Direct Access to Physical therapy: Helping you and Helping Healthcare

It is Thursday evening and you are playing softball. After fielding a ball you throw to first base and feel an intense pain on the front of your shoulder. This is not a new pain but it feels worse than usual. Despite your usual treatment regimen that night (Ibupfrofen and ice), you wake up with a sore, hot shoulder. It is time to get this thing fixed. Afterall you have a tournament next weekend. If you live in California there is no way you are getting started with Physical Therapy before next week. With all the state laws and insurance company hoops to jump through it becomes difficult to get started on your recovery. But in South Dakota and many other states, you can get started that day!

Direct Access: Free to use your own judgement to seek out the appropriate medical professional without being told by another one to do so.

Why is Direct Access to Physical Therapy so important?

1) When you get injured, you want to get started as soon as possible. Direct Access eliminates the wait time to get into the specialist doctor or a costly trip to urgent care.

2) Going directly to Physical Therapy may cut down on healthcare costs (unnecessary imaging, medications, extra copays). These hoops to jump through keep patients from seeking treatment or from getting better faster. Don’t worry. Physical Therapists are trained in medical screening. If you need an x-ray, medications or if Physical Therapy is not appropriate, we will refer you on. The last thing we want is to do is treat someone who has a red flag (non-musculoskeletal pathology not warranting PT).  That is why it is called a red flag. Stop!
Here are some examples of theses hoops patients must jump through in various states/insurance types:
1) You can be evaluated by a PT but can’t receive treatment utility you get a MD referral.
2) You can receive treatment by a PT for 21 days but after that you need a referral.  How often do you completely recover from an injury in 3 weeks?
3) Many states and insurance companies require a signed plan of care by an MD prior to proceeding with care.
*These examples only delay care and provide extra work from all parties. More hoops to jump through make people reluctant to use insurance at all.

Why Physical Therapy?

1) We don’t get you better. We help you get yourself better.

Sure, we are going to use modalities (fancy machines to help you feel less pain and more relaxed) and have you relax on the table for a bit (for massage, joint stretching and other passive techniques). But, this is just a jumpstart or a reset to the system. Once the system is reset we will help you re-enforce the changes. The rest of the work is done by you. We are going to educate you and train you to do what is best during your rehab and going forth.

2) We want to make sure it lasts.

Guess what? You didn’t throw your arm out JUST because your shoulder is weak. There are probably 5 other factors contributing to your recurrent shoulder pain. Ergonomics, posture, exercise habits, sleeping habits, diet, throwing technique…these are just a few things we can identify during your treatment for acute shoulder pain.  Then we can help you prevent another occurrence. We love our patients but, really, we don’t want to see you forever.

Part of “making sure it lasts” is taking you to the next level of fitness. Everyone has body image or fitness goals. We can get you started on working towards those goals during the rehab process.

3) We have an eclectic approach.

We do manual therapy. We do exercise. We use machines. We use tape and braces. We know if you don’t do your homework (home exercise program) and will make you do it in the clinic before we do the passive treatments. The benefit of being eclectic is that we do what is most important for you all the time, not just what you expect us to do.

So next time you are sidelined by a nagging reoccurring injury, get on the horn and call a PT. We will get you started on recovery immediately… IF YOUR STATE HAS DIRECT ACCESS.

*Many states have been labeled direct access but patients DO NOT have clear access (“hoops” described above).  See below in Direct Access spelled out state by state. There is lot of current advocacy related to clear direct Physical Therapy access in these states. Please help support this effort.

References and More Information

American Physical Therapy Association info on Direct Access

Direct Access Spelled out State by State

Clout for Direct Access to Physical Therapy

Yoga or Pilates? Part II

If you are attempting to decide between Yoga or Pilates, this and my previous blog will give you a rundown of each and how to decide which might best suit your needs.

Part II – Pilates

Part one included a full description of the various styles of Yoga and how to choose the best one for you.    The Pilates Method was founded on and continues to be based on the visions of its founder Joseph Pilates.  He was a an athlete interested in Eastern AND Western medicine who developed a practice that would give you the tone and strength of a boxer or dancer.  Similar to Yoga, it follows the principles of balancing the body.  Also like Yoga it is a practice of poses and postures however it incorporates a repetition / fine tuning of a secondary movement while sustaining that posture.  The exercises are focused more on precise and concentrated control in small to large ranges of movement for improving flexibility and developing the core or “Powerhouse”.   The last two principles similar to Yoga are coordination of breath and Flow of movement during engagement of the postures.

