Comment

Congratulations Dr. Gary Heshiki, DPT (A letter to my younger self)

A few weeks ago, I achieved a milestone I once thought might never happen—I earned my Doctor of Physiotherapy degree. My patients call me Gary, but the title "Dr." is mostly on paper and for marketing materials.

The journey wasn’t without its doubts. Over the past two years since I enrolled in the program, I've had many moments of self-reflection.

During this time, younger coaches and former colleagues often reached out asking the same question: Should I pursue this path, too? Is it worth it?

This is what I’d tell them—and what I’d tell my younger self if I had the chance.

Dear Gary,

In two years, you will have gone through it but you will make it through your program. It won’t come without many low points, some of which you aren’t sure if you’ll survive. You do but this is what I would want you to know.

Going to PT school is more an act of attrition than it is challenging academically. The more time you spend learning about modalities and techniques, the less you will want to use them. Your previous experiences will serve as a double-edged sword. You will have managed very complex problems for people, successfully, and yet you will be challenged to bite your tongue and be tested to regurgitate less effective methods of treatment.

You'll encounter many educators who seem disengaged, lacking the passion to teach, or have honest conversations about needed changes in the profession. It’s tough because you genuinely care about making a difference, and it’s frustrating to see the cycle of tired techniques taught as the basics.

You will learn that with an increased scope of practice, you may question your ability to do good. As personal training and massage therapy are less regulated, your ability to help people at a lower price point is something to consider as it will change. The degree isn’t cheap, so you will end up seeing people less often due to needing to charge more. This in turn results in the inability to see problems fully like you may prefer to.

Your classmates will be the saving grace. Not only because you find a few good friends but because in them you can influence the next generation of clinicians. You get to share your experiences and educate them on what you know, knowing this is what spurs your desire to become a clinical educator. Mind you, not all of them are going to be open or ready for what you have to share.

At times you will question if this was the right decision, and to be frank, I don’t have an answer as to whether it was just yet either. What I can say is the growth you experience and having your skills stretched to find a greater level of competency is worth it. You will come out of this a better professional and a better human. Trust me.

Good luck,

Old man Gary (only two years older)

Comment

Comment

Why Your Back Keeps Hurting

Pain in general, is rooted in perception. Therefore, if we change our perception we can then change our current experience with pain.

But what does that mean, how does changing your perception influence your pain?

Think about cooking dinner, you’re making this pasta dish that needs a splash of lemon. You squeeze the lemon and now you have this stinging sensation at your fingertips. You have a cut that you are now clearly aware of. It was always there, you were just unaware. As time passes, you still feel the discomfort, long after washing your hands and enjoying your meal.

Let’s take this concept a step deeper.

When we think about perception, we first think about vision. This is our primary way of experiencing the world using our eyes. Next is our vestibular system, located in our ears which senses changes in position and space. The last is the one most coaches and therapists are aware of, proprioception. We experience the world through our movement. Changes in vision or vestibular systems can influence things like balance and gait, therefore it makes sense that this shapes how well you can interact with the world.

The one place we have a large direct impact is movement-based training inputs.

How you move right now is your interpretation of the world

Muscles have spindles that detect the rate of stretching that occurs during your movement.

This information (afferent information) goes up to your brain, which in less than a second creates a plan for movement and produces an electrical current (efferent information) to produce muscle contractions. This is a closed feedback loop that will provide a road map for how much tone or tension you feel at rest. It’s why you have tight shoulder muscles, no amount of massages is going to change that.

When you try to massage, foam roll, trigger point, acupuncture/dry needle, stretch, cup, or whatever; it attempts to circumvent the incoming information at the muscle tissue level. This is why you get a temporary decrease in tension and an increased ability to move deeper.

This is the problem of thinking I can loosen up before a lift, run, or movement-based activity and get stronger there. You have temporarily increased your range of motion but overall, your movement capacity remains the same. This is why you have to continue loosening yourself up before training. From a macro perspective, your movement is the same, at a micro level, it is continuing to stagnate.

I say this half joking, but have you thought about moving better?

It’s important to keep in mind that until you intervene at the appropriate level, it will not change your movement quality (let alone alter any tissue composition properties).

This cross-section of muscle illustrates the point that all levels of muscle, tissues sense tension. Regardless of what you’re doing, you’re either improving tissue quality or it’s getting worse. Maintenance is a myth.

Change the incoming information in your back to increase the utilization rate of your muscles. This will be due to an improved outgoing signal.

And no, you can’t just stretch (because if it was going to work, it would’ve already the other times you’ve tried to stretch your back).

