuned and always
Continuing from where I left off in the last blog post here are some things to know-
8. If you are not able to secure a scholarship don’t get disheartened. There are a few other options like on campus jobs. They won’t cover your finances like a GA,TA or a RA, but hey, every bit counts right. In North American, this could be working in your college cafeteria, working in the gym reception or the recreation center of your university, library, student help center or coaching center. One gets paid on an hourly basis and we are permitted to work 20 hours when school is in session and 40 hours during summer break, end of semester break etc. Working off campus is illegal in the USA and if caught you could be looking at deportation. I’ll advise against it. Canada is more relaxed and allows off campus jobs with similar restrictions on working hours as the US. This could be one of the important factors to consider when deciding where you would like to pursue your masters.
9. Back in 2011, on campus jobs were minimum wage jobs fetching $7.25/hr. This might have changed now as the minimum wage has raised. Some on campus jobs where you tutor other undergraduate students in subjects like maths, sciences etc can be a little higher paying depending upon what university one goes to.
10. CPT (curricular practical training)- is temporary employment authorization off campus that is offered in US universities which could be from 6-12 months while you are still studying in the program. This employment must be in the field of study. Consider employment under CPT as a regular job, you give the interview, you negotiate your salary. You are looking at much higher salaries (especially in our profession) compared to on-campus jobs but remember that one must have a physical therapy license to even consider this option. Also, most schools won’t offer them in the first or second semester. Depends on their policy, so don’t count on it when you first start school.
11. OPT (optional practical training)- is a temporary employment authorization offered mostly at the end of one’s studies (can be offered after one year of completion of studies as well). You must apply for it a few months before graduation, do not forgot to apply. If you do not, you will miss this very important period to work and gain some North American experience. It’s also a buffer period or a transition period between being a F1 student to getting a H1B if that’s the route you wish to choose. It is offered for 1 year and if your course is a STEM program (science, technology, engineering and mathematics) you are eligible to get a 17 month extension on your already 1 year OPT period. It’s called OPT extension. I know that exercise science falls under it ( I don’t think a Masters in physical therapy does, but I’m not sure about all schools) but make sure you ask your school before assuming. Needless to say, to work under this period as a physiotherapist/physical therapist you will still need your license.
12. Masters is physical therapy is not a very common course offered in the US anyways (very few schools were offering it in 2011, I’m not sure about it now). This program has slowly been outdated and replaced with a 3 year doctorate of physical therapy (DPT) program in most of the schools across the USA. Basically it’s the same as our BPT. For specialization in particular fields like orthopedics, sports, geriatric etc, there are many residencies and other courses offered by APTA but generally not a full time 2 year university course. (I did masters in exercise science. To know more about it follow my previous blog HERE). In Canada, there is no bachelors in physiotherapy anymore. Here, bachelors could be in psychology major, exercise science etc where you gain credits in anatomy, physiology etc and then apply for a masters in physiotherapy which is a 2 year program (similar to our bachelors). Again, just like the US, to pursue specialization in different fields, there are smaller courses and workshops but no full time post graduate program.
13. Some common questions that I get asked often are ‘what are credits?’. Consider credits as a form of unit. Every subject that one takes during a semester has a certain number of credits assigned to it (generally 3-4). To graduate one must complete a set amount of credits. To give you an example, for my program, I needed 36 credits to graduate from a masters programs and every subject was assigned 3-4 credits. Most universities will present tuition fee in terms of fee per credit. You can do the maths and calculate your full course fee.
14. Finally, remember that unlike our colleges and universities where the curriculum is preset for us, in North American universities you choose what courses you would like to take. There are core courses which are mandatory and then there are a bunch of elective courses to choose from. For the most part, you choose what subjects or courses interest you and choose which semester you plan to take it. Of course, your advisor will be there to guide you through the process.
Hopefully this information will help you to make a better informed decision when deciding what country and program you wish to pursue.
Next blog post will focus on physiotherapy as a career abroad and thing you should know before making a decision.
