Do you know the symptoms of mild knee arthritis and how those symptoms translate to x-ray studies?

As many of you know I am an avid golfer and a former army paratrooper. Between the acl rupture and meniscal damage sustained during my army career and the wear and tear on the right knee from my quest to over take Tiger's number 1 ranking, (I dont think Tiger has much to worry about), I have a low level effusion (swelling) of the knee. I have no pain but occasionally a feeling of stiffness after playing more than 18 holes. My knee's tolerance level seems to be about 18 holes of golf before effusion begins. Steep inclines, hitting out of sand traps and just the 18 holes of compression on the knee seem to be the major issues. I have no feeling of giving way or instability.

Here's your post rehab challenge. Develop an exercise program for a 46 year old male he can perform at home. You have a Bowflex, a stationary bike, dumbbells from 10-50 pounds and a Swiss ball. The program goal is at the end of 18 holes there is minimal effusion with no residual stiffness the next morning. Take a look at the x-rays below for a look at arthritic changes that causes a mild effusion in the knee. The knee on the right shows narrowing along the lateral joint line and if you look closely you will see mild osteophytes (bone spurs) right at the joint line. This x-ray shows the early stages of osteoarthritis of the knee.




Dr Mike

Post Rehab Tip #14 - When do I use McKenzie or back extension exercises?

McKenzie or back extension exercises are best used with clients diagnosed with lumbar disc herniation. The goal of McKenzie exercise is to centralize radiating pain into the low back and then eliminate the pain. In recent years I have noted the shotgun use of McKenzie exercise on all lumbar post rehab clients. The McKenzie exercise concept should be used with discogenic clients in a very structured process. There are 3 exercises associated with the McKenzie concept. They are:

1) Prone Lying

2) Prone Prop

3) Prone Press-Up

These exercises, properly used with strategies to minimize spinal flexion and prolonged sitting, will make a significant difference in managing the post rehab lumbar disc herniation client after their discharge from physical therapy or chiropractic care. Click the link below to watch my demonstration of the McKenzie exercise sequence.

Dr Mike

Post Rehab Referrals - How do I contact physical therapists, physicians and chiropractors?

The lifeblood of any post rehab or medical exercise practice is developing referral relationships with local medical professionals. Approaching physical therapists, chiropractors and/or physicians requires an organized process as well as understanding the needs of these referral sources. You must develop a post rehab/medical exercise marketing package and presentation to maximize your chances of establishing a referral relationship. Once you make your presentation but referrals aren't coming in you must ask yourself four questions. The organized approach, the contents of the post rehab marketing package and the four questions are included in my recent interview with David Gilks, MEPD. Please click the link below to listen and learn how to contact medical professionals.


Dr Mike

I referred my client to a physician but he never came back. How do I get my client back?

In an earlier blog post I discussed a problem many post rehab professionals encounter, the loss of a client when you refer the client to a medical professional for an evaluation. Here are three strategies you can use to prevent the loss of your client.

1) Send a letter of introduction to the medical professional. This letter should be given to the medical professional by the client and not given to the front desk staff or nurse. This letter will introduce your client and outline the exercise program you developed for the client as well as listing the client's complaints. In the letter request the evaluator to contact you with recommendations for modification of the client's exercise program.

2) Contact the medical professional's office the next day to find out if exercise modifications are warranted and/or if the client needs medical treatment. Also, thank the medical professional for assessing the client.

3) Contact the client and ask the outcome of the evaluation visit and the recommendations given to the client.

One of these three actions will allow you to obtain the information you need to modify the client's exercise program and avoid the loss of your client. Sometimes medical professionals may dismiss you because they simply don't understand you want to be involved in the management of the client's condition. This is where clearly outlining your role/scope as well as the benefits exercise offers to the client (without exercising the affected area) can win the day and develop a referral relationship with the medical professional. I can't say this will happen in 100% of the cases but it will help establish you as the post rehab professional in your community.

Dr Mike

Post Rehab Practice Builder...Developing an Affiliate Program

Have you heard of affiliate program many Internet marketers use to promote their products and skyrocket their revenue. Well David Gilks, MEPD owner of Core Essentials of Naniamo, BC developed his own affiliate program to market businesses owned by clients that use his studio and post rehab training services marketing his business to potential new clients. David's affiliate program titled the "Inner Circle - Platinum Card Advantage" is a unique marketing concept and this is the first time I have heard of it used to market post rehab services. Click the link below to listen to my interview with David. If you want to develop an affiliate program in your practice join our "Post Rehab Profits & Protocols" program by going to www.profitsandprotocols.com.