Comment

Comment

Not Like Us: Not All Physiotherapy or Training is the Same

"I'm sick, can you please direct me to the cheapest doctor that will do an adequate job?"

- No one, ever, probably.

How often do we purchase sessions with a therapist based on price or convenience? "I need a physiotherapist, do you know the closest, least expensive one?"

This presumes that all Physiotherapists are the same, which in part is due to the lack of diversity within the physiotherapy space in Sydney - Australia (though this is also seen in America as well).

Standards in Physiotherapy

It's a catch-22 as a consumer -- you don't know what to do but need to hire someone. The problem? How do you know if the local physio around the corner can manage your specific injury, pick out compensations, and how your lifestyle may contribute to your issues?

A major change as an American living in Sydney is that Australia still offers a range of degree types, from Bachelor’s level to Doctor of Physiotherapy. Subsequently, this increases the public’s perception that all physiotherapists are the same. Compounding this misconception is that most treatments are passive, relying heavily on massage or machine treatments with minimal exercise.

The result is similar across the board, is it any wonder the public’s perception is what it is?

Either said treatment helps buy you time until you feel better or you end up in a situation where you have a recurring chronic pain that comes back. Worse, you bounce around from clinician to clinician in search of the elusive therapist who can legitimately help you.

Why Do Some Therapists Cost $200+ per hour?

It comes down to the market rate based on what everyone else in the area is doing that will determine the costs. This also is built on the assumption that on average, most professionals manage and treat people similarly.

Price often acts as a filter for quality, though this is not always the case as seen online with flashy marketing that may provide poor quality services or products.

So can the $70 physiotherapist within your insurance group help your daughter with her ACL physiotherapy post-surgical rehab? Maybe.

I bet that a $200 per hour Physiotherapist who can outline more than following a standardized protocol that has continued to produce a 1 in 5 re-rupture rate might be a better solution.

Yes, it's a lot more money, but if you want the job done right, you hire once and you hire right. I'd rather spend three months with a more knowledgeable, more expensive therapist than 9 months with a less pricey, less experienced one if it means I'll get the best long-term results.

I expect all my patients to leave me with some level of knowledge about their issues and how to go about managing their bodies on their own if needed.

Too often the movement industry writes articles about how the consumer needs to become more educated, pushing the onus on them. While I agree a more educated customer is beneficial, I also feel that the industry needs to take more accountability by raising their expectations around standards of practice.  Only then will people stop associating physiotherapy with a massage, dry needling, shockwave, trigger point work, or insert whatever modality that only provides temporary relief instead of being a long-term solution.

Comment

4 Common Reasons For Back Pain and What to Do About It (Updated 8/12/24)

Comment

4 Common Reasons For Back Pain and What to Do About It (Updated 8/12/24)

IMG_5325.jpg

The alarm goes off, you roll over to turn it off as you take a glimpse at the time, 6 AM.

Sigh, it’s okay, time to eat before heading to the gym. As you gingerly roll out of bed, you go to stand only to feel stiffer than usual. You make your way to the kitchen and are met with an immediate uncomfortable sensation. You continue to move but this sharp debilitating pain starts running throughout your back and radiating down your leg. As the sensation increases, you are frozen by the pain.

Tell me if this sounds familiar:

You sneeze and throw out your back
Bend over to tie your shoes, throw your back out
Rotate to place an object on the floor from a seated position and are met with back pain.

What all these innocuous scenarios have in common is that they’re not the reasons why your back hurts. They were the last straw, a coincidence because no one would argue that sneezing or tying your shoes are mechanisms for low back pain. There’s no such thing as non-specific back pain, only reasons that have yet to be snuffed out.

(2024: All continues to ring true, it isn’t so much the act of bending over to do something or lifting in a particular way that injured the back, but the accumulation of the load through tissues that weren’t properly trained and have now yielded.

I also disagree to the extent that we can have non-specific back pain in that we cannot point to the exact cause of the pain. This is also a shortcoming of research in that all low back pain, even similar presentations are different, and therefore extrapolating that to a larger population has its limitations.)

Relax…You’ll be Okay

Many individuals come into my office with some kind of “generic” back pain or self-diagnosed sciatica. Their pain is real and they don’t care so much about what it is (at least not in the moment) and are more interested in if we can get rid of the issue.

After tissue exploration and manual therapy, we stand up to perform some exercises to help improve the tissue’s capacity. I’m quick to let them know it’s not as bad as they think and that together we can solve this. Not surprisingly, most individuals I’ve worked on will remark that they feel immediate relief.

I’m not some magician, but I let clients know that bending over, sneezing, or standing up wasn’t the reason for their pain. Instead, it was one of the following reason(s).

