If Only Our Bodies Came With User Manuals!
It's tough to know when its okay to push through pain or stiffness, or to know if the recent shoulder tweak that happened last week is of any importance. Over the last number of years I've picked up a number of strategies from research and experts in the sports medicine and orthopaedic world - I hope this can serve as a general guide! (NB - this is a blue print for simple shoulder injuries, and will not fit every situation. Use the following information as the guide that it is, and seek additional advice if you need further guidance!)
Did You Hurt Your Shoulder Within The Last 7 Days?
To start it off, if you've hurt your shoulder in the last 7 days, read through the following flow chart, and then the corresponding text below:
Grade 2-3 muscle, tendon, ligament, labral or joint capsule tear
If you experience significant pain, possibly with swelling or bruising, it is likely that you have significantly injured your soft tissues. While outliers exist (bone fracture or nerve involvement), it is most likely an issue related to a tear of a muscle, tendon, ligament, or the joint structure, If the pain in significant, a trip to the ER or family doctor may be the best first option.
In terms of rehabilitation, it is probably best to let the shoulder heal for at least 7 days from the initial injury date before starting active rehab exercises. During this time you should see your local physiotherapist or sports medicine physician for an accurate diagnosis and to develop a treatment plan.
During the first 7 days, you can support the shoulder with tape or a sling, apply ice (if you need to numb the pain), and perform pain-free range of motion. You should continue to exercise your lower body during this time. You can reasonably expect that there will be a range of motion limitation and/or strength reduction for at least 3 weeks from the date of the injury. It would be advisable to avoid loading the injured tissues with exercise for at least 3 weeks as the injury heals. As per standard tissue healing timelines, the injured tissues will not reach their full strength for up to 9-12 months in a healthy adult… so it is important that you do not re-injure it in the first 3-6 months (to be conservative).
Muscle spasm, acute tendonitis, grade 1 muscle, tendon or ligament tear.
If you've come to the conclusion that it's likely a muscle spasm, or minor muscle strain / ligament sprain, start immediately with soft tissue release, foam rolling, and gentle stretching into the areas of tightness. Within the first 3-7 days, start to do some light and pain-free resistance exercises to the surrounding muscles (e.g. easy rotator cuff exercises with a theraband). By the end of week 2 you should have loosened up most of the muscle tightness around the shoulder, and should be starting to gradually increase load/exercise for the shoulder. If your discomfort and limited range of motion is not gone within the first 2 weeks, get it assessed and treated. These small nagging injuries have a way of accumulating over the years and may predispose you to a more severe problem in the future.
Have You Had Shoulder Pain For More Than 7 Days?
This becomes more complicated as we have to discern between a number of different potential concerns.
Acromioclavicular (AC) joint dysfunction - There are a few differed reasons that you may develop AC joint dysfunction.
First, and most simple, is a direct hit to your shoulder. You will remember this happening, so in this case, its not too complicated. You will likely experience pain and joint laxity when you press on the AC joint, and in severe cases you may experience a 'separated shoulder' that looks like this:
The good news about separated shoulders is that physiotherapy (as opposed to surgery) is often enough to help athletes and recreationalists return to their sports and daily activities pain free.
If you do not remember a direct trauma, the following may apply to you:
The AC joint is often the site of arthritis and come on from overuse or impact (most often seen in athletes (hockey, football, baseball, weight lifters, or overhead work). Pain and dysfunction from the AC joint often can cause impingement of the rotator cuff, and as such may present with muscle weakness, pain down the arm as far as the elbow, and a painful arc of motion. The symptoms that you experience during the arc of motion can help differentiate if it is just the joint that is irritable, or if there may be a rotator cuff impingement; If you have pain between 45-120 degrees abduction, but no pain before or after this range, then it is likely that you have an impingement of supraspinatus muscle (with or without an inflamed bursa). If you only have pain at the very top of this range of motion, it is likely that your AC joint is irritable.
Assessment-informed treatment is often the key if it is a chronic pain:
1) You may benefit from other tests that can be done by a physiotherapist to assess joint integrity.
2) An X-ray may be of benefit to ensure there is no bone spur or congenital abnormality of the acromion,
3) A diagnostic ultrasound may be helpful to discern whether the supraspinatus tendon or subacromial bursa are irritated.
Conservative treatment is the first-line treatment, as you will almost certainly have tightness and weakness of the surrounding shoulder musculature which may be causing secondary pain. A good assessment is usually needed to assess and treat the neck, thoracic spine, scapulothoracic rhythm, sternoclavicular joint mobility, scapulohumeral rhythm, and the AC joint. Most importantly, returning to a quality, pain-free exercise program will quicken the recovery.