Deciding to uproot oneself and moving to a new country can be quite a daunting task, leaving loved ones behind and stepping into the less known. It requires courage and a leap of faith. However, it must be done, to step out of our comfort zone and to challenge ourselves to be able to rely on our own no mater the situation is a great environment for growth and learning. In this blog post I will share some tips that will hopefully make this journey a little less bumpy and ambiguous. In the interest of keeping these blogs short, I will divide them into multiple parts as it’s nearly impossible to keep it short and cover everything. The first two parts are for students planning to study abroad and the following parts will focus on physiotherapy as a career abroad. Here are a list of things to consider-
For higher education – 1. The language barrier- while most of us speak English well and have cracked the IELTS/TOFEL, often the local lingo can be a little different and being able to have seamless confident communication can be a big asset. Try to understand the local lingo and immerse yourself in their language long before you have to move.
2. When looking for other students traveling to the same school as yours (university or college is often called school) start early. Mostly all schools have FB groups of international students. It is an excellent place to start networking. Alternatively, look for contacts or acquaintances that have been to your school before and feel free to contact your international students office to connect you with other students or for any other help.
3. Common sites to look for apartments or roommates in the USA- craigslist and sulekha and kijiji in Canada.
4. Unlike ours, North America has a culture of small talk, use it to break ice with strangers in your class, mostly everyone is open and friendly.
5. Following up on the last point, explore and delve into your hobbies and use them to network and build a social circle. One of the biggest challenges international students face living abroad is struggling with having a social life and starting from scratch. Go out and network with students in your college who are not just from your country but locals and other international students as well. It took me a while to figure this out as I was a bit shy initially. Do this early to have a fulfilling school experience. Some good places to start are your school gym, international students office and all the programs they offer, college intra-murals(sports organized by the school for its students played casually but with league and championships games) etc. Universities abroad are like mini townships with a plethora of activities for all kinds of hobbies and interests. I strongly advise you to use them.
6. Scholarships and grants- it is great if you can get them, it takes a lot of financial burden off ones shoulders. There are many offered, GA (graduate Assistant), RA (research assistant), TA (teaching assistant). In addition, you may even be able to secure an on-campus job which is the only form of employment offered in USA apart from CPT & OPT (more on that later). In Canada, rules are a little relaxed and you can work off campus with some restrictions on hours.
7. Let’s break this down a little further, a GA is offered to students in graduate programs (what we often refer to as postgraduate or masters). It’s more of a generic scholarship in which you may be given clerical office work by the professor or department that hires you like scheduling data entry in computers, file stacking (what I did) etc, all depends upon your department’s or professor’s requirements so such a scholarship does not have to be in your own department. I encourage you to try different departments in your college as this greatly improves your chances. Students often do not consider looking outside their department, the worse that could happen is a rejection. Smile and move on. A teaching assistant position is generally granted in ones own department and often depends upon your GPA. It involves teaching either undergraduate students some classes or/and helping your professor in your own class. One must demonstrate advanced knowledge in their respective fields to be able to secure this scholarship. You could also find it in different department like maths, biology, physics etc. RA is generally offered if you decide to participate in research as part of your studies and is almost always in your own department and field of study. Each of these may offer either waving your tuition fee partially or fully (unlikely) or paying you hourly or in lump sum.
I’m not nearly done yet, some more points coming in part two of the blog post.
This blog post will be a quick one. I often utilize the upper limb tension tests (ULTT) to assess patients with pain and other radicular symptoms going down the arm. I check first the unaffected side and then the affected side to compare asymmetries and also use it for mobilization of nerve roots. However, as a reoccuring theme I have been aggressive with my tension tests in the past just like so many other techniques and have had less than favourable results. So in accordance with my ‘less is more’ thought process (in terms of pressure/force/aggressivness) I have made some tweaks in how I perform my nerve mobilizations. This is especially true for ULTT and LLTT tests and mobs because these are provocative manuvers and ‘I like lightning bolts running down my arms and legs’ said NO ONE EVER. Today we will discuss Median Nerve Neurodynamics.