Dr Mike

When I make a referral to a medical professional my client never comes back, what do I do?

I am a strong advocate for referring clients in your post rehab practice to a medical professional for evaluation if you encounter a situation beyond your scope of practice. But more post rehab professionals are noting the complete loss of the client referred. The medical professional may advise the client simply to discontinue exercise or institute a program of treatment for the client without communicating the findings of the assessment and/or recommenndations for treatment. I can see how this can be very frustrating for the post rehab professional. In your attempt to act professionally by making a referral to lose the client annd receive no communication. I would certainly feel used.

I would follow up with the client directly and find out what recommendations were made. If you have made a referral and sent along a letter of introduction with your client, you certainly deserve to know the outcome of the visit. In this situation, I will admit this is not professional conduct on the part of the medical professional. Medical professionals regularly receive referrals and common practice is to send a follow-up report to the referral source with recommendations and a thank you. I can only guess the medical professional may not feel a referral from a fitness professional warrants a follow-up report. In one of my next blog posts I will note a strategy that will help you eliminate this situation and make it easier to communicate with medical professionals.

If you have encountered this issue, please share your experience with other post rehab professionals by commenting here on the Post Rehab Blog. Thanks.

Dr Mike

When do I begin exercise after a cortisone injection?

The post rehab professional is often faced with managing the post rehab client after a cortisone injection. I just got back from teaching our first post rehab skills workshop. During one of the workshop breaks the participants asked when is it safe to begin exercise after cortisone injection. First, understand cortisone injections are an attempt to break the "pain/inflammatory" cycle associated with an injury. Once the pain cycle is broken, exercise is used to strengthen and stabilize the area. Wait at least 24 hours before beginning any exercise after cortisone injection. The injection itself may cause pain. If the client has pain beyond the 24 hour period, wait until the pain from the injection has completely subsided before beginning exercise. Contact the client's physician or physical therapist before you begin exercise. Start with gentle exercise and a gradual increase in intensity based on the client's tolerance. Gentle ROM and stretching exercise followed by light resistance activities for the first one or two sessions after the injection is my recommendation then you can gradually progress back to the levels the client was able to tolerate before the injection. Remember, the cortisone is used to break the pain cycle to allow strength and stability training. The cortisone may completely eliminate the client's pain but the underlying pathology is still present. Progressive strength and stability training is a major factor in the resolution of the condition. If later during the course of the post rehab program the client's symptoms re-appear, contact the client's physician immediately for program guidelines or possible referral for further evaluation.

Dr Mike


Dr Mike

Post Rehab Tip #13 - What documents do I need for insurance reimbursement?

When seeking insurance reimbursement for post rehab services contact the client’s insurance claims adjuster. You will need the following documents when you make the contact:

a. Signed post rehab referral for the client's physician
b. Post Rehab Program Goals (functionally-based)
c. Post Rehab Program Design (include duration, frequency & number of sessions)
d. Post Rehab Assessment

Securing insurance reimbursement for post rehab services requires more than having these documents on hand. How to negotiate the insurance reimbursement maze is reviewed in detail in our "Insurance Reimbursement for Post Rehab Professionals" workshop. Dealing with insurance carriers is becoming part of the daily life for post rehab professionals. This and other streams of post rehab income are reviewed in our podcast titled "Multiple Streams of Post Rehab Income". Follow this link to listen in our how to develop multiple streams of income in your post rehab practice - Multiple Streams.


Dr Mike

3 Keys to Managing Post Rehab Bicipital Tendinitis

Tendinitis, regardless of the region affected, occurs often with athletes. Managing the bicipital tendinitis client is challenging but if following the "3 Keys" you will see a positive functional outcome. The 3 keys are:

1. Eliminate bicep activities until receiving approval from physician or therapist.

2. Strengthen the rotator cuff and scapular musculature.

3. Avoid overhead activities or any activities that increase pain.

Follow these 3 keys and you will develop safe and effective programs for the post rehab biceps tendinitis. Please click the link below to listen to my discussion of 3 keys.