Differentiating Reasons for a Stiff Shoulder Joint
One of the easiest ways to assess a stiff joint, is to look at passive range of motion, and try to assess the end-feel of the motion. If you are lacking 45 degrees of passive shoulder external rotation, and it feels like there is a capsular or joint restriction (hard end-feel), you likely fit into this category. Often, these cases require a medical approach to rule out other pathologies - be prepared to seek a referral to your family doctor or sports medicine physician for some imaging (to rule out sinister pathology or rule in arthritis), or blood work.
To assess passive shoulder external rotation, lay down on your back, and with you painful arm completely relaxed, use a broomstick or cane to gentle push the painful arm outwards (rotating the shoulder out). Keep your elbow relaxed and next to your ribcage. Remember... you are trying to assess the stiffness of the joint, so all muscles in the painful arm must remain relaxed!
If you have had a previous shoulder trauma, are 50+ years old or have a family history of arthritis, the most likely problem is that of glenohumeral osteoarthritis (could be from previous instability, or because of normal wear and tear associated with age).
Manual therapy that focuses on improving joint capsule mobility is often required to make progress. Various joint injections exist that may help with lubrication of the joint, or inflammation within the joint. At home, patients can start with rolling tight muscles on the back of the shoulder joint to loosen any tissues that may be restricting the joint mobility. Ultimately, most progress will be made with the help of physiotherapy or medical intervention.
Adhesive Capsulitis (Frozen Shoulder)
The most likely alternative reason for a stiff shoulder is adhesive capsulitis. The strongest risk factor for developing adhesive capsulitis is being a peri-menopausal female. Other risk factors include thyroid disorders, diabetes, cervical disc issues, post-op mastectomies, a recent fall/trauma, and having a previous frozen shoulder. The shoulder seems to stiffen and become painful without a usual cause, and keeps patients awake at night. We see patterns of limited external rotation, internal rotation and flexion.
If the diagnosis of adhesive capsulitis is reached, patients may find a cortisone injection helpful in the early stages. There has also been some clinical evidence showing that manipulation of the fibrotic joint under a nerve block may be of benefit.. Otherwise, regular physiotherapy that includes stretching, shockwave therapy, and manual therapy (soft tissue release, IMS, and joint mobilizations) will provide the greatest benefit.
Shoulder Pain with Limited Active Range of Motion but Without Joint Stiffness
If you do not have a stiff glenohumeral joint (more than 45 degrees passive external rotation), yet there is shoulder pain and limited active range of motion, a skilled practitioner will take you through a number of tests to help determine whether the pain is coming from a rotator cuff tear, labral tear or ligamentous tear (this is usually preceded by a dislocation / subluxation). The diagnosis of a tear must be ascertained by the clinic history, movement exam, special tests, response to treatment, and possibly ultrasound/MRI/other imaging.
For the purposes of this article I am going to avoid the discussion of which special tests may be useful for diagnosing tears; This is a contentious issue as most special tests are... not that special; they are not very specific toward testing just one tissue and often lead to false positives. This topic is beyond the scope of this article.
Shoulder Pain Without a Clear Pattern
Very few patients fit into this category, so if you think that you do, its likely that you've missed something during your self-assessment. Excluding this caveat, I write this last section for completion.
1. Referred Pain - A painful shoulder that has no pattern of painful movement may be experiencing referred symptoms from the neck, diaphragm or the heart.
2. Cancer/Metastases - A number of different viscera can create pain into the shoulder region. Most likely include the lung, liver, and gallbladder. Typically you will experience unrelenting pain (nothing can make the symptoms change), difficulty sleeping at night, excessive fatigue, weight loss, a fever, or any number of other changes in your normal health. See the following link for more information:
3. Pain Syndromes - Widespread hypersensitivity/hyperalgesia may also affect the shoulder. Various non-specific pain syndromes may create shoulder pain and include: Chronic Regional Pain Syndrome, Myofascial Pain Syndrome & Fibromyalgia.
A Final Note
In most cases of shoulder pain, an exercise program is the key component necessary to return to full function without pain. In cases of partial thicken tendon tears, full thickness tendon tears or subacromial impingement, a specific and progressive exercise program often provides improved function, reduced pain and reduced need of surgery when compared with a general exercise program (1, 2, 3).
My typical progression in the clinic is:
1) Determine if patient has any red flags that indicate immediate medical assessment / intervention.
2) Assess full body movement to determine how one area of the body may be affecting another.
3) Assess the shoulder for joint integrity, ligament and tendon damage, flexibility and strength.
4) Perform manual therapy, IMS and shockwave (if needed) to reduce pain and improve joint position/posture.
5) Provide patient with a specific, graduated exercise program.
6) Assess progress of the shoulder and repeat 2-6 as indicated until full function is .recovered, or a referral is indicated to see a sports medicine specialist.
(1) Björnsson Hallgren, H. C., Adolfsson, L. E., Johansson, K., Öberg, B., Peterson, A., & Holmgren, T. M. (2017). Specific exercises for subacromial pain: Good results maintained for 5 years. Acta Orthopaedica, 1-6.
