Movement is everything—when it is compromised, life takes on a different, more ominous tone. Fear not, for physical therapists advocate a respite from pain through targeted movements. Whether recovering from a sports injury, in chronic back pain or living with a disease such as Parkinson’s, cerebral palsy, rheumatoid arthritis or a brain injury, physical therapists work with your whole body to retrain your muscles back into working order, giving you a renewed sense of mobility and independence.

SRQ: What are some of the reasons that people seek out physical therapy? Mary Hart, PT (Hart Physical Therapy): When people don’t feel well, especially if they have pain, they aren’t able to function. They usually seek out help if the pain doesn’t go away on its own within a few weeks. Also, if people have long-term conditions that need specialized care, such as Parkinson’s disease, stroke, osteoporosis, even back and neck pain, they will seek out professional care. Michael Selvaggi, DPT (Clinical Director, Gulfcoast Physical Therapy): Everything under the sun, as far any kind of ailment, from Parkinson’s, stroke, post-stroke, to orthopedic injuries, wound care and a lot of women’s health issues that people don’t really understand or know about. There are many things that physical therapy does—it’s so broad. It’s a more natural, conservative, holistic approach to medication and surgery. And it’s been proven to really get outcomes. Antonio Teresi, PTA, CPT (Owner, Gulfcoast Physical Therapy): A lot of the things we see as therapists are lower-back, shoulder and neck pain. The body is just designed to break down as far as the lower back and shoulders go. As we age, people get less and less active, and as they become more sedentary, things start to break down. It’s our job to teach them how to take care of themselves, because if it works here, it will work at home as well. But you have to put your effort into it. Work, time and effort are how you get results. Chip Fisher, PT (Clinical Director, FYZICAL Therapy and Balance Center): We’re treating anything that is limiting someone’s quality of life, as well as the ability to function safely, so a lot of balance therapy. Loss of balance usually happens because of inactivity or because of an ailment, and can absolutely be improved upon to allow you to have the quality of life that you want to have. One other aspect we treat is balance and fall prevention, which is much better than trying to recuperate after a fall with all the other orthopedic injuries that can occur from that fall. A majority of people don’t equate that their balance can be helped by a physical therapist. Statistics show that one in every three people over the age of 65 are going to fall this year. 

What is the general stance on whether to have surgery or try physical therapy, and how do you help people decide what is the best way to go? Hart: We are the least invasive option available within the health care system that we have and physical therapists are able to do a differential diagnosis clinically. Teaching people how to treat the root cause is extremely important—people don’t just lose their functional mobility as they get older, it has to do with them not knowing how to hold their bodies easily or correctly. Physical therapy first is a really good intervention, because we are the least invasive, we can teach people how to help themselves. That way, they can be pain free, and move more easily, keeping their functional mobility, being able to participate in recreational things—or even just walking, doing stairs and being able to squat safely without losing their balance. We have a responsibility not just to educate people, but also to show them how—in the least invasive way—not to trigger their pain. Each individual has their own set of triggers for pain, there are no two alike—you treat the whole person: their perception of movement, their thoughts, emotions and their physical manifestations. For example, stress manifests itself in different ways in different people. We have ways to approach symptoms that are specialized for specific conditions. We have programs that are specialized for Parkinson’s, for stroke, for osteoporosis, back and neck and we focus on what the individual needs with the condition that they have and we teach them how to be less dependent on a healthcare system that is becoming less and less available to them. Fisher: Surgery may be the fix for an injury in, say, the knee, but not a fix for what functionally was wrong with you, which could have been an imbalance in your strength, flexibility and alignment, and surgery or no surgery, you needed to correct those issues that are creating more stress on your knee joint. Selvaggi: You can always get surgery. It should always be the last resort; you should always try other areas to fix the problem first. Take a conservative approach. We have to motivate the patients and educate the public on what physical therapy can offer. Worst case scenario: if you try physical therapy before surgery, you are either going to get better, or—if you don’t get better—you have surgery but you are going to have a better outcome after surgery because we do this thing called “pre-habilitation.” If someone goes for years with a bad knee and they are not using it as often as they should, those muscles start to atrophy and start to build tissue that restricts, becoming weaker. When you have surgery on a weak joint, it takes a bit longer to rehabilitate it after surgery if you haven’t spent time building up the muscle fibers, increasing the range of motion and getting them as functional as possible before the surgery. There is no downside to getting physical therapy beforehand. A lot of this has to do with imbalance and posture. They say sitting is the new smoking. You get the rounded shoulders, the forward head posture and weak knees coming in from weak external knee abductors. We fix the imposture and the imbalance. I tell my patients all the time: If you are building a house, you’ve got to put down the foundation—a concrete slab to keep it steady—then the walls and roof. But if the foundation cracks, what is going to happen to the rest of the house? It’s going to start tilting. If you don’t fix the foundation of the house (or the original cause of the problem), and you just fix the wall and the roof instead, it’s going to cave right back in. You have to fix the foundation. It’s not just about a knee that hurts—it could be stemming from the ankle, the hip, the back.