Dr Mike

3 Keys to Managing the Post Rehab LCL Sprain

We spoke about managing the MCL post rehab client and now we will discuss managing the LCL post rehab client. Some of the keys are same for the MCL but there is one important distinction. The 3 keys are:

1) Limit knee flexion to less than 90 degrees.

2) Strengthen the quadriceps and hamstrings.

3) Avoid activities that increase swelling and/or pain.

These 3 keys are very similar for the post rehab management of the MCL client. Listen to my discussion of these 3 keys by clicking the link below.

Dr Mike

3 Keys to Managing the Post Rehab Achilles Tendon Rupture Client

Though we often see Achilles tendon ruptures in the middle-aged population, it is seen in athletes. Once the tendon has healed from the surgical repair or via conservative treatment, this client will need a post rehab program after discharge from physical therapy. The 3 keys to managing the Achilles rupture in a post rehab setting include:

1) Improve and maintain ROM

2) Increase strength and power in the gastroc and soleus

3) Improve stability for return to functional activities

Follow these 3 keys to establish a safe and effective post rehab program for the Achilles tendon rupture. Click the link below to listen to my description of these 3 keys.

Dr Mike

Post Rehabilitation - The Future is Bright and Profitable

AAHFRP offered the first post rehab course, the Medical Exercise Specialist workshop, in Washington, DC in 1994. The acceptance and usage of post rehab services by fitness participants, health clubs, medical professionals and insurance carriers has exceeded our wildest dreams. Our hope was to expose fitness professionals to the basic concepts in exercise management of common medical conditions. Now post rehab fitness has become a standard part of the rehab management model and we see more physical therapy clinics and hospital-based fitness facilities adding post rehab and medical exercise programs throughout North America.

The future of post rehab fitness and medical exercise services are bright. The aging of the baby boomers and the overwhelming numbers of hypertensives, diabetics and other chronic diseases will heighten the need for post rehab fitness and medical exercise services. Within the next decade we will see university exercise physiology and kinesiology programs offering concentrations in medical exercise and post rehab fitness. We will also see physical therapy clinics, sports medicine centers and hospital-based fitness centers establishing the "medical exercise specialist" or "post rehab conditioning specialist" as job titles within the organization with various levels of specialization and training. Insurance carriers will embrace medical exercise as a standard component of treatment for conditions such as diabetes, hypertension and other cardiovascular disorders. The same will be true of post rehab fitness for conditions such as osteoarthritis and disc herniations along with some surgical procedures including acl reconstructions, laminectomies and total joint replacements. Post rehab services will be utilized after physical therapy and chiropractic services once the client is medically stable and has received the maximum benefit from the treatment provided by the licensed medical professionals. Though insurance reimbursement will become common place for post rehab services, group programs will increase as insurance reimbursement decreases per session. Medical exercise specialists and post rehab conditioning specialists will become staff members in physical therapy clinics and sports med centers but licensure is quite a way off. States will begin registering fitness professionals. To obtain insurance reimbursement, post rehab professionals must hold the MES or PRCS certification as well as a personal training certification.

The next decade will one of tremendous growth for the post rehab arena. Opportunities will abound and income will grow but so will administrative tasks such as writing progress reports, documenting sessions and authoring progress summaries. This means a cottage industry will develop around post rehab fitness. Software programs, administrative workshops, liability insurance plans, practice management workshops and even lawsuits will become part of the post rehab phenomenon. Just think of it, higher incomes, greater respect from medical professionals, higher liability premiums and the need to practice defensively. Welcome to the medical community.

Post Rehab Tips #12 - Levels of Assistance

Sometimes you will receive a referral to work with a client that requires assistance with balance, transfers and ambulation. You must be aware of the three levels of assistance. The levels of assistance are:

a. Maximal Assistance
b. Moderate Assistance
c. Minimal Assistance

Click on the link below to listen to the definition of each level and how impact on the post rehab program.


Dr Mike

3 Keys to Managing the Post Rehab Rotator Cuff Client

Rotator cuff injuries are common in sports requiring overhead activities. The tear of the rotator cuff can be both painful and functionally limiting. The exercise management of rotator cuff tears is based in 3 keys that include:

1) Strengthen the rotator cuff muscles.

2) Avoid overhead activities and increase the subacromial space.

3) Strengthen the periscapular musculature.

These 3 keys form the foundation of a safe and effective post rehab program for the rotator cuff tear client. These keys will optimize the possibilities of a positive functional outcome. Click the link below to listen to the discussion of these 3 keys.