(2) Holmgren, T., Hallgren, H. B., Öberg, B., Adolfsson, L., & Johansson, K. (2012). Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study. Bmj, 344, e787.
(3) Kukkonen, J., Joukainen, A., Lehtinen, J., Mattila, K. T., Tuominen, E. K. J., Kauko, T., & Äärimaa, V. (2014). Treatment of non-traumatic rotator cuff tears. Bone Joint J, 96(1), 75-81.
This blog post may seem light on medicine/rehab, but actually addresses what I feel is one of the most important things a rehab professional (or any professional) can do on a daily basis!
"We have two ears and one mouth so that we can listen twice as much as we speak." - Epictetus
It doesn't matter if you've heard this from a greek philosopher, fortune cookie, or from your mom! The advice is tried and true, featured in every good leadership book and used to great success during first dates, enjoying 50 years of marriage, impressing your boss, or watching the superbowl. Bottom line: If you are trying to achieve a goal, you must first learn the rules of the game and REALLY understand the people involved... and the best way to start the process is through attentive listening.
What Do You Listen For?
Although you may have a few specific questions that you are interested in asking, let the other person talk, and start with an open-ended conversation. Often this approach allows the patient to speak about tangents that will give you insight into their day to day life, athletic pursuits, readiness to change lifestyle habits, etc. If there are any questions that have been unanswered, pointedly ask them. This proves to the patient that you have been listening, they have been understood, and your goal is to help them.
Do Something Meaningful With It
Attentive listening is great, but you need become an important part of the conversation - be empathetic, provide insight to the topic, and ask purposeful questions. You then need to apply the information within your field. In my profession that means orthopaedic and neurological tests, referral for imaging or to specialists, treatment techniques, coaching exercise, and providing education/reassurance.
This entire process builds a therapeutic alliance between practitioner and patient.
Having a therapeutic alliance is so important that it has has been proposed to be fundamental(!) to the therapeutic process. A better alliance has been associated with improved treatment outcomes in patients receiving care from all health care practitioners (research is supported for physiotherapists, psychiatrists, physicians, and nurses). This means that without an alliance between the patient and practitioner, you should expect sub-par treatment results - and this is the same across all fields of medicine!
Supporting Research in Physiotherapy
1) A 2010 systematic review by Hall and colleauges (2010) found that patients with chronic lower back pain experienced better outcomes when practitioners applied sham pain modalities (interferential current) and actively created an alliance with their patients, than when real pain modalities were applied without attempting to create an alliance.
The lesson here is that active listening, empathy and encouragement can be more beneficial than using select pain modalities.
2) A 2016 systematic review by Lakke and Meerman (2016) found that the way a patient perceives their working alliance during treatment predicts pain reduction and improvement in physical functioning. They found a significant correlation in all five studies between working alliance and the outcome of pain severity, pain interference, and physical functioning.
The lesson here is that when influencing pain, a patient’s perceived working alliance during treatment predicts pain reduction and improvement in physical functioning. In patients with musculoskeletal pain, it is recommended to inquire about a patient’s therapeutic alliance with their health care team. The results of this conversation can create an opportunity to create a mutual plan to ensure that both patient and therapists fully understand desires and goals, or that a referral to another practitioner may be the most beneficial.
So... have a conversation with your patient! (Patients... have a conversation with your practitioner!). Learn from each other, teach each other, share a story...
This is key to building trust, good communication, enjoying the treatment process, better recovery, and having an enjoyable day!
Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., & Ferreira, M. L. (2010). The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy, 90(8), 1099.
Lakke, S. E., & Meerman, S. (2016). Does working alliance have an influence on pain and physical functioning in patients with chronic musculoskeletal pain; a systematic review. Journal of Compassionate Health Care, 3(1), 1.
Consistent Training Leads to Skilled Running
Most athletes will attest that consistency is the most important aspect in progressing fitness and skill through training. This is why injuries set you back from reaching your full potential, or at least reaching goals in a timely fashion.
While running, there are many things we can do to prevent injuries and some of them require very little time to implement, although learning the most effective way to implement them is individualized and may take years to achieve personal efficiency. Indeed, running is a skill, and it takes a long time to learn how to use your body in the most effective way.
With a good training plan you will improve your efficiency, which will reduce physical and mental fatigue, reduce injury risk, and ultimately improve your performance! If you are new to running, or are simply wanting to improve, try these movement tweaks the next time you head out the door. N.B . These tweaks are good guidelines, but if you have a preexisting dysfunction (remember a dysfunction may not present with pain or any other symptom), you may benefit from a personalized approach. If you fall into this group, book in for a running assessment or seek guidance from a running coach, or rehab professional with post-graduate training in running assessments.
