Clinical Conversations

LOW BACK PAIN—What you should do while waiting for your first physical therapy appointment

LOW BACK PAIN—What you should do while waiting for your first physical therapy appointment…

SITTING:

Sitting Posture Important Low Back PainSit as little as possible.  Standing or lying down are preferable to sitting when in acute low back pain.  If you must sit, sit only in a straight backed chair with good posture.  Avoid couches or soft chairs.  Use a towel roll to support the natural curve of your spine.

BENDING:

Do not bend forwards as in touching your toes when in acute low back pain—even if it feels like you are doing good by  “stretching” the muscles of the low back.  Rather than reaching down to get things, squat down using the legs and keep the back absolutely straight.

LYING:

Try to lie more on your stomach rather than on your back.  Avoid the temptation to lie on your back with the head and knees propped up—this just rounds the back more and places inappropriate stress on injured structures.

Low Back Pain lie on your stomach not your back

EXERCISES:

You should stay normally active–in other words try not to stay in bed for long periods.  Move around, take walk if you can.  Do not do the knees to chest exercise you may have learned before.  This is an advanced exercise and usually not appropriate for acute conditions.  It is better in most cases to lie on your stomach and work towards supporting yourself on the elbows.

 Low Back Pain Don't do Knees To Chest Exercises  Low Back Pain Exercise On Stomach Elbow Support
NO! YES!
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Low back and bilateral leg pain: Our Clinical Case of the Week

BACKGROUND:

Up to 80% of the population will experience low back pain (LBP) at some point in their adult life (Croft et al 1997).  It is estimated that health care costs for low back pain are larger than for any other disease for which economic analysis is available (Maniadakis and Gray 2000) ($31 billion/year).  There is little to no evidence supporting the use of traction, thermal modalities, or electrical stimulation for the treatment of LBP. Unfortunately, these strategies are commonly used for the bulk of LBP treatment.   Many studies conclude that the McKenzie method of evaluation and treatment for LBP is superior to that of standard treatment (general stretching and strengthening).  What makes the McKenzie approach different is its classification system. Based off of symptom response to repeated lumbar spine movements, patients are classified into 1 of 3 syndromes (derangement, dysfunction, postural).  After patients have been classified, their individualized treatment plan is created. The McKenzie method also emphasizes self-treatment and long term symptom management.  I consider this the most valued aspect of treatment, as statistics show LBP is recurring in nature. Let’s review a case of a patient with a very successful outcome utilizing the McKenzie method.

SYMPTOMS:

Patient presented to therapy 2 weeks after the onset of LBP with bilateral leg pain.  Patient described sharp pain which radiated down to the left foot and down to the right shin. Symptoms started after a weekend of working (auto mechanic) which involved repetitive bending and lifting of heavy equipment. Patient rated worst pain as an 11/10 for the back and a 10/10 for the left leg, occurring on a daily basis.  Patient was severely limited with walking, sitting and sleep.

THERAPIST’S EVALUATION AND FINDINGS:

Patient demonstrated pain with all lumbar spine motions in standing.  There was no neurological (strength, sensory, reflex, neural tension) deficit.  This is important to test when there is a presence of leg pain.

Baseline symptoms= LBP + left foot tingling.  Patient was asked to bend forward 10 times, touching his toes.  This resulted in increased low back pain, no effect on foot tingling.  Bending backwards 10 times also increased LBP with no effect on foot tingling.  Patient was then asked to lie on his stomach and perform prone press ups (a back bend using arms to push up into extension). This exercise abolished left foot symptoms, better leaving the clinic that day.

PATIENT HOMEWORK AND OUTCOMES:

Patient was given prone press-ups to be done every hour until his follow up appointment.  The next day, the patient returned to the clinic happily reporting that he had not experienced leg pain in over 24 hours!  The patient was even able to perform tasks associated with moving into his new home that weekend.  In 2 weeks his back pain rating had decreased to a 3/10 and he was experiencing little to no leg symptoms!  Patient continued therapy over the next few months with exercise progressions and modifications as needed.  At discharge, patient was able to perform his duties as an auto mechanic and continue his training as a member of the National Guard.

HAVE A MECHANICAL EVALUATION FOR YOUR LOW BACK PAIN:

Do not fall victim to chronic low back pain.  This is associated with huge healthcare costs, over utilization of medication and surgery. All of which would otherwise be avoided with a simple exercise, requiring no special equipment.   The patient from this week’s case left the clinic feeling very empowered by his own ability to treat his symptoms and was no longer considering having major spine surgery.