Dr Mike

Post Rehabilitation Red Flags.........when should you refer or proceed with caution?

When should you refer your client to a medical professionals? Do you know the signs your client needs an evaluation by a licensed medical professional? If you are not 100% sure, then using our post rehab red flags might be helpful. These red flags are reviewed in each of our post rehab workshops and these are a vitally important concept all post rehab and corrective exercise professionals must embrace and understand. The red flags are listed above. When you see these red flags, as a post rehab professional, you must refer the client to a medical professional or modify the client's exercise program. It's up to you, the post rehab professional, to determine is a referral or program modification is necessary. For more information on the post rehab red flags go to www.postrehabfoundations.com.

Dr Mike

Member Spotlight - Focus Integrated Fitness

Our members in the spotlight for this segment are the owners of Focus Integrated Fitness of New York City, Gabe Valencia, MES and Joe Masiello, MES. Gabe and Joe bring a very unique approach to the development of fitness programming and the education of personal trainers. This is a great interview. Every post rehab professional and anyone interested in developing their own fitness facility should listen. Please click the link below to listen to this fantastic interview.

Dr Mike

Corrective Exercise.....when to correct or when to refer?

As post rehab courses and guidelines proliferate, knowing when to appropriately use corrective exercise techniques and post rehab training programs seems to get lost in the discussion. Simply the presentation of a client with a postural fault, muscular imbalance or pain is sometimes not enough of a reason to begin corrective exercise. A thorough medical history and assessment on the client must be completed first. Also, discussion with the client's physician or physical therapist is required to ensure you have the full picture before proceeding with exercise. Its interesting that few corrective exercise or post rehab courses really focus on the pathology and assessment of these postural faults, pain and/or imbalances but they do readily encourage exercise. Remember, posture and pain may be the result of a long-term condition or fault and what we see is not what is really going on with the client. The introduction of corrective exercise can exacerbate a dormant condition. Sometimes pulling the string of a postural fault may cause the breakdown of other faults and result in the client having more pain. Now it is important to get to the underlying problem but if you can't anticipate the possible complications, then you shouldn't begin corrective exercise without a thorough history, assessment and discussion with the client's physician. Remember, what is you see is not what you get in posture or with pain. Though a thorough assessment, medical history, x-rays, CAT Scans and MRI's are not 100% accurate, these allow us to eliminate possible conditions. Then we can start to correct faults with a better understanding of possible causes. I am not saying corrective exercise is not great for clear cut postural faults which are easily corrected. But in the back of your mind you should always think, what other complications might be causing the pain or fault and have I given enough consideration to these complications. What you see with human posture and pain is seldom what you get. If you see red flags, talk to the client's physician or therapist. We will discuss the post rehab red flags in our next blog post.


Dr Mike

3 Keys to Managing the Post Rehab Low Back Pain Exercise Program

Back pain affects 80% of the American population at some point in their lives. For many, this back pain becomes a constant part of their lives. The exercise management of chronic low back pain (LBP) is an important skill the post rehab professional must master. LBP is seen in both the athletic and non-athletic populations. There are 3 key components of the exercise program for the chronic LBP client in a post rehab setting. The 3 key components are:

1) Cardiovascular training with appropriate levels of support.

2) Spinal stabilization including techniques in lifting, pushing, pulling and carrying as well as flexibility training.

3) Lower extremity strengthening.

These 3 components must be included in each LBP client's exercise program design. Include these 3 essential components and you will see positive outcomes with your LBP clients. Click the link below to listen to my discussion of these 3 key components.

Dr Mike

Post Rehab Tip #11 - The step-by-step medical history interview

A thorough medical history must be completed on each post rehab client. Verbally ask the client each question on the med history form. Direct interaction with the client allows for a much more accurate medical history appraisal and avoids the possibility of a medical condition slipping through the cracks. The medical condition missed in the medical history may result in the client exacerbating an old condition or causing a new injury. The most important aspect of the medical history is to listen. Your client will tell you every medical concern they have but you must listen closely for the subtle meanings within the medical history interview. The importance and approach to taking a medical history is reviewed in our Medical Exercise Specialist and Essentials of Post Rehab Fitness workshops.