It's Much More Than One Foot in Front of The Other
1) Upright posture.
At the start of your run, and periodically during your run, remind yourself to be tall. Think about elongating your entire spinal column; That is... if you had a string attached to the top of your head that connects down through the middle of your body, think about pulling that string up! You should not dramatically change your spinal curve with this, but you should feel that you are slightly taller.
Why? When done appropriately, this helps to engage your multifidus muscles (spinal stabilizers), and make you aware of your core. This will help prevent energy loss due to poor stability, and will better allow you to apply force through your hips - helping to propel you forwards. It also helps with diaphragmatic activation and reduces the amount of airway resistance during breathing. PS - it might be a good idea to start thinking about upright posture during the rest of your day, as we spend thousands of hours hunched over at work and at home each year, and BELIEVE IT OR NOT!, this affects our athletic performance!
2) Forward lean from the feet / ankles
"Lean forward from the ankles!"
Running should be efficient. Leaning forward from the ankles aids in this efficiency, because it moves your center of mass slightly forward, and allows you to fall into your next stride. Don't forget #1 - it is too easy to let your forward lean come from hinging at the hips - "Stay Tall", and keep your head up, as you need to be looking forward!
3) Posterior-chain propulsion
"Push, don't pull!"
If we lean forward from the ankles, we will fall forward and must flex our hip joint and extend our knee to "catch" us from falling on our face. We can use this forward energy most effectively by pushing ourselves forward, as soon as our foot hits the ground. Try to see if you can feel yourself pushing forward using your glutes, hamstrings and calves.
4) Shortened stride and increased cadence
"Shorten your stride and increase your cadence!"
"Imagine that you are a ball, and as you are rolling over the ground, you are attempting to touch as many different places on the ground as possible"
Most research suggests that elite runners who stay injury-free run with a cadence between 160-190 BPM. In most runners this improves multiple metrics (decreased "breaking phase", decreased vertical oscillation, decreased need for force absorption), and ultimately it decreases the amount of wear and tear / abuse placed on joints and muscles. In addition, it is said to improve efficiency in the long-term after the athlete adjusts to running in this way.
The best place for our foot to land is directly under our center of mass because it minimizes the "breaking phase". The breaking phase is best described as wasted energy in the time between the foot striking the ground, and the push off phase when we propel ourself forwards. To ensure that we land with a vertical tibia - it is crucial to having a high cadence and a shortened stride.
5) Land with your foot under your center of mass
"Most often, you should land using a midfoot strike"
The jury is still out on what the best type of foot strike looks like in endurance athletes, but here is what we do know:
A) A midfoot strike is mostly likely to place the foot under your center of mass while running on flat ground.
B) Landing with a forefoot strike lends to a 2.6 times decrease in injury risk compared to rearfoot strikers (1).
C) Landing on the forefoot or midfoot places more stress on the foot musculature and Achilles tendon. Landing on the rearfoot places more compressive loading forces at the tibiofemoral and patellofemoral joints of the knee.
C) Rearfoot strikers tend to land with their foot in front of the body, which leads to have a longer stride and greater vertical loading (increased forces applied to the body) (2).
D) Wearing shoes with larger heels lends to heel striking, whereas taking shoes off leads to landing on the forefoot or midfoot, with the strike being closer to the body.
As always, we are reminded that science has limitations and common sense prevails, therefore do what feels right... BUT my recommendation would be to run on variable terrain, AND:
A) As you run uphill, strike with your forefoot or midfoot.
B) As you run the flats, strike mostly with your midfoot.
C) As you run downhill, midfoot or heel strike may be best.
These are but a few ways to immediately change your running form, in an effort to improve efficiency and promote injury-free training. General recommendations are terrible because they assume that all people are alike, so make no mistake - it is probably best to have a running assessment done to determine whether you truly need to change your running form. Nevertheless, exposing yourself to learn different styles of running will grow your running skill-sets and your body's durability, ultimately making you a better athlete!
1) Daoud, Adam I., et al. "Foot strike and injury rates in endurance runners: a retrospective study." Med Sci Sports Exerc 44.7 (2012): 1325-34.
2) Williams III, Dorsey S., Irene S. McClay, and Kurt T. Manal. "Lower extremity mechanics in runners with a converted forefoot strike pattern." Journal of Applied Biomechanics 16.2 (2000): 210-218.
I've had several clients ask what the initials stand for after my name. This is a great question as it can be difficult for clients, and clinicians across Canada and the rest of the world to stay informed on the latest and/or greatest in qualifications and designations.
Although more initials following a physiotherapists' name may mean that they have completed more training, some qualifications require more intensive training, may be more widely accepted as an industry standard, or may be more relevant to patient needs.
This article should serve to provide you with a basic level of knowledge, and will give you additional resources if you wish to do further reading! This article will not, however, provide you with a background on all available credentials, as there are dozens of courses that provide continuing education and do not have acronyms that can be used after a clinicians name.
