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-
Since most of us are working from home on our makeshift workstations/couches etc there are too many sore necks and backs going around. Here’s a new video to hopefully keep you away from those statistic. Hope it helps.
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.
Following up on my blog post last week (which you could find Here), in this blog post I put forth some Median nerve Neurodynamics home exercises. The general principle remains the same for me. Start slow, try to keep the exercises pain free/threat free if possible or at least to a minimum with head bend to the same side slowing progressing to head neutral and eventually away from the side that is being stretched. I start with sliders and then progress to tensioners.
If any of the exercises increase pain levels, I instruct my patients to either go gentler and if that does not help, I ask them to stop.
Enough said, here are some videos-
1. Unilateral exercises with nerve mobilization @ the wrist level-
2. Unilateral exercises with nerve mobilization @ the shoulder and the fingers-
3. Unilateral exercises with nerve mobilization @ the elbow with head neutral and slowly progressing to sliders.
(Starting position is shoulder abduction not flexion as mentioned in the video, sorry for the error but you knew that).
4. Unilateral exercises with nerve mobilization @ the elbow level with sliders and tensioners –
5. Bilateral exercises like the prayer stretch, butler’s busy bee-
I would love to know some of your favorite exercises, tweaks and variations. That’s all I got for this post. Keep fighting the good fight. Until next time.
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.
The thoracic spine (T-Spine) is an interesting part of the body. In recent times it has taken the brunt of the modern sedentary lifestyle of being hunched over on a chair and working on a computer for hours in a day for many months and years. These modern sedentary lifestyle changes and new work/office setups have had implications on our musculoskeletal system. What is interesting is that the T-Spine itself presents only with a few symptoms like mid back myofascial pain, stiffness, loss of mobility etc. However, other joints in proximity of the T-Spine are affected adversely due to this. Here is a list of problems we often see in an physiotherapy office that our closely related to an excessively stiff kyphotic T-Spine.
Shoulder impingement- An excessively kyphotic mid back places the scapula in a downwardly rotated, anteriorly tipping and protracted position. This position of the scapula has shown to decrease the sub acromion space in the shoulder when performing overhead activities leading to a common problem we see often; shoulder impingement/pain. Try this little test, try elevating your arm up to the maximum flexion elevation with a straight Tspine and shoulders pulled down and back and then with an excessive hunched over position. Which one feels better and which is worse? See the video below and try it yourself.
Neck pain- A kyphotic hunched over posture tips the head (weighing about 10-12 lbs approx.) anteriorly and extends our line of sight downwards to the floor. For compensation, we tilt the head backward which increases Cervical lordosis and causes upper cervical spine to go into extension to have a regular straight field of vision. This causes increase tone/tension in the cervical extensors often compressing the greater occipital nerve and other important cervical structures causing symptoms like neck pain, headaches, radiating symptoms etc.
Low back pain- An excessive kyphotic T-Spine pushes the thorax anteriorly and causes compensatory increase in the lumbar lordosis due to increased tension in the lumbar extensors causing pain at the low back. This is the classic presentation of the ‘Lower Crossed Syndrome’.
Breathing- Along with the above compensation, the thorax lifts up due to inability of the abdominal muscles to provide inferior stabilization (lower ribs flaring) decreasing overall chest expansion and causing poor breathing quality and control.
Furthermore, if you follow the joint-by- joint model of training by Cook and Boyle, you can see that the thoracic spine is meant to be mobile but has a tendency to get stiff.
So, here our some strategies/exercises we can use to maintain general T-Spine mobility. The angles drawn in the video are not exactly accurate and are used for demonstration purpose only-
Bench/chair thoracic spine extension with stick-
T-Spine extension on foam roller
T-Spine windmill rotation
Four point T-Spine rotation
Threading the needle
Closing thoughts, the mid back is meant to provide mobility but tends to get stiff and excessively kyphotic given our contemporary lifestyles. This can open the floodgates to a myriad of musculo-skeletal problems. It is paramount to keep working on its mobility.