How do you dissuade people from rushing to surgery? How do you convince people to take the longer route of, say, a six-month physical therapy course versus surgery? Teresi: Sometimes doctors rush into surgery just because they can. But you have to get to the foundation of the issues that are potentially causing other issues. And sometimes surgery is unavoidable—you tear an ACL, you have to reconstruct that; you tear a meniscus, you have to repair it. Some doctors don’t believe in therapy at all and think once they’ve fixed the problem via surgery, you can do a few exercises for a few days and then are done with it. You have to really follow through. People don’t realize the deficits that they have until they do things that are hard. You can have pain and inflammation that lingers because you never got it corrected back to where it should be, and surgery won’t necessarily do that. Hart: I don’t find it difficult to dissuade people. When people come to us, they have a desire to get better. I have my own technique that I developed over 20 years. When someone comes in, I look at the whole person, I look at the way they sit in the waiting room, how they get up from sitting, how they stand, how they walk, what is the alignment like, how they hold themselves, how they move mechanically. You have to understand how the body is designed and how it is meant to move. We see people mostly that have loss of function, pain not because of some specific injury—with these, right off the bat you know that it’s something in the pattern of movement. We want to make sure that they form habits that work for them. I find that if I can treat them and show them one or two things they can do from day one to relieve their pain, it sells them to come back. And when they come back, they feel refreshed, confident and empowered because you have given them something that they can do for themselves. That’s their motivation—feeling good. Fisher: More and more doctors are aware of how physical therapy can help their patients. Within our own field, we have been trying to promote the benefits to doctors, and there are a lot of good doctors in Sarasota, that we can educate and help—and if we can’t help fix the problem, then we’ll refer patients back to the doctor. From a very conservative approach, a good physician will refer patients to physical therapy first before jumping to surgery. Secondly, you have to be your own best advocate. There is still a misconception that physical therapists, or physical therapy in general, are going to cause you to hurt. You are here because you are in pain not to cause you pain. 

How do you get patients to recognize when they are pushing themselves too hard? Selvaggi: I give them a cue: if they are coming in to my office in pain, all the activities I give them shouldn’t be painful. I say: if there is any discomfort here, stop. They let me know when it’s too much because they know themselves better than I do—if they don’t relay the message I’m not going to understand that this movement was hurting. It helps us diagnose exactly what is going on and helps us to tailor the exercise program as needed. Our first thing in the plan of action should be to try and reduce the pain. We don’t want them working into pain, exacerbating their symptoms. It’s exciting when we do some movements and the patient says, “Wow, it doesn’t hurt!” We have very good numbers, and the evidence is there. There are different modalities, and different ways to relieve pain, but the biggest thing we do is patient education. We can give the exercises, we can show you what you need to know and monitor progress, but education and letting the public know why this is happening is it. I’ll take out a skeleton and literally show them what’s going on. Or I’ll ask them to bring in imaging, and I’ll read the imaging results. Hart: I agree with that and I also think that we need to show patients how to feel good in their whole body. I like working from the nervous system out because the nervous system is a global system. When you have a problem, your whole body compensates around that problem, and we have to teach people how to know when they are doing things that are too intense. Even the exercises we give them, they might be good, but people can be doing them too intensely. We show them what to look for in their body and what it feels like when they are at an appropriate intensity, where the exercise is not causing the nervous system to react, causing the muscles to go into protective guarding. We teach them how to position their posture correctly and how to pace the activity and the intensity of the activity. It’s a collaborative approach—what I do helps them be able to do the exercises more easily and what they do helps me go in and treat more effectively. That is why it is so important to deal with each individual’s set of pain triggers in movement, the reason for resistance because movement is perceived by the nervous system as dangerous and painful, and that is why people stop moving—they don’t feel good.