(2024: This whole list is fine but I don’t love the framing of it from a nocebo perspective. Meaning, that if you don’t do these, you’ll have back pain, which is not true.

I still believe that much of the lower back problems that plague people often comes down to any of the following things below)

Your spine moves when your hips should

By now, most know that if you’re always putting yourself into bad spots, it’s not if but when will you get into trouble. Your body is no different.

(2024: It should really say if you’re only moving in one particular way, its a matter of when not if you will likely end up with some trouble.

The way I wrote this originally sounds real doom and gloom)

The topic of posture is at the current forefront of social media with polarizing views that you have to be a certain way for perfect posture or that posture doesn’t matter. The truth is always somewhere in the middle. If you’ve read my work on Instagram you’ve heard me say this but it begs to be said again:

“The best posture for you is one that is always changing.”

Your movement capacity is the same. Say you have a job that requires you to bend over and move 15 lb sandbags. If you were only required to move 10 bags, you could move them however you felt and likely be fine. But if you needed to do that for 8 hours each day, 6 days a week; you’re probably going to want to move in a biomechanically sound manner.

Learning to hinge, disassociate the hip from lumbar movement, and rotate well all go a long way in improving load-bearing capacity and providing you with different ways to move.

(2024: most of that is still solid, if you only know how to move one way, learning options is always a great idea)

Related to movement from the hips and not the lower back would be the ability to contract into hip extension without compensation. Lying on the floor offers a great deal of stability and lets you see what each side is capable of doing.

If one can’t get good hip extension while lying down, there stands a solid chance there is excess motion elsewhere when upright. Remember it’s not the movement itself that needs to be a particular way, rather it’s needing more options.

(2024: same same)

Your Spine Doesn’t Segment Well

Can you Cat-Cow? Many have performed this ubiquitous yoga movement, but few have used it to asses their capacity to move their spine.

Common for individuals with lower back pain is an inability to move segmentally through their lumbar spine without overly hinging through their mid-backs. When this is the case, a hinge point develops and this is the site of stress. The back is a bridge, so the load should be evenly distributed versus being placed just in one section of the vertebral column.

(2024: I agree with 90% of what I’ve written with the exception of the hinge point comment. While I may visually see a hinge point, we can’t assume that this is the exact site where you’ll have pain. Even if anecdotally all the spines I’ve assessed with some degree of discomfort show up with a TL junction hinge point.

Research says otherwise that you can have a hinge point and be asymptomatic, so there’s that.)

Your Hips Don’t Move Well

Single leg stability: You should be able to drop down to about an equal depth on both sides. This is an easy way to assess whether one hip moves better than the other. Things to note would be how smooth each side feels and if the foot/knee collapses during the squat.

(2024 neuromuscular retraining is still important)

The RNT split squat is a great way to help shore up the strength and their stability on that side. The band helps pull your knee into compensation, so you use your muscles to maintain proper tension and alignment during the exercise.

(2024: Still a fan of using your own muscles to correct positional problems)

90-90 Hip Transitions: These are a fantastic way to mobilize and loosen up the hips before activity. I also like them to discern if there’s a control issue somewhere along the chain. You go from transitions to a lunge and squat pattern during them as well here.

(2024: These are only helpful if you can get into this position correctly. If you try to get into the 90-90 position and your knee is barking at you loudly, how do you expect this to go? The inability to get into positions is a requisite to express movement where you want it.

You Have a Structural Problem

Spinal Compression Test
Take a seat and sit up tall
•Get into a good “posture” with your arms by your side (slight arch in your back)
•Grab the chair with your hands and pull up to compress your spine.
•Did you have pain in your back now that it we added a bit of compression in the rounded position?
•If so, it would mean that even when your spine is in a good biomechnical position, it doesn’t tolerate compressive forces well.
(2024: Oh the cringe I feel for feeding into this nocebo narrative. Look I can gather this same information subjectively from you. What does this test tell you? Posterior spinal tissue and potentially others are unable to handle a simple load going through them.)

Shear Test:
•Same as above but let your back round out
•Did this recreate your pain?
•If so, it would indicate that your pain is triggered by lifting out neutral, flexion intolerance.

(2024: Same for this crap…I mean this test. I could have gathered this from a conversation where you tell me being slumped or flexed hurts your back more and it feels better when you’re not in this position.)

What to do if these tests come back positive?

Flexion Intolerance
•Try not to slouch too much when standing or sitting
•When bending down to grab things, learn to hinge properly or kneel down in addition to improving core strength
•Lie stomach down a few times a day.
Extension Intolerance

  • When standing, try to vary positions. When seated, sit back into your chair.