Dr Mike

3 Keys to Managing Post Rehab MCL Sprain

Another common injury we see with athletes is the MCL sprain in the knee. The MCL is a stabilizer of the knee and often damaged. Though MCL ruptures are seldom surgically repaired, the occurrence of 1st and 2nd degree sprains is common. The 3 keys to managing this client in a post rehab setting are as follows:

1) Avoid full knee extension until authorized by physician or physical therapist.

2) Strengthen the quad and accentuate vastus medialis recruitment.

3) Avoid activities that increase swelling.

These 3 keys are the foundation of the post rehab program for the MCL client. Also remember, PFS is always lurking with the effused knee. Effuse is common with MCL involvement. Please click the link below to listen to the discussion of these 3 keys.

Dr Mike

Post Rehab Challenge
Your client is a 24 year-old cyclist. She sustained a 2nd degree of the left MCL. She has completed physical therapy and now she has full ROM but an atrohied quadriceps. She has some swelling and point tenderness at the MCL after cycling. How would you adjust the seat for this client and what motion would you limit until the swelling and point tenderness are gone? What complications are associated with knee swelling or effusion?

When does post rehabilitation begin......acute, subacute or chronic stage?

At what stage during the rehab process does post rehab begin? Does it start in the acute stage? Is post rehab only allowed during the chronic stage? Where should post rehab begin? Well there are no established standards on post rehab but we know the acute client is not ready for post rehab. For some clients in the subacute stage post rehab exercise is appropriate but we can say that 80-90% of all post rehab clients are in the chronic stage. The chronic client and/or the client in the late stages of sub-acute phase are the ideal post rehab client. The client is ready for post rehab when he or she is medically stable, is able to participate in 30-60 minutes of exercise with rest breaks, has completed physical therapy or chiropractic care, and has a referral from a physician. The chart belows outlines the stages of recovery and identifies key characteristics of each stage as well as the appropriate professional to deliver services. The chart will make the understanding of the stages of rehab clear to all post rehab professionals.

Dr Mike

3 Keys to Managing Post Rehab AC Joint Separations

AC joint sprains are common in contact sports. Sports such as judo have an abundance of AC joint sprains. AC joint sprains and separations are use synonymously. The danger to the AC joint is both cartilaginous and ligamentous. The damage to these structures causes inflammation, pain, instability and weakness in the shoulder. The AC joint separation, on presentation, looks similar to impingement syndrome. The 3 keys to managing AC joint separation are as follows:

1) Limit overhead and full adduction activities

2) Strengthen the rotator cuff

3) Identify AC joint separation

These keys will help you develop a safe and effective post rehab program for the post rehab AC joint separation clinic.

Dr Mike

Post Rehab Challenge
What are the signs and symptoms that identify the AC joint separation? How is the AC joint separation differentiated from shoulder impingement?

Have you really seen a sports medicine clinic?

Today I came across a great article in "Fast Company" magazine. One of the lead articles is titled "The Most Valuable Player in Sports". The article discusses James Andrews, MD of Birmingham, AL. Dr Andrews is one of the best known orthopedic and sports medicine surgeons in North America. I was lucky ennough several years ago to visit Dr Andrew's clinic in Birmingham and spend 2 days there learning their philosophy to orthopedics and sports medicine. This is one of the most comprehensive sports medicine clinics around. The incorporation of cutting edge orthopedics, advanced physical therapy and rehabilitation techniques and dynamic sports conditioning is the basis for the best sports med facilities. I was also lucky to do a week long fellowship at Cincinnati Sports Medicine in Cincinnati, OH. If you really want to see the ideal model of a sports medicine clinic visit one of these facilities or attend the annual Cincinnati Sports Medicine Symposium held in Hilton Head, SC in May. If you cant attend, purchase the symposium DVD's to learn advanced sports medicine concepts. You will be glad you did.

Dr Mike

3 Keys to Managing the Post Rehab Meniscal Tear Client

Meniscal tears are common in runners and other athletes. If you can manage the post rehab meniscal tear client, you will have great success as a post rehab professional. Arthroscopic surgery sometimes diminishes the importance of the rehab process afterward. This sometimes leads the client to neglect rehabilitation and start running before the meniscus has fulled healed and the quadriceps has regained its strength. The 3 keys to managing PFS are noted below:

1) Control swelling

2) Strengthen the quadriceps and recruit the vastus medialis

3) Avoid high impact activities


Dr Mike

Post Rehab Challenge
Your client is the same 46 year-old female noted in the previous 'post rehab challenge". Please explain the importance of the meniscus and why the menisci are the most important structures ih the knee and not the cruciates.