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Pseudo Tennis Elbow: A Commonly Misdiagnosed Mechanical Problem

Test-for-painful-grip,-wrist-and-elbow-extendedLateral epicondylitis, more commonly known as “tennis elbow,” is a pathology that is familiar to physical therapists and the general public.  What is lesser known is “pseudo tennis elbow,” a mechanical problem with a very simple solution!  Unfortunately, therapists whom are not familiar with the utilization of mechanical diagnosis may unknowingly miss this common elbow derangement.  As a therapist practicing the McKenzie method of mechanical diagnosis, I have diagnosed BOTH of my current elbow pain patients as derangements (or pseudo tennis elbow).

Symptoms

Our patient, “Jane” presented to therapy with intermittent right elbow pain, worsening over the last 3 months. Jane reported difficulty with gripping, lifting, carrying and global limited function of the right arm.  Jane described symptoms as “variable” meaning she could perform a task that produced his elbow pain. Then, perform the same task or movement again without experiencing any pain at all!  This variability of pain is the hallmark of a derangement and should not be misdiagnosed as a tendonitis, which would indicate inflammation (in which case pain would be constant).  Jane rated worst elbow pain as a 6/10.

Physical Therapist Evaluation & Findings

Objective findings included pain with passive elbow flexion and extension as well as pain with active wrist extension and with gripping a tennis ball.  Because of my experience as a mechanical therapist, I am familiar with a technique called a mobilization with movement (MWM), developed by Brian Mulligan (a colleague of Robin McKenzie).  The mobilization provides a lateral force over the ulna at the elbow joint. While the patient applied this force, she was able to grip the tennis ball PAIN FREE!  This same technique was applied for other painful baselines and achieved the same results of ABOLITION OF ALL PAIN!  This ability to turn symptoms off with a mobilization indicates an elbow derangement and the MWM is used as the treatment strategy.

Patient Homework and Outcomes

Jane was asked to perform the MWM utilizing the lateral glide while gripping a tennis ball to be performed 10-20 times every hour.  The theory is that this mobilization is repositioning the joint in order for it to articulate correctly, resulting in improved range of motion and strength after.  Jane returned to the clinic the next day with reports of at least 25% improvement! Objective findings were retested and nearly all baselines had improved in less than 24 hours!  Jane returned 1 week later and reported an 85% overall improvement with symptoms.

Get Your Own Mechanical Assessment

Don’t be misdiagnosed! Straightforward pathologies which require one exercise to treat are commonly missed with standard treatment.  This results in extra therapy visits, and more of your time and money.  It is worth your time to see if your pain has a MECHANICAL component.  A simple solution may otherwise be missed.

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Tough Chronic Hip Pain – Problem Found and Fixed

Image of Back and Hip Nick Rinard PTThe case study I would like to share with you today is only the second hip derangement of this type that I have seen in 18 years of practice.  “Jim” was a 55 year old male who presented with right hip pain that started for no apparent reason 5-6 months prior to coming to physical therapy.  He said the pain was provoked only when he was walking, but it occurred consistently at a distance of about 50 to 100 yards.  Often it was so painful he could not continue walking.  Jim figured out that changing his right foot position enabled him to walk a little further, albeit slowly, and then he could resume normal walking for another 50 yards or so.  He would change the foot position by stepping partway onto a curb or raised ground such that the outer edge of his foot was tilted up (eversion, as we therapists call it), and then he would angle his right knee inwardly.  That was the only way he had found to improve walking, but the hip just would not stay better.

In desperation, Jim said he had looked online and tried numerous “hip exercises” without any relief.  He consulted his doctor, who recommended MDT, which we do here at Nick Rinard Physical Therapy.

Assessment

The mechanical assessment was positive for only two findings:  limited and painful hip motion into flexion (folding the knee to chest), and weak and painful testing of hamstring resistance.  The protocol for ruling out a joint derangement is to repeat motions to determine if the baselines change.  The question is which motion to repeat.  One can move either into the most painful direction, go the opposite direction, or check rotations.  I chose to go into the most painful direction, in this case, flexion.  But before testing I wanted to establish how far Jim could walk in the clinic before his pain started.  By the time he walked one length of the hallway and back, he reported pain.  I then instructed Jim to bend his knee to chest (compressing the groin) repeatedly and after 20 to 30 times.  It produced his familiar pain initially, then the pain abolished and his motion increased.  I tested walking after that and Jim said there was no pain even after walking 3 lengths up and back through the hallway!  I gave Jim his exercises and scheduled him for 2 days later.