Rules & Regulations enforced by College of Physiotherapists
1) Only Registered Physiotherapists are allowed to use the initials of PT or RPT. In the most simple signature, a physiotherapist may use these initials after their name (E.g. Jacob Carter, PT).
2) Typically the first 1-3 sets of letters seen after a Physiotherapist's name will be their university qualifications.
BPT (Bachelor of Physiotherapy)
BScPT (Bachelor of Science in Physiotherapy)
MPT (Master of Physiotherapy)
MScPT (Master of Science in Physiotherapy)
DPT (Doctor of Physiotherapy)
tDPT (Transitional Doctor of Physiotherapy)
All physiotherapists will hold a Bachelor Degree. Prior to 2012, Physiotherapists were only required to obtain a Bachelor Degree of Physiotherapy.
As of 2012, the minimum required competency to enter the profession is now a Masters degree. For example, I was required to complete a four year Bachelors degree in a health science field prior to two full years of intensive studying during my Masters degree. The previous system did not require the more liberal/background education - instead the four year Bachelor of Physiotherapy degree focused on a specific and applicable curriculum.
As of 2020, the United States requires all physiotherapists to hold a Doctor of Physical Therapy. This is pushing the industry standards higher, and I believe that you will gradually see more Physiotherapists in Canada that hold this level of education. Perhaps one day, you will see that Physiotherapists in Canada are required to hold this level of education as well.
College of Physiotherapists of Ontario
Manual Therapy Designations
1) FCAMT (Federation of Canadian Academy of Manipulative Therapists) / FCAMPT (Federation of Canadian Academy of Manipulative Physiotherapists)
This has been an industry standard for the last few decades. To become certified is a rigorous process as it is internationally standardized and tested by world leaders in Physiotherapy. The program teaches extensive theory and application techniques as related to functional anatomy, human movement, and manual therapy. Its most common criticism is that there is too much of an emphasis on theory, the theory taught is outdated, and excessive classroom time is spent re-teaching previously learned concepts. While I partially agree with this criticism, I would rather too much theory than too little when it comes to safely performing potentially dangerous techniques such as spinal manipulation.
Physiotherapists can obtain this credential via two avenues: Option one takes 5 or more years to complete and requires taking seven courses (approx 64 days in classroom with 7 exams), passing an intermediate practical exam, passing a final practical and written exam, and accumulating 150 hours hours of mentorship and peer study. Option two is outlined next (Master of Clinical Science).
Canadian Academy of Manipulative Physiotherapy
Orthopaedic Division of The Canadian Physiotherapy Association
Orthopaedic Division Education
2) MClSc (Master of Clinical Science)
Although there are many universities in the world that offer this degree, Canadian Physiotherapists most likely to have taken the part-time, 12 month program taught at Western University in London, Ontario. The program is comprised of course work and clinical mentorship that focuses on neuromuscular dysfunction in which graduates learn spinal manipulation and participate in a research project. Graduates are eligible to apply for the FCAMPT credentials.
University of Western Ontario MClSc Program
3) CMT (Certification in Spinal Manipulation), Cert. MT (Advanced Certification in Manual Therapy), Dip. MT (Advanced Diploma in Manual Therapy), DMPT (Doctor of Manual Physical Therapy).
The Swodeam Institute was created by Jim Meadows, who has been called one of the top manual therapists in the world. The Swodeam Institute has been offering courses in one form or another since 1985 (including teaching and examining for FCAMPT), but in the last decade has taken his courses to the mainstream audience in Canada and USA. He offers a series of courses that build on knowledge learned in university, and in his course series.
To achieve the Dip. MT, students spend 24 days in the classroom but spend extensive time participating in self-directed learning via online and distributed material. The course vision is that self-motivated students will be able to learn as much (or more) compared to the FCAMT certification process, but in less time.
4) COMT (Certificate in Orthopaedic Manual Therapy)
A 4 week intensive certification offered by 'Manual Concepts' in Perth, Australia that covers spinal and peripheral manipulation (amongst many other techniques). The course offers students learning opportunities from numerous world leading expert clinicians, researchers and teachers. The competition of this course may lead to an accelerated completion of the Masters in Clinical Science (Manipulative Therapy stream) at Curtin University of Technology.
1) GunnIMS (Gunn Intramuscular Stimulation) or CGIMS (Certified Gunn Intramuscular Stimulation)
IMS was conceptualized, researched and popularized by Dr. Chan Gunn out of the University of British Columbia in Vancouver, BC. The technique treats neuromuscular pain, and focuses on treating pain centrally (from the source of the nerve at the spinal column) and peripherally (at the source of pain).
Physiotherapists that have been practicing for 4+ years, and have completed a certain level of post-graduate training can register with the iSTOP Institute to study GunnIMS. The course consists of 7 days classroom instruction and practice, written and practical exams, and independent study.