Components of Median nerve neurodynamics involve-
Shoulder abducted to about 60 degree. (Initially, I’d abduct to around 90-110. However, Butler and his colleagues at the NOI group have suggested that shoulder abduction at 60 degrees puts the most tension on the Median nerve root and my patients also seem to tolerate this a little better so I now do it at around 60).
Shoulder depression (I have stopped pushing down on it too much as it can be very aggressive and threatening to some patients. I just try to avoid shoulder hiking).
Full external rotation of shoulder.
Full elbow extension.
Full forearm supination. (In the past, I would often leave some slack here due to focusing on shoulder depression. Try to get end range supination).
Full wrist extension.
Full finger extension. (Important to make sure that the PIP and DIP do not flex).
Here is a video demonstration of the test with some variations.
Please note that in one of the mob variation with elbow movements, I do not press the wrist down into complete extension. That is because prior testing of this variation of nerve mobilization was very threat inducing and provocative and I didn’t want to be very aggressive.
What are your thoughts? Do you have some tweaks on hand placement, body positioning, force applied or different variations? I’d love to hear it.
In the next blog post we will discuss some home exercise programs (HEP) for self mobilization. Happy flossing (but go a little easy maybe). Until next time.
Part deux of this blog is not really a course review but my thought on taking the Certified Mulligan Practitioner exam. To begin, I’ll say this, you don’t need to be a Certified Mulligan Practitioner (CMP) to be a good therapist. I know many physios who are great clinicians but haven’t taken the CMP exam. The Certified Mulligan Practitioner exam is a test to check your competency in Mulligan concept principles and application of techniques passing which you get the title CMP. Like I mentioned in the last blog, the Mulligan concept does not cover a whole lot on assessment/diagnosis. So the testing skips that part too.
What to expect in the test-
I gave the test back in 2010 and back then the test had two components. I have heard that the format has not changed a whole lot but don’t quote me on this.
Written Component- consisted of 50 MCQ’s. The Multiple choice questions which seemed tricky and often felt like they had more than one correct answer (they did not) was the easier part of the exam in my opinion.
The practical component- I believe was demonstration of 10-15 techniques (approx). Successfully passing the exam requires the test taker to be competent in each and every technique of the book and one would be asked to demonstrate any random 10-15 techniques covering all bases. This included everything- NAG’S, SNAG’S, MWM’S, SMWAM, SMWLM, headache SNAG’S, belt techniques, BLR, taping techniques etc. The practical component was conducted by two Mulligan Concept Teachers Association (MCTA) members; in our case one local from India and one from Australia.
Passing requires around 80% scores (approx) and attention to detail is important making sure one applies all the 7 principles of the concept when performing the techniques.
Is it worth it?
I can see why this question would cross someone’s mind. After all, one doesn’t need the title to practice in the profession or even to apply these techniques. You could just do the workshop/seminar course and still apply the concepts in your clinical practice. However, in my opinion it is worth it. Going through the extra grind has its advantages. I’ll give you not one but…. two!!
Early on in my career as a new grad, I always used my CMP credentials to bag better than average job opportunities and a little higher than average salary that a new physio would expect. To the new graduates starting their career in physiotherapy I’d say this, physio school will teach you the basics and how not to harm a patient but some of the curriculum is not up to date with the latest in the field and taking certifications will improve your overall clinical skills. It will also make you a more desirable candidate in the job market. Good physiotherapy offices value continuing education certifications and titles. CMP is a good title to have.
On becoming a CMP, you become part of the network of Certified Mulligan Practitioners. The database for a full list of CMP’s across the world can be found on the Mulligan website here.. This directory can sometimes be a good source of referrals for new patients/clients. I have had other mulligan practitioners refer patients who were around my practice and I have also had patients use this directory to find me directly. It can be quite a useful tool.
Hope this information helps. More course reviews to follow in some upcoming blogs. Lets keep the dialogue going. Until next time.