Progress

When Jim returned he reported that he could walk longer distances without the pain starting, however, he still got to the point where he had to modify his foot position in order to continue.  I knew we were on the right track, and the next step in treating a joint derangement is to progress forces.  I did this manually by applying over-pressure, and instructed Jim to do it in standing by folding his chest down to his knee with it supported on a bench or chair.  By the next visit, Jim reported that this had worked very well and he had not experienced any pain at all!  So, the derangement was reduced and I needed to wean him off the home exercises to see if it would return or not.  I gave him the weaning program and asked to see him back in 2 weeks.

Pain Free

After 2 weeks, Jim came back reporting that he had been able to walk unlimited distances!  He resumed walking his dog, going on walks for exercise, and walking wherever, and whenever he wanted.  He reported his longest walk lasted 4.5 hours.  He said there was no return of the original hip pain from which he had suffered for months.  However, on his last two walks, he had started noticing a new hip pain, this time in the front, not on the sides.  I re-checked his baselines and neither flexion motion nor resisted hamstrings were painful.  That meant it could not be a re-derangement.  Resisted hip flexion was painful, and that was new.  I concluded that his sudden ability to walk pain-free resulted in his over-doing it.  Jim had increased walking too fast and gotten a minor tendonitis.  That was easy to treat, and by his next visit, Jim was pain-free again and able to progress walking, though this time more gradually, which was safer.

Successful Treatment

Jim’s hip treatment was obviously a success.  It took only 4 visits.  This hip derangement was unique because the direction that reduced it (flexion); I have only seen one other hip derangement require flexion to reduce it.  The fact that Jim resumed normal activity too fast is typical of reduced derangements – the patient feels so good that they over do it.  Luckily in Jim’s case, we found the new problem and fixed it just as fast as we found and fixed his chronic hip pain.

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Can TMJ Pain and Dysfunction be Purely Mechanical?

TMJ pain can be a real problem for its victims, limiting their ability to chew and talk, and interrupting sleep. Often, headaches even limit the person’s ability to concentrate! Various treatments have been proposed to alleviate the symptoms of TMJ (Temporomandibular Joint) pain, many of which are very complex and even invasive. Looking at the TMJ as “just another joint” and not predetermining that it has to be complicated has been very freeing for me in using a mechanical approach. Let me explain using a patient example from this week in clinic.

My approach is modeled after the McKenzie Method of Mechanical Diagnosis and Therapy, although very little about TMJ specifically has been written or published about it. (1)

Symptoms and Experience

Now, about the patient. (Name and other identifying information has been omitted to protect privacy). This patient complained of intermittent left jaw pain with wide opening of the mouth. He stated it only occurred then, and otherwise it really was not painful. However, chewing tough foods, he admitted, was sometimes painful. His worst pain occurred with rapid opening of the mouth and could be as intense as 6 on a scale of 1-10.

Therapist’s Evaluation and Findings

Objective findings were limited and painful opening with slight left deviation, limited and painful protrusion, limited and painful right deviation, and no pain or limitation with retraction, or left deviation. Repeated tests performed actively by the patient of protrusion first, then of right deviation resulted in producing the patient’s symptoms, no worse after, but also no change in baseline ROM or pain. Forces were progressed to patient applied over-pressure to right deviation. The patient reported that this produced his pain initially, then decreased pain as he performed more repetitions. Subsequently, he reported wider opening with less pain!

Patient Homework

Home exercises were assigned, which naturally consisted of patient applied over-pressure into repeated right deviation every hour or two as per typical McKenzie protocol. On the second clinic visit two days later, the patient stated he was already 50% improved! This finding confirmed the mechanical diagnosis of derangement syndrome. In this classification, there is a good prognosis for rapid and lasting recovery from the problem.

Get Yourself Evaluated

This is only one clinical example of a purely mechanical TMJ problem. While there are examples of TMJ issues that are not derangements, or even mechanical, often a mechanical cause of the pain can be found and the patient helped by mechanical therapy. It is well worth a thorough examination to determine if your TMJ pain has a mechanical component, and to get appropriate treatment which would otherwise be missed.