2) FDN (Functional Dry Needling)
Kinetacore was founded in 2007 by Edo Zylstra, a clinician, researcher and instructor. Edo based his course development on his previous GunnIMS training at iSTOP, and numerous other philosophies of Trigger Points and Dry Needling. The technique treats neuromuscular pain with the purpose of improving function immediately after treatment. Treatment is similar to GunnIMS and focuses on treating pain centrally (from the source of the nerve at the spinal column) and peripherally (at the source of pain).
To obtain this credential you must take Level 1 and Level 2. Physiotherapists that have been practicing for one year can enrol in Level 1. Enrolling in Level 2 requires a full year of applying Level 1 techniques and records of 200 treatment sessions. Both Level 1 & 2 requires two days of classroom instruction and practice, a written exam, practical exam, and independent study.
3) CAFCI (Certified by Acupuncture Foundation of Canada Institute)
Acupuncture is an ancient, safe alternative form of medicine. From a western-medical perspective, the needles stimulate the release of endorphins (the body’s natural pain-relieving neurohormones) by inserting needles into specific anatomical points to encourage natural healing. The Acupuncture Foundation of Canada Institute offers acupuncture training & certification to medical practitioners.
The completion of their required four courses (including onsite and online components) and exams awards the therapist the letters CAFCI. This course amounts to 200 hours of training, and can be completed in as little time as one year, or at the therapist's desired pace.
4) TCM (Traditional Chinese Medicine)
There are many different programs available across Canada to receive this designation. There are some physiotherapists that have obtained this credential. If a Physiotherapist wishes to practice TCM, they often need to book the patient in for a different appointment, as many TCM practices are not recognized by the Physiotherapy College.
Traditional Chinese Medicine is not regulated nationwide in Canada, however there are currently five provinces with a mandate to protect the public’s right to safe, competent and ethical services offered by registered TCM Practitioners, TCM Acupuncturists, and/or TCM Herbalists who are members of the regulatory bodies.
TCM graduates require 3-5 years of study, and variable amounts of mentorship/study within Canada and Internationally. To be eligible to write the TCM final exams in Canada, students require 3,250 hours of course work and supervised practice/mentorship.
Other variations of qualifications include:
Registered Acupuncturist (R.Ac.) – 3 year program
Registered Traditional Chinese Medicine Practitioner (R.TCM.P) – combined acupuncture and herbology with restrictions - 4 year program
Doctor of TCM (Dr.TCM) – combined acupuncture and herbology without restrictions – 5 year program
The Chinese Medicine and Acupuncture Association of Canada
Soft Tissue Designations
1) ART (Active Release Technique)
Dr. Michael Leahy (Chiropractor) started teaching ART over 30 years ago. The premise of the technique is simple - shorten the tissue, apply directional tension with your hand or elbow, and lengthen the tissue or make it slide relative to the adjacent tissue. I believe this is a valuable technique that has been marketed well. In my opinion, ART teaches techniques that can be learned via other means, and for cheaper prices.
Clinicians may use the ART credential after their name if they take an ART course every 12 months. Clinicans also have the option to become Full Body Certified, which requires taking three courses: Upper Extremity, Lower Extremity, and Spine. Courses are not offered in Canada very often, and cost a great deal of money!
Active Release Technique
2) GT (Graston Technique)
Graston is a form of instrument assisted soft tissue mobilization (IASTM) that serves to address fascial restrictions and scar tissue. The system teaches specific techniques and sells instruments to perform the techniques. It is likely the most well known (or well marketed) system of IASTM in the world, as they were pioneers in the technique. In my opinion, Graston teaches many techniques that can be learned via other means, and for cheaper prices. Since IASTM is not a controlled act, any physiotherapy can perform it and call it IASTM instead of Graston.
Clinicians may use the initials "GT" after their name after taking the Level 2 course (also known as M2). To do so, they must have completed Level 1 (also known as M1) of Graston, and have purchased Graston tools. Level 1 takes 12 hours of training. Level 2 requires clinicians to attend an additional 14 hour course.
Functional Movement Designations
1) FMS (Functional Movement Screen)
The FMS was developed by Gray Cook as a screening tool for fitness trainers to use in identifying limitations and asymmetries in clients without pain or known musculoskeletal dysfunction. The test is designed to have clients move in certain ways where weaknesses and imbalances become noticeable if appropriate mobility and motor control is not utilized.
Any fitness or healthcare professional can become FMS certified. The Level 1 certification process requires an online course or an onsite course. To use the credential after your name, you must complete Level 2, which requires attending an onsite course. Level 2 covers additional information on the screen learned in Level 1, and focuses on improving movement patterns using corrective exercises. Most onsite courses are offered in the USA - it seems that they instruct in Canada only 1-2 times a year.
