Rehabilitation and Performance—From Snake Oil Salespeople to Well-Oiled Machines

from snake oil salespeople to well-oiled machines

ALEXANDER E. POOR, MD

JIM MCCROSSIN, MS, ATC, CSCS, PES, CES, CKTP

ALEX MCKECHNIE, PT, MCSP

Editor’s Note: I asked Jim McCrossin and Alex McKechnie, two of the world’s leaders in core physical therapy and performance training, to help write this chapter. Both are partners in the Vincera Institute. Jimmy, the Philadelphia Flyers’ head athletic trainer, runs the Vincera Rehab Center. Alex, Director of Sports Science for the Toronto Raptors, was one of the conceptualizers of the Institute. Alex originated some of the core performance and rehab fundamentals employed there. He also created the device called Core-X. Another Alex, co-editor Alex Poor, brings together Jim’s and Alex’s thoughts, and adds some of his own.

THE IMPORTANCE OF ATHLETIC TRAINERS AND MANY OTHERS IN THE FITNESS WORLD

Athletic trainers, physical therapists, strength coaches, and some alternative therapists—not necessarily docs—presently command the core. These therapists deal with the core all the time and see the problems with it. I got into this field via the heartfelt convictions of certified athletic trainers. In the mid-1980s, two of them from a professional football team approached me saying, “Doc, this player has a real injury. The coach thinks he’s faking, and our team docs are stumped. No one can diagnose him. We have staked our reputations that he has a real injury, and that you can fix it. Make us look good, Doc.”

Athletic trainers may be the most dedicated group of health professionals right now in the United States. With essentially the same educational background as registered nurses, they have the dedication and tirelessness of physicians of the old day. Often underappreciated, they spend countless hours with their athletes, looking out for them, making house calls, hospital and pharmacy visits—whatever it takes to get their athletes into the best health and mental and physical conditions. Athletic trainers have also become the primary health communicators for many teams, often more than the team doctors, coaches, agents, or administrative staffs.

With that dedication, athletic trainers sometimes even identify these core injuries precisely. More than the rest of us, they know when a player really hurts, and when the injury seems important. Athletic trainers are always “there”—on the field, in the training rooms, and by the players’ sides. They notice the grimaces. They see the impact of these injuries more than any other group of health professionals. They became convinced about the concept of the core way before docs.

Through the insistence of athletic trainers that there were a variety of injuries in this region, I got interested in the core despite a large liver practice, and performed the initial laboratory experiments described in Chapters 3 through 5. At the same time, I cannot minimize the influence of my colleagues, Duke doctors Frank Bassett and Bill Garrett. Frank and Bill encouraged me to listen to the athletic trainers. Frank and Bill saw the core as an undiscovered scientific field, and its study would likely yield the fundamentals of physical performance and optimal use of our muscles, bones, and brain. The bases of this field turn out to be basic anatomy, physiology, pathology, and pharmacology.

Athletic trainers, physical therapists, strength coaches, docs, and so many others turn out to be so important with respect to the core; not only for prevention of injuries, but also for achieving maximal performance in general as well as after surgery. Having said that, we must mention a few words of caution…

WATCH OUT FOR THE SNAKE OIL SALESPERSON (FIGURE 32-1)

Figure 32-1. A snake oil salesperson.

Right now, in this complex world with so much commercialism and so little established scientific data, the lay public logically will have difficulty picking out good therapists from the snake oil salespeople. As we have mentioned multiple times previously, it is easy to injure someone with the wrong training regimens and/or the wrong devices. We have previously talked about the oft-sexy, 2 AM television ads that promote the latest products that may be dangerous. On the other hand, particularly in this developing scientific field, we must keep our minds. Some people who seem like snake oil salesmen or -women may, in fact, be onto something. Let’s be wary, but also not be too quick to label their wares as snake oil.

One tell-tale sign of a snake-oil salesperson is the supposed therapist who says: “I know all about the core; I know exactly what to do.” Whether or not that therapist has a great background, be cautious. Nobody knows all about the core, not yet. In the least, that therapist reflects a closed mind about learning more.

You, sir, are the scion of an ancestral procession of idiots stretching back to the Missing Link.

—Samuel Langhorne Clemens, aka Mark Twain, the author of Tom Sawyer and Huckleberry Finn. The quote comes from a letter from Clemens to a snake oil peddler on November 20, 1905.