(1) http://www.sciencedirect.com/science/article/pii/S1356689X1100230X

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Side Glides on the Wall – Rapid Recovery of Ipsilateral Shift

This week I will tell you about the rapid recovery of an ipsilateral shift.  An ipsilateral shift was described by Robin McKenzie of the McKenzie Method®, and the treatment of this patient of the week follows Mechanical Diagnosis and Therapy® principles exactly as I was taught them.   The patient presents with a lateral shift deformity of the trunk shifted away from the side of dominant pain.

Gerry, (not his real name), arrived with his wife to clinic after suffering 10/10 pain in his back, buttock, and thigh, and had a severe ipsilateral shift.  This had been present for 2 weeks, and Gerry stated it had recently worsened after a massage session.  Gerry could not recall any incident that caused injury or otherwise caused the onset of pain.  He stated he had tried standard chiropractic treatment with no effect.

While I was taking Gerry’s history, his wife reported that he had to crawl to get around their home for the first hour after getting out of bed.  Even at his best, he could barely make it down the hall to my office.  He was completely unable to dress himself, drive or go to work.

The shift made the mechanical diagnosis easy.  It was most likely a mechanical derangement.  Any attempt Garry made to bend forward or backward resulted in severe pain, and nearly no range of motion.  Trying to correct the shift himself, even when leaning against the wall for support, also resulted in severe pain and no gain in range of motion.

Therefore, manual forces had to be applied by the MDT therapist – in this case – me! (I have achieved certification in Mechanical Diagnosis and Therapy® by the McKenzie® Institute, designated by “Cert. MDT”).

Manual shift correction is described in various published works by Robin Anthony McKenzie, the originator of the McKenzie® Method of Mechanical Diagnosis and Therapy®.  It involves full body pressure against the hips and opposite side of the trunk provided by the therapist.  It can be painful to experience, however, only pain that centralizes is permitted, according to McKenzie®.  As I learned in my McKenzie® training from expert therapist Colin Davies, the duration of force application can last a long time – up to 45 minutes.  Gerry’s shift was challenging.  I applied force for 45 minutes, but still there was only minimal correction of his shift!

By day two, Gerry could walk better, but was still shifted.  This time, manual force corrected the shift in 15 minutes.  The next day Gerry could correct his own shift and he was not taking any pain medication anymore!

Now, one week later, he is no longer shifted at all.  He can dress himself, including his socks and shoes, drive, and go to work.  Regarding walking, he only needed to swing his Right arm normally again – he had been supporting his back with it and lost normal gait in the interim.  He reported pain levels of 1-2/10.

Treating Gerry was very satisfying.  His mechanical diagnosis was clear, treatment was difficult, but not confusing.  I credit the McKenzie® Method of Mechanical Diagnosis and Therapy® with giving me the expertise to be so successful in treating this, and other painful spine and joint conditions.  Thank you for your interest in the clinical case study of the week!

Nick Rinard MPT, Cert MDT

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From Knee Injury to Half Marathon Completion in 3 weeks

This is about a shoulder derangement that was identified, and fixed in 10 minutes. But there is more background to the story.

Debbie (a fictitious name for the real person) was training for her first 1/2 Marathon, held in Portland, Oregon. About 3 weeks before the event she presented to physical therapy complaining of pain behind the knee. Such an injury so close to a sporting event is automatically worrisome because it threatens participation. Both Debbie and I were concerned that it could stop her from being able to run the 1/2 marathon!

I performed a mechanical assessment per the McKenzie Method, combined with Cyriax style selective tissue tension tests, and diagnosed the knee pain as “semitendinosis tendinitis”, named according to Laslett nomenclature. It is a lesion of the hamstring.

Although Debbie had good hamstring flexibility, I deduced, based on her history (she was certified as a yoga instructor), that she normally had more. Treatment consisted of stretching out her hamstrings, combined with manual deep tissue mobilization of the hamstring muscle belly. It worked!

She ran the 1/2 Marathon without any knee pain! However, her shoulder became painful during the event! She asked me to look at it 4 days later since it had not subsided on its own.