This is my first blog post review on a workshop/course so it only makes sense that I write about one of the most pivotal workshops early on in my career. Drum roll, ‘The Mulligan Concept’.
Before we begin, I would like to take you’ll on a little flash back in history back to 2009. I was in my 4th and final year and was about to graduate with my bachelors in physiotherapy degree. Needless to say, I was still trying to put all the pieces of the puzzle together (almost a decade later and I still am!) and quite frankly struggling at it. By now I was expected to be able to figure out what was going on with my patients. I could follow the SOAP procedure to get all the information like I was taught but was unable to put it all together. To make matters worse, the few things that I had truly mastered at the end of my 4 years was how to make near perfect loopy circles on the body while giving ultrasound and mastered not to electrocute patients on modalities (that’s right, a slight exaggeration). Modalities were the biggest arsenal in my ‘physio toolkit’ along with some very basic home exercises and frankly it did barely something if anything to my patients pain scores or any other outcomes. It didn’t matter if the machines now had digital panels instead of the knobs, they were all a let down. Maybe I relied on modalities too much (In fact now I know that really was the case). But what else was out there? I had not even started my internship and the future didn’t look so promising. I was looking for a way out. And then…
Enter the Mulligan Concept
This 8 day workshop was everything I need at that time (almost everything). It was a real game changer. Taught by a dynamic and engaging teacher who was also a great role model for a young physio student, the concepts looked pretty straightforward and gave me new hope. I began using the techniques right away and as many physios have reported alike, the results were just like how Brian Mulligan would describe it instantaneous and almost miraculous.
Before we proceed, full disclosure, I am a Certified Mulligan Practitioner and I am biased to this approach in physiotherapy. But I’m even more biased at presenting accurate information through my experience in this blog. So here is my take on what I liked and disliked in this concept-
The 7 general principles of the Mulligan concept apply to every technique on every joint in the body. Now there are many techniques (NAG’s,Reverse NAG’S, SNAGS, MWM’s, SMWAM’s, SMWLM’s, belt assisted MWM’s etc) and even more joints in the body. However, there are no exceptions to the rule.
When a particular glide is applied correctly and it works good to reduce pain with a certain movement, it works just great.
If you follow the general rules of the concept, chances of aggravating patients symptoms are slim. All movements must be pain free or should reduce pain with every repetetion.
The concept focuses on function and I’m a big fan of that. If squatting hurts, your glides will preferably be in squatting, if its walking that gives your patients some grief, the glide is applied in walking (a little difficult) and so on. I’m not a big fan of prolonged passive treatments on a bed if the chief complain is doing some activities. Weight bearing and movement is not just encouraged, its a principle.
Results are generally quick and instantenous.
Most of the techniques are joint biased. It does not address soft tissue work that might be needed on up-regulated, knotted muscles etc. (Brian Mulligan does mention that his techniques should be applied with other interventions). So this course will not address too much of your ‘manual therapy for soft tissue’ needs.
In my mind the biggest short coming in the concept is the lack of understanding of why it works so well when it does. It is based upon the older mal alignment, ‘positional fault’ leading to pain model of explanation which we now know is not the best model to explain something as complex as pain. We have better understanding of these concepts now. I’m not sure if the Mulligan Concept Teachers Association (MCTA) has now changed their explanation/narrative in light of the new pain science research coming out. There is still some ambiguity there.
Unlike some other concepts like the MDT, Maitland etc that focus on the assessment part as well as intervention the Mulligan Concept is more of a treatment system. It won’t do a whole lot in terms of adding to your diagnosis or assessment skills.
Some techniques are too specific and in my humble opinion too subjective from physio to physio. Here’s an example, some glides like the rotational MWM’s require the practitioner to isolate say the L/R transverse process of the C6 vertebral body. This gets even harder by the time we get to the lumbar spine as now we cannot use our digits but gotta use the ulnar border of the hand on specific spinal and transverse processes. Try this with a bunch of your physio friends and see if you can agree upon your palpation skills every time on every segment of the spine. I struggle with some of these palpatory methods that need us to be highly specific and have such subjectivity. Another example is the PA mobilization (sorry not Mulligan but I had to throw it in there). I have found movement based observatory method more quantifiable.