  • Work on improving mechanics during movement and core strength as well.

Ultimately should you have an issue, be sure to visit a professional to help rule out any serious problems. The advice shared here should help the majority of individuals get on the right track, but you always want to be sure to not overlook a larger problem.

(2024: What if all these “tests” are done and it’s fine? You may discover you’re not flexion intolerant but extension intolerant as pain only happens with extension-based movements like standing positions. Advice would be the opposite focusing on less rigidity through the lower back and focus on fluidity with movement.

I suppose the problem is that when anyone has back pain, it’s such a nuanced problem specific to each individual. Therefore sifting through social media or any website will try to sell you a paint-by-numbers approach. Again, this may help some, but what about individuals who don’t get better? This all goes back to, no two presentations for back pain will be the same, even if they have an identical diagnosis.

Don’t buy a choose-your-own-adventure for your lower back pain, hire a qualified professional.)

Closing thoughts in 2024: The majority of insidious low back pain has a few things in common. Poor spinal segmentation and a lack of variable coordinated movement.

All “neutral” spine movements have flexion involved, in fact even in those that visually appear neutral throughout experienced spinal flexion through the lumbar vertebrae. (Thesis paper here).

  • The primary goal is to settle down any acute flare-ups

  • Manage the spine based on what it’s showing you.

    • Can it flex well?

    • Does it extend well?

    • Does any hinge point correlate with an area of lower back pain?

    • If it lacks sagittal plane movement, does it compensate sagittally or laterally?

  • How is this person’s breathing? Are they able to demonstrate good IAP (Intra-abdominal pressure)?

These are just a few things I’d would start with just from an observation standpoint. From there I would assess with my hands and put together the pieces of the puzzle along with the information I get from our discussion as to what to tell you and where to go with treatment.

Comment

Trouble with Standard Model Therapeutic Screening

You’ve woken up and you have pain across the back of your hips and gluteal area with some discomfort out into your hamstring. You go visit your therapist or chiro who pushes on your vertebrae to tell you that L5-S1 is not moving well (they can’t actually feel it move). They may then ask you to do a squat, and you shift away from the side that’s bothering you. It makes perfect sense that you move away given it hurts on the opposite side. You sit back down on the table and get your muscle strength checked, glute med/min and ankles are weak and it’s causing your hips to be off balance.

While nothing is unsafe (priority number 1), it is inherently short-sighted to assume anything about this all-too-common assessment provides insight beyond an inability to control movement and a lack of strength in areas where you’d expect it to be weak. Not to mention manual muscle testing is a very unreliable “quantified” way of measuring strength.

(In my opinion, the grading scale makes sense only for gross movements not fine, where a 0 means nothing, a 3 is held on your own, and a 5 is where you can hold against some kind of resistance. Trying to specify and say it’s a 3+ or 4- is way too subjective to be used reliably.)

In this example (or any movement screen), a squat screen where you aren’t moving well only tells me you can’t squat, and nothing beyond that where you leap being told you have hip dysfunction or weakness.

This may be a motor control problem that is dependent on neurological mechanisms such as speed and activation. If these neurological mechanisms have good incoming and outgoing information flow between the joints, muscles, and connective tissues; motor learning can occur.

A lack of balance here manifests as altered movement.

Muscle strength is useful clinically when we look at potential neuropathic-related problems like radiculopathy, but outside of that context, being told you have weakness is an unreliable cause. Your pain may inhibit firing but remember that pain may not be coming from the area of discomfort rather your brain sending a signal that something is not right.

Like a smoke detector, it only tells you there’s an increase in heat or smoke not that there’s a fire. Pain is the smoke detector, something’s not right and we need to investigate WHY.

Find a therapist who looks at the why instead of what.

When I ponder about that statement, it means going beyond the superficial explanations of if this is “out of balance” and you need to strengthen muscles to pull it back.

Simply treating the symptoms or focusing on strengthening specific muscles may not be enough to address the root cause of the problem. Sometimes, the pain may temporarily decrease due to accidental problem-solving by the therapist, but the underlying issue may persist. In such cases, the pain is likely to resurface once you resume your activities. This happens when the therapist focuses on WHAT instead of WHY.

So what is the why behind your pain? No one can say, but to fit it into a neat box where it’s an “If this, do that” approach is not going to cut it for the majority of more complex problems that people get.

This I suppose, is the point of this article, when a treatment is based on an assessment that only looks at one subsystem (which is a part of a complex multi-systems entity like a human) it will fall short when it isn’t a muscular system problem.