How do you treat a patient with an orthopedic injury or pain, compared to a patient with a neurological disease such as Parkinson’s or cerebral palsy? Hart: With something like proprioceptive neuromuscular facilitation stretching (PNF), you can treat an orthopedic patient, but you still have to deal with the nervous system. With PNF you can deal with timing, you can deal with sequencing (scapularhumeral rhythm). For someone that has brain injury, you deal with all the aspects of good health, whether it’s alignment, having the spine balanced so they can hold themself up, along with balance in different positions. These are things you think about differently with a neurological condition, you have to deal with retraining the developmental sequence. You have to have an approach tailored for neurological conditions—stroke, Parkinson’s—you can’t treat them effectively with a purely orthopedic approach. With a neurological condition, you have to treat the whole person from the get-go. Fisher: Two patients, whether they present as orthopedic or neurological, even if they have the same pain or issue, are completely different. Two people with Parkinson’s or lumbar stenosis—their treatment could technically be completely different depending on those issues and how their life has progressed and where they are in their health right now. The word that we have been leaving out is evaluation. Physical therapists do a lot of evaluation—evaluation is so important because that is where we develop a plan. Regardless of whether it is neurological or orthopedic, male or female, two of the same problem, it’s the evaluation that will set the tone of the entire treatment going forward. Selvaggi: I 100 percent agree, evaluation is the foundation of the treatment. We check movement patterns, we check sensations, reflexes (which are neuromuscular issues), strength and how the patient walks. We check the skin and even discoloration in the skin. When we meet you, we look how you sit, stand, walk, talk, turn—everything—while we are talking to you so we can learn. Hart: Our evaluation is ongoing, every time the patient comes in, we are constantly observing the patient not just on the first day, but always. Are we getting the outcome that we want with this patient? What would make the biggest change in their condition? We spend a lot of time on assessing and evaluation.

How do you integrate other aspects of physical therapy such as massage therapy or acupuncture into people’s programs? Teresi: A common one that we use is electrical stimulation, which is used to help reduce swelling, agitation, pain sensations and so on. We can use this to help give the muscle a little jump-start, like a car. Sometimes we use lasers to help reduce swelling and inflammation. Fisher: I always tell my patients that we have to figure out what the right recipe is, using all the right ingredients that we have as physical therapists. It may not be a specific tool that we have, it may just be our knowledge of movement and the body. We are constantly educating ourselves on the newest technologies, cutting-edge technologies and the advances in that knowledge so we will always be able to help treat our patients. Selvaggi: My thing with modalities is that they are good, for instance, if they make the patient feel better and give relief. There’s also a placebo effect. Everything has moved toward evidence-based research, I don’t want people to think modality is the cure. It’s like a cortisone shot or a Band-Aid—they make you feel better, but you can’t just take the shot. You need to have physical therapy alongside the shot. In the state of Florida, we are fighting for dry needling, which is available in a lot of other states. Physical therapy is expanding and continuing to grow—it is a doctorate-level degree now. We are musculoskeletal professionals—no one knows the body like we do, except orthopedic surgeons but they do surgery. We know the conservative approach. Modalities have their place but research has shown that good therapeutic exercise and a good regimen is the key to fixing the problem. 

About Our Participants

Anthony Teresi, PTA, CPT earned his AS degree in physical therapy from St. Petersburg College in 1993. He continued his education by receiving his certification as a personal trainer in 2000. His work experiences include HealthSouth Rehab Hospital and Heartland Healthcare and Rehabilitation, and he has settled into outpatient care since 2000. In April 2008, Teresi opened Gulfcoast Physical Therapy.

Mary Hart, PT is the founder of Hart Physical Therapy in Sarasota, FL and The Hart Technique, a unique, collaborative treatment method with a holistic, whole-body approach. Hart received a degree in physical therapy from the University of California’s School of Medicine at San Francisco. She went on to Kaiser Permanente Hospital in Vallejo, CA to complete a residency in proprioceptive neuromuscular facilitation.

Michael A. Selvaggi, DPT is an Army veteran and Florida native who received his bachelor of science degree in exercise science from the University of South Florida and his doctor of physical therapy degree from Nova Southeastern University. Selvaggi also serves as an adjunct lab instructor for Nova Southeastern University HE-DPT program in Tampa, FL. He’s worked at Tampa General Hospital treating a variety of injuries and pathologies from orthopedics to cardiopulmonary and neurological disorders. Selvaggi now serves as the clinical director for rehabilitation at Gulfcoast Physical Therapy and Performance Center.

Chip Fisher, PT graduated with a master’s degree in physical therapy from Duquesne University in Pittsburgh, PA and has served as the clinical director of physical therapy at Fyzical Therapy and Balance Centers in Sarasota, FL since 2006. His areas of clinical expertise include balance and vestibular disorders, neck and back disorders, general orthopedic and neurological disorders and temporomandibular joint disorder (TMJ) issues.