She presented with what appeared to be a clear contractile lesion of the infraspinatus tendon, with a weak resisted test of lateral rotation. However, there were two pieces of information that were inconsistent with this conclusion. 1) Resisted shoulder flexion was painful with the elbow positioned behind the body, but painless with the elbow in front. 2)
There was no tenderness at all near the infraspinatus tendon, which would be typical , but not required, for the lesion to be harbored in the infraspinatus tendon.

Further mechanical assessment was needed, and this followed the McKenzie Method of Mechanical Diagnosis and Therapy. Repeated tests would differentiate between a derangement and other possible pathologies. I surmised that the arm bone could have been malpositioned in the shoulder girdle from Debbie pumping her arms while running. The logical step was to reverse the activity of arm pumping and correct the derangement. So I instructed her to reach all the way across her body with that arm and then push it further using the other hand. This became less and less painful until there was no pain! Furthermore, it resulted in much less pain produced by resisted flexion afterward! Another exercise–that of rotating the arm bone back into place–worked well also, virtually rendering all prior painful tests, painless!

Needless to say, Debbie was very pleased with both the rapid results with her shoulder, and grateful that her knee pain was treated in time for her to complete her 1/2 marathon!

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To those injured in this terrible Boston marathon tragedy

Building in Boston, MassachusettsOur hearts go out to the survivors and the families of victims at the Boston marathon explosion…

Please pass on the word around town:  MDT Physical Therapy will treat any of the Portlanders (OR) who were injured in this terrible Boston marathon tragedy at no out of pocket costs* to the athletes or their families in 2013.   Please call us at 503-244-6232  for full details & arrangements.

Our prayers go out to you…

 

*Valid for treatment started in 2013, up to 5 visits if patient has no/poor insurance benefits; proof of presence at the Boston Marathon required. MDT Physical therapy reserves the right to discontinue the offer at any time.

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Medical Advisory: MDT is a Superior Form of Physical Therapy

Medical Advisory: MDT is a Superior Form of Physical Therapy

This is page 2, continued from <<Choose your Physical Therapist Wisely

If you sustained your injuries in a motor vehicle accident, or work-related injury, then your chances of getting better are improved if you choose an MDT therapist. There is a financial advantage also since the total cost of your therapy will be less, based on the fewer number of visits MDT uses. Your PIP money will go further, and you will not have to sacrifice a large amount of money out of your settlement just to pay high physical therapy bills. If you are a worker, your case will be less likely to be denied if you are getting better faster, than if your recovery drags on. Believe me, insurance adjusters are less likely to keep your case open if you are not improving in physical therapy.

So you can see that MDT is a superior form of physical therapy. What about MDT compared to Chiropractic care? I tell my patients that Chiropractic treatment is indeed mechanical, but there are two distinct reasons it is not superior to MDT. The first reason has to do with the evaluation, and the second reason has to do with the treatment. A chiropractor first must take an X-ray to make the diagnosis. Unfortunately, there is little evidence to suggest a chiropractic diagnosis is reliable, and therefore, treatment based on an unreliable diagnosis is a guess at best. Secondly, chiropractic treatment is performed to the patient, not by the patient. Any improvement in the patient’s condition, therefore, is dependent on them going back for more visits! As mentioned, MDT treatments consist primarily of exercises that the patient performs so you can treat yourself when not in the clinic. This obviously results in less pain, a speedier recovery, less visits, and money saved!

By reading this essay, you are now equipped with knowledge to seek out the best care possible for your injuries. Don’t waste time going to traditional physical therapy, or chiropractic for many visits. It is better to get an MDT evaluation to determine if your condition will respond mechanically or not, and if it is mechanical, then the treatment is more effective and takes less time!

In closing, I would like to mention how MDT compared to traditional physical therapy in an objective study conducted by a third party. The average improvement in traditional physical was only 78 percent, and it took an average of 11 visits to achieve this. By contrast, MDT got patients 93 percent better in only 6.5 visits! The data speak for themselves. Don’t settle for less effective treatment for your injury – find a Cert MDT therapist who is using the MDT method properly, and get better faster!

Nick Rinard is president of, and a therapist at, Nick Rinard Physical Therapy, a private physical therapy clinic.

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Medical Advisory: Choose Your Physical Therapist Wisely

Medical Advisory: Choose Your Physical Therapist Wisely

by

Nick Rinard MPT Cert MDT Owner of MDT Physical TherapyNick Rinard

The purpose of this essay is to inform you that not all Physical Therapy is the same. Some are more effective than others. If you had Physical Therapy, did it work? If you are going to Physical Therapy now, is it helping? If yes, you should continue until you are better. However, if you are not getting better, or if you need Physical Therapy in the future, then you should read on.