MOVING FORWARD

Certainly, we all have a lot more still to learn. Several principles for core training have emerged. Not everyone knows these. One reason may be that the principles have never been expressed clearly in a textbook. Alas, that excuse should hold true no longer… We certainly recognize that enumerating “basic principles” may trigger debate. Plus, what gives us the right to do this? The answer to this is we don’t know. We had the opportunity to write this book, so we figured we have been helping drive this field, so why not? Someone had to start somewhere. We welcome debate and alternative hypotheses about the fundamentals. In the next few chapters, we have assembled some megastars in core physical therapy and athletic training. We already mentioned Alex and Jimmy. We also have Andrew Small, a young Australian physical therapist, and then Tracey Vincel and Andrew Barr, therapists in New York City in whom I have a lot of confidence.

Success is never final, failure is never fatal. It’s courage that counts.

—John Wooden, the “Wizard of Westwood,” who won 10 NCAA basketball titles with UCLA in a 12-year time frame.

We divide this chapter into 2 parts: how to recognize the right therapist from the snake oil salesperson and the right principles.

IDENTIFYING THE RIGHT THERAPIST

Ask yourself any of the following 3 questions.

I want to get back into shape, who do I get to help me?
I pulled a big muscle in my thigh, who knows what to do?
How do I get an athlete from the operating table all the way back to stardom?

For all 3, you start out by trying to identify the right therapist.

The third question may seem the easiest to answer because of the abundant resources often available to a potential star athlete. The reality is that the answer to Question 3 may be the most difficult, even considering the optimal settings. Getting the player “all the way back” shall be addressed further in the following chapter.

So, where does one start? How does one find the “right therapist”? Look at the choices: physical therapist, strength coach, personal trainer, athletic trainer, physiatrist…the list goes on. For a patient, or even a referring doc, it can be mind-boggling trying to decipher where to go. Consider all the specialties, the special credentialing, and the many initials that follow each specialist’s name. Lines of distinction between fitness specialties remain obscure, at least to most people out there. Know that that the fitness world is now second to the financial world in terms of number of workers within it. Inability to discriminate causes frustration. No wonder so many people go out and buy the latest fitness video, and give up the quest to find the right therapist.

Let’s say you are not a therapist. You are just anybody and either have an injury that you deem not serious or have simply decided you want to get back into shape. What do you do? Where do you go? If you have no background whatsoever in any of the fitness fields, you undoubtedly will feel lost. Probably, you would latch onto the first person whom a friend suggests, or who sounds good, or who talks a good game and acts like he/she knows something. In reality, figuring out the right therapist, without some direction, may be like finding the “eighth” wonder of the world.

Many experienced therapists get frustrated thinking about the above scenario. So many people, it seems, claim to be fitness experts nowadays. Then frustration can turn to exasperation when a therapist compares the educational backgrounds. Consider reading an article written in Men’s Health written by Bryan Krahn.1 Krahn articulates, with unpleasant language, that exasperation. The world is, certainly, not as bad as Krahn portrays it, but he does make a valid point about the huge amount of deception that lurks within the fitness industry.

Eight Tips for Finding the Right Therapist

In the spirit of Krahn’s blog (without the crassness) and the “eighth” wonder, we have come up with 8 tips for patients/clients/athletes for deciphering a good therapist:

Look at the therapist’s training. The initials (“credentials”) after the therapist’s name may, or may not, mean something. In general, the longer the list…the more you should question. Watch out for quantity (eg, number of credentials or number of spoken words) substituting for quality. Find out specifically where the therapist trained, did internships, etc. Ask how long those internships lasted (eg, a few weeks or a month vs a full year or two). Make sure they were not online courses. Look up the reputation of the schools and ask directly or research the meaning of those initials.

See if the therapist is currently working with legitimate colleagues. Many therapists list well-known people as colleagues. Watch out; there are lots of ways to fudge those data. Ask specifically about the schools, institutions, doctors, etc, with whom he/she affiliates. Look up the institutions and doctors if you don’t recognize them. Challenge the therapist with respect to the specific ways that therapist works with the colleagues or institution listed.

Find current clients of the therapists and quiz them. Don’t be swooned by the names of big-name athletes, performers, etc. Some of the best and worst therapists drop names like you wouldn’t believe. Be wary of the “nutritional” side. You have seen the scams chronicled in newspapers involving anabolic steroids. Some of those scams grew out of legitimate clinics. On the other hand, recognize that sometimes there is a real rationale for anabolic steroids, and that their acceptance is actually evolving. Right now, most anabolic steroid usage is inappropriate. You do have to pay attention to criminal conviction or eviction of a therapist from a legitimate organization. Currently, the best therapy locales often make special points to differentiate themselves from such activities. On the other hand, keep your mind open here.