Functional Movement Screen
2) SFMA (Selective Functional Movement Assessment)
The SFMA was also developed by Gray Cook. The SFMA is meant as a tool for medical/rehab professionals to diagnose movement dysfunction, and efficiently discern the root cause for symptoms. The SFMA is meant to be used for clients who have pain with movement, or who have musculoskeletal dysfunction. The approach teaches that dysfunction is either a joint stability, tissue extensibility or motor control problem. The systematic process uses concepts of altered motor control, the neurodevelopmental perspective, and regional interdependence to direct assessment and treatment.
A physiotherapist who lists this credential after their name must complete an online seminar, and a 2 day onsite course (with exams). To improve levels of understanding, clinicians can take Level 2 and Level 3. Most onsite courses are offered in the USA - it seems that they instruct in Canada only 1-2 times a year.
Selective Functional Movement Assessment
1) CHT (Certified Hand Therapist)
Certified Hand Therapists are known for their skill in diagnosing and treating upper extremity (shoulder to hand) dysfunction. They are credentialed through the Hand Therapy Certification Commission (HTCC).
Clinicians may use the CHT credential after their name if they pass the Hand Therapy Certification Examination (four hour examination consisting of 200 multiple choice). As of May 2017, Physiotherapists and Occupational Therapists will be eligible to apply for the examination if they have been registered for three years (previously, five years was the minimum). In addition, candidates must have 4000 hours of "hands on" (haha) practice.
Hand Therapy Certification Commission
2) Certified Pelvic Health Physiotherapist
There are many organizations that teach Pelvic Health / Women's Health / Men's Health courses in Canada and the USA. These courses focus on theory and internal manual therapy techniques.
There are varying regulations across Canada, depending on the province. For example, in Ontario you must be approved by the College of Physiotherapists and placed on the specialized roster to provide "internal assessment or internal rehabilitation of pelvic musculature". However, in Alberta, this is not the case. Furthermore, in Alberta there does not appear to be any regulation in place on what courses a physiotherapist must complete to call themselves a Certified Pelvic Health Physiotherapist in Alberta. There are many clinicians that will use this title who have taken a singular course, and conversely, there are many clinicans that may use this title if they have taken multiple courses - Therefore... buyer beware (or at least do your homework!).
One of the best well known instructional institutions in Canada is Pelvic Health Solutions
College of Physiotherapist of Ontario
Physiotherapy Alberta - Note that Pelvic Rehabilitation is not listed as a restricted activity
Falling Short of a Full Recovery: Part 2
There is a growing body of evidence that demonstrates the effectiveness of physiotherapy. The profession has seen growth that can be largely attributed to ongoing research, higher level of training, expansion of restricted activities (e.g. use of acupuncture needles, performing spinal manipulation, prescribing diagnostic imaging, endotracheal suctioning, etc.), inter-professional collaboration, and the many leaders that advocate for the profession and push it to higher levels. Despite this, in day-to-day practice, we hear from patients that their pain has not improved or that physiotherapy does not work. Why?
Let's start by noting that poor adherence is not exclusive to Physiotherapy; It has been identified in many healthcare disciplines, including physiotherapy (Jack, McLean, Moffett & Gardiner, 2010, Martin et al., 2015). Ultimately adherence to treatment has implications on effectiveness, patient wellbeing, and the overall cost of treating the dysfunction in the long term (e.g. costs may bleed into primary healthcare and/or the treatment of other co-morbid conditions). Although there is no accurate data on the number of patients that fail physiotherapy in Canada, individual clinicians and clinics in which I have worked have seen non-adherence rates in the range of 5 to 25%. The validated research that does exist is outdated, is not exclusive to training in Canada, and does not subdivide adherence based on education/credentials, skill-sets employed in treatment, years of experience, etc. Studies indicate widely different non-adherence rates in physiotherapy; Two older studies found that between 14% (Vasey, 1990) and 70% (Sluijs, Kok, Van Der Zee., 1993) of physiotherapy patients did not adhere to the recommended treatment or number of follow-up appointments.
The best quality research available on this topic was published in 2010. The authors completed a literature review of 20 studies (that varied in patient demographics, practitioner demographics, assessment of dysfunction, treatment of dysfunction, and every other variable you can think of...) and found that the majority of available research has focused on factors that were in the patient's control. They concluded that "There was strong evidence that poor treatment adherence was associated with low levels of physical activity at baseline or in previous weeks, low in-treatment adherence with exercise, low self-efficacy, depression, anxiety, helplessness, poor social support/activity, greater perceived number of barriers to exercise and increased pain levels during exercise" (Jack, McLean, Moffett & Gardiner, 2010). It is clear that more research is needed on barriers introduced by health professionals and health organizations.