First choice for treating spinal pain

Mechanical Diagnosis and Therapy (MDT) has been shown in numerous scientific studies to be the most effective type of Physical Therapy available today. In a poll of Physical Therapists nationwide, MDT was the first choice for treating spinal pain (APTA publication 2002). This is a good thing, since it shows that the profession of Physical Therapy is gaining more and more scientific evidence to support its use. However, you should know just what MDT is so you can be sure you are actually receiving it.

Development of MDT

MDT was developed in New Zealand by a physiotherapist named Robin McKenzie. Mr. McKenzie noticed that his patients got better faster, and could control their pain themselves, compared to patients being treated traditionally. He founded the McKenzie Institute and has been training therapists since 1980. You should choose a therapist that is a certified MDT therapist, designated by Cert MDT.

What – no gadgets?

The MDT method does not rely on technological gadgets such as ultrasound or electrical stimulation commonly used in traditional Physical Therapy. There is little evidence to show that these machines actually help in recovery. Instead, Mechanical Diagnosis and Therapy, as its name suggests, uses mechanical forces to centralize referred pain, and to correct the physical problem. Exercises designed specifically for each patient, affect pain immediately, and can be performed by the patient whenever pain arises. Over a short time, these exercises heal the injury and allow full recovery. In our clinic, Nick Rinard Physical Therapy, the average number of visits is only six and a half!

Your Time is Valuable

A very important part of the MDT method is the evaluation on the first day. A qualified Cert MDT therapist should be able to identify if you will respond or not. This way, if the problem is not mechanical, valuable time in your recovery is not wasted, since you would not go through several weeks of rehabilitation to discover at the end that it did not help. Doctors who have the best interests of their patient in mind prefer MDT for this very reason. If your doctor is not aware of the MDT method, then you can choose an MDT therapist yourself. It is considered standard practice and has been accepted by the medical community.

Medical Advisory: MDT is a Superior Form of Physical Therapy

If you sustained your injuries in a motor vehicle accident, or work-related injury, then your chances of getting better are improved if you choose an MDT therapist. There is a financial advantage also since the total cost of your therapy will be less, based on the fewer number of visits MDT uses. Your PIP money will go further, and you will not have to sacrifice a large amount of money out of your settlement just to pay high physical therapy bills. If you are a worker, your case will be less likely to be denied if you are getting better faster, than if your recovery drags on. Believe me, insurance adjusters are less likely to keep your case open if you are not improving in physical therapy.

MDT compared to Chiropractic

So you can see that MDT is a superior form of physical therapy. What about MDT compared to Chiropractic care? I tell my patients that Chiropractic treatment is indeed mechanical, but there are two distinct reasons it is not superior to MDT. The first reason has to do with the evaluation, and the second reason has to do with the treatment. A chiropractor first must take an X-ray to make the diagnosis. Unfortunately, there is little evidence to suggest a chiropractic diagnosis is reliable, and therefore, treatment based on an unreliable diagnosis is a guess at best. Secondly, chiropractic treatment is performed to the patient, not by the patient. Any improvement in the patient’s condition, therefore, is dependent on them going back for more visits! As mentioned, MDT treatments consist primarily of exercises that the patient performs so you can treat yourself when not in the clinic. This obviously results in less pain, a speedier recovery, less visits, and money saved!

MDT Treatment is more effective and takes less time

By reading this essay, you are now equipped with knowledge to seek out the best care possible for your injuries. Don’t waste time going to traditional physical therapy, or chiropractic for many visits. It is better to get an MDT evaluation to determine if your condition will respond mechanically or not, and if it is mechanical, then the treatment is more effective and takes less time!

Better in only 6.5 visits

In closing, I would like to mention how MDT compared to traditional physical therapy in an objective study conducted by a third party. The average improvement in traditional physical was only 78 percent, and it took an average of 11 visits to achieve this. By contrast, MDT got patients 93 percent better in only 6.5 visits! The data speak for themselves. Don’t settle for less effective treatment for your injury – find a Cert MDT therapist who is using the MDT method properly, and get better faster!

Nick Rinard is president of, and a therapist at, Nick Rinard Physical Therapy, a private physical therapy clinic.

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