A few weeks ago I had the opportunity to connect with a fellow physical therapist in the Boston area, Dr. Ramez Antoun, PT, DPT, SFMA, PNF. Dr. Antoun is a graduate of UMASS Lowell’s DPT program as well as Kaiser Permanente’s Proprioceptive Neuromuscular Facilitation (PNF) fellowship in Vallejo, CA. He is SFMA and Dry Needling certified and is currently pursuing his COMT for manual therapy through the Institute of Orthopedic Manual Therapy (IOMT). He is the founder of NEUROPEDICS, a cash based physical therapy service – currently based in Somerville, MA: http://www.neuropedicspt.com/
Below is a highlight of the interview I had with Dr. Antoun:
JC: I know you’ve written on the PNF philosophies in your blog, which can be found here: http://www.neuropedicspt.com/professional-blog. But could you highlight some of these PNF philosophies?
RA: If you’ve read the book “Start with WHY” by Simon Sinek, he talks about the golden circle and how the core is the WHY statement (the why we do what we do), the outer ring is the HOW (how we do what we do), and the outermost ring is the WHAT (what products we will use, dumbbells, kettlebells etc…). As residents of PNF, we are introduced to philosophies.
The first philosophy of PNF is that every living thing has potential – this is rooted in neuroplasticity research. The brain is constantly able to make new connections, new patterns, new associations, which is one of the things we have to truly believe in when rehabbing [clients], because from a neurological standpoint, we have very debilitated [clients] (strokes/TBI) who are paralyzed and believing they can’t walk again, and that innate belief that you can create changes based, on neuro plasticity, that they can walk again, is the first stepping stone of PNF – going into treatment with a positive attitude. This leads me to philosophy number 2, which is treating the whole person. The whole human being encompasses the emotional (i.e. using positive language), the physical (i.e. biomechanical interventions), and the intellectual (i.e. educating the client). The third philosophy is always start with what the person can do – so a positive approach. We’re trained as therapists and trainers to look for weaknesses or impairments and highlight those when we’re talking through an evaluation process, but in PNF, first comment on what you see what’s good. For example: I see that your right shoulder moves really well, especially into upward rotation. The left side, not as good, but we can work with that. Rather than “Oh, that L side is tight, what’s going on there?” To me, the client is already coming to us broken down; a piece of their identity was already taken away from them. So one of the things I can do for them on initial contact is to be positive. The fourth philosophy is movement always needs to be purposeful and leading towards a functional goal. So our exercise program/progression should show a sense of progression back to functional. So I think 4×4 matrix (SFMA): supine/prone à quadruped à kneeling à standing.
JC: I completely agree with everything you’ve touched upon. Being positive. I don’t think that is something talked about enough in PT school. What was it like to go through the PNF residency in Vallejo, CA and how was this philosophy (#2) integrated?
RA: So the residency is 9 months, and it is split into 3 phases: 3month resident, 6month resident, 9month resident. You know how in PT school you always had a strength and problem list when evaluating/treating patients? When ever we did patient demos or working with a patient, they would force to always write down the positives, even within a treatment. In PT school, when a client doesn’t move the way you want them to, you say “No, not like that”. One time I was co-treating with my mentor, and she said, “That’s assuming that that movement is bad”. But when dealing with a neurological population, every movement needs to be considered beautiful, because if they couldn’t do that, then that would be paralysis. Instead of saying no, articulate what movement they did. For example, if you wanted them to reach up over 90 and they reached down below 90 articulate it “Good, you were able to reach down at this angle, now lets try to reach upward overhead”. That was huge, just being able to change my vocabulary and trying to not say “NO”.
JC: That’s a great philosophy, and along the lines of “any movement is better than no movement”.
RA: The only time to say no (and this can be applied to all populations) is when the movement is deemed unsafe and it was going to harm them. This brings us to the principle of “Protect before you correct” from Functional Movement Systems. For example, if someone is doing a lift, and his or her lumbar spine goes into flexion at the bottom, then “No, that is not how we load the spine”. There still is a framework of right and wrong, we still have to respect biomechanical movement. But nonetheless, we shouldn’t be quick to jump into giving negative feedback.
JC: I don’t like the segregation in the PT world. We have distinct settings that we practice in (acute care, inpatient rehab, ortho, sports etc…), but at the end of the day, our goal is to get the client in front of us to move better in the safest way possible. However, I feel that many therapists don’t see it that way, and think, “I’m an ortho therapist I don’t know what to do with a stroke patient”. I don’t like this separation.
RA: There is definitely overlap. There is a whole renaissance of where neuro and ortho are starting to blend together. And there’s a blend of the concepts in the sports world; neuro muscular control, neuro developmental postures, actually can make people move better than in isolation. But it hasn’t been like that. If you go back in history – guys like Maitland, Kaltenborn, Mulligan, Maggie Knott etc…. – They all hung out. They all influenced each other. I don’t know what made that message lost, that the neuro and ortho aspects need to be separated. But I think that they are starting to be marketed again, together.
JC: I completely agree, again. I’m not sure how the curriculum was at Umass Lowell, but at Emory, we were introduced to acute care, ortho, neuro, all separately and in isolation from each other.
RA: I think that it needs to be that way, initially. But by third year, maybe introducing the concept through a course like “Neuro for the orthopedic therapist” might be helpful. I don’t know if we can do ortho for the neuro therapist, but in the PNF residency in Vallejo, there were many therapists who had completed orthopedic training – if we had a patient who couldn’t get into a certain position due to tone or joint restrictions, then they would perform joint mobs. Then we’d follow it up with more neuro-based techniques, rolling etc…
JC: I felt very fortunate that while I was at Emory I had a professor (Dr. Baudo) – who has influenced my clinical reasoning and treatment philosophies a lot – whose big principle was segmental innervation. She would say, “If I have an athlete with an ankle sprain, why am I mobilizing L4/L5/S1? Because what do you think innervates the ankle? L4-5/S1.” So for me, a lot of diagnoses come back to the spine. If I can get one facet joint to move a little better, it could free up any tension on the underlying nerve.
RA: From a biomechanical aspect I might explain it like that. From a sensorimotor perspective I might explain it as stimulating the mechanoreceptors at that particular level, which can send feedback into the central nervous system to get an improved output from the brain for the dermatomal distribution. For patients, I explain it with the following visual explanation: Think about watering a plant. The pump is the spine, the hose is the nerve, the water is the electrical signal, and the plant is the muscle. If the pump isn’t working right, the plant isn’t going to get great water (poor water pressure). If we keep obsessing about why the end of the hose isn’t spitting out water and never look at or check out the pump to see if it’s working, how are we going to expect to help the plant grow? Go to the source of the problem.
Hope you guys enjoyed this interview. Please check out more of Dr. Antoun’s work on Facebook/Instagram at Neuropedics Physical Therapy and Sports Medicine Consulting.