3 Keys to Managing the Post Rehab Patello-Femoral Syndrome Client

Patello-Femoral Syndrome (PFS) is another common condition seen in athletes. PFS is associated with weakness of the quadriceps and chronic effusion (swelling). PFS can curtail a post rehab training program. There are 3 keys to managing the post rehab PFS client. The 3 keys are listed below.

1) Recruit the vastus medialis.

2) Stretch the IT band.

3) Strengthen the quadriceps.

4) Control swelling - this is the bonus key.

Click the link below to listen to my discussion of these 3 keys.



Dr Mike

Post Rehab Challenge
Your client is a 46 year-old runner training for a 10K run. She reports low grade anterior knee pain after prolonged sitting. She also has mild swelling after running greater than 2K. Please develop the exercise program for this client and explain how the swelling might assist in the development of PFS.

3 Keys to Managing the Post Rehab Spondylolethesis Client

Spondylolethesis is another condiion commonly seen in athletes. Managing the spondylolethesis is challenging. Spondylolethesis are graded using a 1-4 or 1-3 scale. Severe spondylos (grade 3-4) are sometimes treated surgically. Those spondylos that are non-surgically managed (1-3) should be referred for post rehab conditioning after discharge from physical therapy. There are 3 keys to managing the post rehab spondylolethesis client. The 3 keys are:

1) Determine the grade of the spondylolethesis. This information will come from the physician, physical therapist or chiropractor.

2) Avoid lumbar extension 10 degrees beyond neutral.

3) Strengthen the abdominals and position the client is slight lumbar flexion for normal activities. Slight flexion protects the spinal cord from damage.

Follow these 3 keys to develop a safe and effective post rehab program for the spondylolethesis client. Click the link below to listen to my discussion of these 3 keys.


Dr Mike

Post Rehab Tip #10 - Overall Leg Strength in Post Rehab Fitness

"Overall Leg Strength" is a concept to be considered when working with clients referred with lower extremity disorders such as total knee or hip replacement and ACL rupture. Overall leg strengthening simply means strengthening the muscles of the lower extremity to lift 2-3 x bodyweight. This is important for climbing stairs, stepping off curbs and getting out of a chair. The lower extremity must be able to control and support the client's bodyweight. Closed chain exercises such as the lateral step up, leg press (both bilateral and unilateral) and wall squats improve overall leg strength. Overall leg strength is vitally important to the clients functional capacity and level of independence.


Dr Mike

3 Keys to Managing the Post Rehab ACL Reconstruction

As surgical technology improves so does the rehabilitation of the ACL reconstructed knee. The number of ACL reconstructions has increased as our understanding of the ACL has improved and our ability to diagnosis the symptoms and signs. ACL reconstructions are common in athletes. Let's list the 3 keys to managing these clients.

1) Control swelling!!

2) Activate the vastus medialis as quickly as possible.

3) Improve overall leg strength while protecting the new ACL graft.

These 3 keys are important during all stages of rehabilitation for the ACL reconstruction. Remember these 3 keys as you manage the post rehab ACL client and you will see must better functional outcomes.

Dr Mike


Post Rehab Challenge
Your client is a 27 year old fencer with a right ACL reconstruction which performed 22 weeks ago. He completed physical therapy and has moderate quadriceps atrophy but full pain-free ROM with both flexion and extension. His ACL was reconstructed using a hamstring graft. He is able to walk with no pain or gait deviation. He has de-rotation brace but he runs with a slight limp when in the stance phase on the right side. He has clearance from his physician and physical therapist to begin the post rehab program. Please explain what activities are restricted or contraindicated for the ACL reconstruction client and why.

3 Keys to Managing the Post Rehab Hamstring

Hamstring pulls are another common injury seen in athletes. Chronic hamstring pulls can limit athletic performance and drag on until properly managed. There are 3 keys to managing the post rehab hamstring client. These 3 keys include:

1) Allow time for proper healing;

2) After the tissue damage has healed, make the tissue pliable with stretching:

3) Use proper strengthening and stretching techniques to prepare the athlete for return to sports.