I am not the biggest fan of the Mulligan Taping techniques. Some of the taping techniques are supposed to ‘hold’ the joint in the correct position. I don’t think a tape on the skin can keep for example a shoulder in a postero-lateral position and keep it from falling back in a ‘mal-position’. There are other examples too and I can state a few but I wont. You get the point. There are better taping courses out there with better explanation of why we belief taping works. Also, baring a few conditions, I like tape that permits motion not restrict it.
There is no ugly.
To sum it all up I think the Mulligan Concept has some shortcomings but is all in all a great concept. It definetly changed the trajectory of my professional career and taught me a lot. I will endorse it to anyone who cares to hear my opinion. Its a good concept to be familiar with.
Now would you want to go the extra distance to get recoganised in the system as a Certified Mulligan Practitioner (CMP), go through the pains of going through a written and practical exams like I did? More on that in part two of the blog post series. Until then
As we already know, the problem of glutes amnesia has reached epidemic proportions. Our lifestyle is not like what it used to be. More work gets done sitting on our behinds all day than ever before. Spend too long in sitting and we slowly start to lose the important movement of hip extension. In this blog post I would like to discuss two conditions that I have often seen in the past which can be directly or indirectly related to loss of hip extension (both lack of active control and loss of ROM). Seen in the general population and often perpetuated in runners. Lets begin-
Low back pain– while the causes for LBP could be endless, we will discuss the role of inhibited glutes and lack of proper hip extension in LBP. If we spend 8+ hours a day sitting on a chair (hip flexion), the glutes will be in an overstretched position and often inhibited. To add to those woes, the hip also gets stuck in a flexion position with classic ilicaus and psoas tightness. Now to maintain a upright posture and to compensate for tightness caused by excessive prolonged hip flexion which would put our trunk in a forward lean, the back extensors have to work harder to keep us upright. This often manifests as an increased lumbar lordosis (low back curvature). Prolonged time in this position can cause increase in tone of the lumbar erectors and could potentially cause low back pain. I see this often with recreational runners or those who are new to running. During running, if your hip do not go in to enough extension, the back begins to arch and the erectors being part of the posterior chain have to work extra hard. Remember the body is a great compensator but over time this catches up. This, I believe is often one of the common reasons why recreational runners come to see us for low back pain with running. If you are an athlete or a runner, this is not the best situation for running. Your glutes have lost their VIP status. No one likes weak glutes, unacceptable.
Plantar fascitis– I often find people with plantar fascitis have well developed calf muscles. It appears like its ‘calf raises’ day everyday for these folks however on further questioning you may find that they might not have been doing any calf strengthening exercises. If such is the case, I implore you to check for their active hip extension in walking or running especially during the midstance, heel off and toe off of the stance phase. This is the time when the leg should start to cross back behind the body due to hip extension. This is the primary movement that propels us forward. Now if the body lacks this crucial movement, due to weakness of the glutes max or tightness of the ilio-psoas etc the calf seems to become a more significant driver to push the body forward. Now multiply this a few thousand times a day (even more if you are a runner) over a few weeks, months or years and we have a overworked calf complex. As we all know, the calf exerts a pull on the plantar fascia (remember its a two joint muscle) and that irretates the PF blah blah, we all know this. So improving active hip extension and utilizing the full potential of the glutes is crucial to give the calf a break and in turn might relieve some stress of the PF.
The take home message is simple- Hip extension is a crucial movement for many daily activities and a lack of which might cause LBP or PF. When treating these conditions, don’t make the mistake of running after the symptoms like I have so often in the past. Here’s a little video to give you an idea of my thought process when analyzing hip extension in running.
(PS- this is not the only thing I look for, I’m only focusing on Hip extension here).