Find a therapist who is flexible in his/her thinking. A good therapist should truly read through an existent protocol from an outside doc and be willing to call directly and work with previous therapists or treating physicians. The refusal to do that is an absolute indicator of someone with whom you don’t want to work. For example, the right kind of early, aggressive, postsurgical physical therapy is very important at Vincera with respect to rehabilitation after core muscle repairs, in order to prevent certain types of scar build-up; so much so that the patient begins therapy the day after surgery. When we get a report that an outside therapist has looked at our postop protocol and pronounced impulsively, “This is way too aggressive—you need to wait a while before you start this,” we tell the patient to switch therapists. We actually coach our patients on comments of a potentially bad therapist.

In general, therapists should be willing to, in the least, pick up the phone and call, and go through a referrer’s protocol with the referrer, particularly when that has been requested. Without that, critical statements serve only to undermine the confidence in everybody.

Watch out for big words and ultra-aggressive people. The therapist should also be able to talk to you so that you can understand. When you hear big words or phrases that you do not understand, know there are only 2 possible explanations for that. The therapist may be sincere and innocently overlooking your lack of training; or the therapist is, indeed, double-talking. As implied previously, lots of double-talking scammers live in this field. Absolutely, you should ask them to explain things so that you understand them. If they cannot, politely say “Adios, Amigo.”

Think the same way for the ultra-aggressive people. Distrust the therapist who insists on interventional therapy that just plain seems wrong (eg, active release therapy within a few days after surgical repair, or, for that matter, dry-needling or extreme stretching). The therapist may even legitimize the offer by citing the initials after his/her name to show that he/she is well-credentialed in a particular therapy. Keep in mind, however, that many of those therapies do have roles. The point is that they must be used wisely.

Krahn says, “Beware of the liars and scammers.” The top 3 clues that you are dealing with a scammer are (1) goofy qualifications, (2) evasiveness about the qualifications, and (3) “buzzword wizardry.” The last refers to a form of double-talking, using seeming catchwords or phrases with the explanations just not making perfect sense. Trust your instincts: If you don’t totally understand the rationale for a therapy, believe yourself not the therapist. Other things to watch out include the big promises (eg, you will become the next superhero), the overly talkative therapist, and the terribly out-of-shape therapist. If the therapist can’t keep in reasonable shape, don’t trust the person’s ethic. Also, watch out for the scam artist, who tells you, ad nauseam, about his/her superhero background, or the one who prioritizes entertainment over exercise, or therapists who try to convince you to also take pills or buy a club membership.

Trust a well-known athlete who has gone through something similar, if you can get access to one of them. The chances are that the athlete, or one of his/her agents, has gone through the research. Of course, make sure the athlete has done well. Know, however, that this recommended process is, by no means, failsafe.
And finally, look at the soft stuff. Pay attention to your general feelings about the therapist. Consider the therapist’s flexibility and modesty. Do you like him/her? Do you think you will be able to trust the prospective therapist? Trust, good vibes, and convenience (travel time, etc) mean a lot. Don’t be fooled by the well-publicized reputation. The therapist with the great name may also be set in his/her ways (ie, to a fault).

THE RIGHT PRINCIPLES

When one says “the right principles,” one may mean a lot of things. Let’s narrow that down for this chapter. We are talking about the right principles that athletic trainers should have when they take care of their players. We are talking about the total care of the player—physical, psychological, nutritional, and whatever else it takes to make the player as great as he/she can. We shall provide a case example, and then list what we think are the right core rehabilitation and performance principles. Like all other aspects of this book, you may argue with any of these. These principles merely open the discussion.

Let us begin with Kyle Lowry. His story was written up as a “Medical Mystery” for the Sunday Philadelphia Inquirer newspaper.2 Consider this case from the perspective of what the athletic trainers and physical therapists did for Kyle. They watched him like hawks and figured out a really bad thing that what was going on with him. They corrected the problem and subsequently provided first-class core care that helped Kyle to become a mega-star in the NBA.

Diagnosing and Managing a Tricky Core Injury

As we said, Kyle’s story appeared in the Sunday Philadelphia Inquirer within a series called “Medical Mysteries.” We present it here, in a modified form, from the same perspective.

The Mystery

Kyle was in his sixth year of the NBA. The Villanova University standout was drafted in 2006, after his sophomore year. He finally had the chance to play regularly. It was now March 2012, and he was a point guard with the Houston Rockets. Kyle knew he could be a star (Figure 32-2). But that darn pain in his belly was such a distraction.