Barriers to Success
Clinician understands patient goals: Ask the patient about the circumstances surrounding their injury: Do they need to return to full health for a specific competition or a specific date? Is the patient training for a specific task? What is their required level of function in sport or daily function? Has the patient created a SMART goal? (SMART stands for Specific, Measurable, Attainable, Realistic and Timely).
Patient readiness to change: The very motivated patients will likely stand out, but some patients are a bit harder to read. As a result we need to discern their level of motivation, as this directly correlates to their level of commitment in receiving treatment, and to their home exercise program. (E.g. Did they come to physiotherapy because they were told they should by their parents, spouse, coach?)
Adequate timeline for rehabilitation: Does the patient have enough time to adequately treat their dysfunction (e.g. A sports competition in 2 weeks may impair the ability for full recovery).
Correct pathoanatomical diagnosis of dysfunction: Clinicians should arrive at a precise and accurate diagnosis.
Correct diagnosis of related impairments: If the patient has a complex history, the clinician may need to revisit previous injuries to determine stage of healing and any impairments that affect regional interdependence.
Treating the dysfunction in the most effective manner: Comprehensive literature reviews indicate that the most effective combination treatment modalities includes exercise, manual therapy (soft tissue release, joint mobilization and manipulation), IMS/dry needling, and pain education. There is evolving evidence that supports shockwave therapy and laser therapy. The evidence found in Western Medical Research is weak (or moderate at best) for the use of ultrasound, TENS, IFC, NMES, and acupuncture.
Implications of past medical history, lifestyle choices: Patients may not heal as well or as quickly if they have other co-morbid conditions or impairments, regularly use or abuse drugs/alcohol, do not sleep well, do not eat well, or live in a stressful environment. Alternatively, patients can expect faster resolution if they have a clean bill of health, active lifestyle, healthy diet, sleep well, are proactive, and experience a healthy level of stress in their life.
Clinician provides proper education to patient: What is Physiotherapy? What can I expect during the assessment? Why am I having pain? What is 'pain'? Do I have any derangement (actual tissue damage)? What is my prognosis (can I expect a full recovery and how long will it take)? What can I expect during a given treatment? Do I need to do anything at home/in the gym to make a full recovery? How much time do I need to dedicate to this?
Clinician motivates patient: Some patients need a little extra help to overcome their injury as they struggle with depression, anxiety, helplessness, poor social supports, or barriers as related to exercise or pain. Getting to know your patients, checking in, and making yourself easy to access (e.g. providing patients with you email address) can make a world of difference.
Commitment of time and resources: Some patients can only afford the initial assessment, whereas others happily follow their clinician’s recommendations. It is difficult to discuss finances with a patient, but this information is crucial to developing a proper treatment plan. To indirectly address this variable, I recommend a certain number of treatments based on the assessment findings and the patient's goals. Ultimately this gives control back to the patient, as they are now equipped with the knowledge of their diagnosis and optimal treatment plan. The result is that the patient can make an informed decision on treatment frequency, affordability and their perceived value of the treatment. Lastly, if there are insurance programs that exist and may assist patients in paying for treatment, I will recommend that the patient research potential options.
Patient understands clinician: Sometimes medical professionals speak using a lot of medical language (jargon) that is not understood by all patients. Clinicians must allow open communication and have ample time to answer their patients questions. If you are a clinician that runs out of time during an assessment for effective communication, your clients may appreciate if you open additional avenues of communication (E.g. email).
Patient is satisfied with lack of pain, but understands they have not fully recovered: If a patient provides me with this explanation, it may be because I have not provided proper education or assessed their function. Alternatively, there may be other variables at play, which means that I need to allocate additional time to chat with the patient and determine underlying reasons. Otherwise, I am happy to accept their informed decision and encourage the patient to follow-up if they have any questions or concerns.
In theory, providing an evidence-based, individualized treatment should lead to the best clinical results. In practicality, there are many other variables that clinicians may need to address to treat the patient as a person and achieve real and lasting results. It can be challenging as a clinician to be aware of all of these variables, all of the time. As a result, the clinician and client must create a partnership where open communication absolves barriers and leads to amazing outcomes!
Martin, L. R., Williams, S. L., Haskard, K. B., & DiMatteo, M. R. (2005). The challenge of patient adherence. Ther Clin Risk Manag, 1(3), 189-199.
Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual therapy, 15(3), 220-228.
Sluijs, E. M., Kok, G. J., & van der Zee, J. (1993). Correlates of exercise compliance in physical therapy. Physical therapy, 73(11), 771-782.
Vasey, L. M. (1990). DNAs and DNCTs—Why do patients fail to begin or to complete a course of physiotherapy treatment?. Physiotherapy, 76(9), 575-578.
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Jacob Carter lives and works in Canmore, Alberta. He combines research evidence with clinical expertise to educate other healthcare professionals, athletes, and the general public on a variety of health topics.