One of the main reasons that Physical Therapists are such advocates of The Pilates Method is that it focuses on the main stabilizing structures of the trunk that tend to contributing or directly linked with the spinal and peripheral injuries we see every day.  The Serratus Anterior, Longus Coli, Transverse Abdominis, Multifidis, pelvic floor, diaphragm, deep hip rotators, and rotator cuff are the key contributors for local stabilization the spine, hips, and shoulders.  Many of these muscle groups segmentally attach to the spine / ribcage  which enhance the positioning and precise movements necessary for rehabilitating or preventing an injured spine.  The big “mover” muscles on the surface of the body (pecs, lats, traps, gluteals, and rectus abdominis) are responsible for large, powerful movements required for daily movements and enhancing athletic performance.   However if they get weak / shortened due to postural changes or over training they become problematic.  While Pilates strengthens the deep stabilizers as mentioned above, it also works at elongating these superficial “movers” that might be problematic.

Joseph Pilates

Joseph Pilates

The Pilates Method founder was a boxer, diver, skier, gymnast, and war hero (as a Nurse) from Germany.  He served in WWI and invented his first apparatus (a version similar to today’s Reformer and Cadillac) in which he attached springs to hospital beds so that wounded soldiers could continue to strengthen their bodies while healing from their injuries.  In a lot of ways, Joseph Pilates was a Physical Therapist, although Physical Therapy was not invented in the US until the Polio Epidemic.  These were the first indications that Nurses could not care for the sick/wounded patients in addition provide rehabilitation.  They needed another practitioner to emphasize the relearning of fine and gross motor skills necessary for them to return to prior level of function.  We will save that for another Blog.

Well, the Pilates idea was a hit.  He was asked to train military personnel, famous athletes, and eventually emigrated to NYC to open his first studio in 1926.  He went on to develop 500+ exercises on the principles still used today:  concentration, control, centering, flow, precision, and breathing.  He turned Pilates into an art and developed many instructors to continue advancing and spreading the benefits of it.  This video demonstrates how beautiful the movements are when performed by advanced students.  The movements came to assist in the physical training of advanced technical dancing and continues to be one of the training methods of choice for them.

The Practice

1)  Mat Classes – as in Yoga Classes, mat classes follow a logical sequence of postures/exercises.  Similar to Yoga, classes are in group setting and do not allow for individual instruction.  Classes are usually offered in gyms (as part of the membership) or Pilates studios for 15-20$.

2)  Apparatus or Machine work – Using the Reformer, Cadillac, Wunda Chair, Ladder Barrel and Magic Circle (to name a few) these sessions are usually one on one or very small groups.  This allows for more individual manual and verbal cues from the instructor on proper breathing and form.  One of the downfalls of the individual lesson is that it costs a lot more.  It is comparable to having a personal trainer (50-120$/ hour).    Of course, some the the best success stories come from those who hire individualized training. 

In my opinion, there are good, bad, and mediocre instructors.  Most people only need mediocre instructors to actually see a change.  Once you learn the form, the instructor becomes a coach more than anything.  If your goals are to become advanced at Pilates, then get a good instructor, pay the bucks, and watch your body dramatically change.  If you are motivated and have the opportunity to take a few individual classes to get going and maintain your practice with a Mat class, you will see good results.  It just depends on your ultimate goal.  If you have an injury and want to continue your Pilates practice after a rehabilitation course, I would recommend individualized Pilates.  This will allow you to communicate better with your instructor on proper modifications and any symptoms you  may be having.

Like Yoga Studios, Pilates studios can be found in every City in the world and in many private locations (homes) as well.  A good list of resources are listed below to help you find a reputable location.

To answer the original question…

Depending on your ultimate goals, the factors described above will help you make a decision on which is best for you.  I tell my clients who have never experienced either to begin with Yoga.  Especially if you have limited flexibility.  Many of the Pilates poses (even the beginners ones) require at least a moderate amount of hip flexibility and if attempted might leave you feeling frustrated.  For those who have natural flexibility or hypermobility in the joints, Pilates would better meet your deficits safely as it would focus on supporting your spine.  Now, does that mean that Yoga doesn’t improve core stability and Pilates doesn’t improve flexibility?  No.  Quite the opposite.  Both practices will improve these deficits, they just focus on them in a slightly different manner.  Many people will choose Yoga for the spiritual component alone.  Myself included.  To solve this problem of choosing, gyms have come up with classes that work on Yoga and Pilates principles (eg. PiYo at 24 hour fitness).

In the end, it might be better to do a little of both.  Find your preference by trying a few classes of each and finding your FLOW.


Ellie Herman – advanced Pilates instructor and advocate

Descriptions of Pilates equipment

Balanced Body Pilates – a comprehensive Pilates resource

Stott Pilates – another comprehensive Pilates resource


Pain Management – The Traffic Light System

Exercising with an injury or during rehabilitation is confusing.  After a surgery or with a chronic injury a lot of variables contribute to how you manage your habits and react to pain.  Many athletes will endure the pain and ATTEMPT to train through the symptoms.  On the other end of the spectrum people who have had a lot of chronic issues such as spinal pain, headaches, and other repetitive strain injuries tend to avoid pain or fear any activities that cause their symptoms.  It is not a perfect science to determine when to endure the pain, when to rest, when to take medications, or when to ice/heat.  In attempt of generalizing how to manage pain, I use The Traffic Light System. 

Now, before I educate someone on how to use The Traffic Light System, I have asked them many questions such as:  intensity of pain, episodes of pain, activities that increase it, time to recover, sleeping habits, medical history, medication use…  I could probably spend 20 minutes asking specific questions about pain during a Physical Therapy evaluation.  However, most people are afraid of pain.  To focus on it will usually only cause a more heightened response.  Pain, life stress, lack of exercise, and fear of activities can lead to something called central sensitization.  This is when your nerve receptors become sensitive to pain eventually  leading to inaccurate processing.  Non-painful stimuli become painful.  Everyone has a friend, family member, or patient who has been overcome by this type of pain mechanism.  You know… the type that has dedicated their life to treatment modalities such as Massage, Yoga, Chiropractic, Acupuncture, Physical Therapy, MRI’s, and finding the latest research on the surgery to cure their pain.  At one time these people had an acute injury that was not managed properly thus leading to fear of activities and central sensitization.   Many have gone through emotional cognitive events during or prior to the injury predisposing them to this type of pain “mutation.”  These factors eventually lead to chronic pain.  If you follow the Traffic Light System you should avoid this  “mutation.”

We are going to describe how to use The Traffic Light System by using an exercise example:   2 sets of 15 squats to improve your leg strength for decreased pain during running.

Red Light - STOP! During the exercise, if the pain is severe, sharp, radiating down the leg, or your leg completely collapses MORE THAN TWO TIMES do not continue with the exercise or activity you are performing.  If you are walking or using the stairs, modify as needed to reduce the pain.

Yellow LightProceed with Caution.  If the pain intensifies with the movement or exercise (mildly), continue for 5-10 reps.  If the exercise intensifies your pain, STOP.  If the exercise seems to loosen things up and you are able to continue without pain, PROCEED with the exercise.  If you have a pain that is unstable in terms of how it reacts to activities, you should not push yourself with intensity (# of sets, reps, speed, vigor).  This is where we get the term “listen to your pain.”

Green Light - Continue with the exercise.  If you do not get your pain, finish out the exercise and progress as muscle soreness allows.

Again, this is a very general way for you to assess your pain during activities.  If you have any doubt, STOP the exercise.  Attempt a similar type of movement to see if it creates pain in the same location (example: lunge).  The Yellow Light and Green Light needs to be progressed as an experiment.  Do a little extra and assess what happens to your body or pain for the next 24 hours.  If you feel the same or better, continue or progress with the exercise.  If you feel worse and know that the pain is not related to any other activity you have done that day, take a step back in intensity of the activity.  If you can’t figure out the equation, seek professional advise.



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