These are 3 very simple concepts but they are often overlooked in the management of the post rehab hamstring client. Remembering these 3 concepts will allow you to develop better and more effective exercise programs for your clients. Please click the link below to here my discussion of these 3 concepts.

Post Rehab Challenge
Where in the running cycle does the hamstring pull occur? Heel strike, footflat or push off?

Dr Mike

3 Keys to Managing the Post Rehab Shoulder Dislocation

One of the few conditions that requires immobilization for a significant period after injury is the shoulder dislocation. Dislocations are common injuries suffered by athletes. Once physical therapy care is over, the shoulder dislocation client should be referred to a post rehab program to continued strengthening. Let's outline the 3 keys to managing the post rehab shoulder dislocation client.

1) Improve joint stability

2) Strengthen the pectoralis

3) Avoid extreme shoulder horizontal abduction, external rotation and extension

These 3 keys are a foundation for the post rehab shoulder dislocation program. Developing the post rehab program based on this foundation will produce positive functional results.

Dr Mike

Post Rehab Challenge
Your client is a 48 year old female who fell on an outstretched hand resulting in a shoulder dislocation. She completed a 7 week program of physical therapy. She presents at your facility with a post rehab referral signed by her physician. She has 160 degrees of shoulder flexion and abduction. Both movements are pain free. She does have weakness when reaching overhead but no pain. Her rotator cuff muscles are weak. Which muscle(s) are important to strengthen to improve her joint stability? Which ligament structures are damaged with shoulder dislocation?

Post Rehab Tip #9 - Understanding Bone Spurs or Osteophytes

Bone spurs are known as osteophytes. Osteophytes occur as a result of osteoarthritic changes. Rheumatoid arthritis (RA) does not cause osteophytes. RA usually polishes the end of long bones. When the physician looks at an x-ray, an indicator of osteoarthritis is the presence of bone spurs along the margins of the joint. Osteophytes are a normal occurrence with osteoarthritis.


Dr Mike

3 Keys to Managing the Post Rehab Ankle Sprain

Chronic ankle sprains are a constant presence in training rooms in all sports. The ankle sprain is the most nagging injury an athlete can sustain. Without proper management, the residual effects can limit the athlete for months. There are 3 keys concepts in managing the post rehab ankle sprain. The 3 keys are:

1) Control swelling at all times. Use ice, NSAID's (prescribed by a MD or DO) and elevation to control the swelling.

2) Strengthen the peroneals using both open and closed chained methods. The peroneals are the primary muscles to strengthen but other muscles in the leg should be strengthened also.

3) Even a series of first degree sprains will cause instability. Refer the client for assessment by a medical professional if instability persists.


Every ankle sprain, regardless of severity, should be seen by a physician, chiropractor or physical therapist. Once the client is past the acute and subacute phases, post rehab exercise may begin. In many situations, the client attempts to manage his ankle sprain on his own and this results in a prolonging of the chronic stage and instability. Exercise management of the ankle sprain is important to the restoration of function. If you remember these 3 keys, you will see significant improvement in your client's function. Please click the link below to listen to my explanation of these 3 keys.

Dr Mike

Post Rehab Challenge
Your client is a 28 year old soccer player with a recent history of a second degree sprain of the left ankle. After 2 weeks of treatment by the team trainer and release by the team physician; the client is now practicing again. He has no pain and very minimal swelling. He is icing his ankle twice per day and wearing a brace during practice. What is the most common type of ankle sprain and which ligament is usually involved? Please outline both open and closed chain exercises you would design for this client to improve his functional capacity.

Post Rehab Insurance Reimbursement

For many fitness professionals entering the post rehab and medical exercise market, their first question is, "can I receive insurance reimbursement for providing post rehab services"? Well, the answer is yes, but there is a "post rehab ideal client scenario" that makes the possibility of reimbursement much greater. The "ideal post rehab scenario" and/or "post rehab insurance reimbursement criteria" is outlined below.

The key for post rehab professionals is understanding the insurance reimbursement maze and being able to identify the client scenario that offers the best chance for reimbursement. There is an "ideal post rehab scenario" that is usually reimbursed to some degree by the insurance carrier. We have titled this the "Post Rehab Insurance Reimbursement Criteria". It is as follows:

1) The client must have insurance coverage through a workman's compensation, motor vehicle accident claim or have a third party insurance carrier such as Blue Cross/Shield, ATENA or Connecticut General (these are just examples) .

2) The client must have sustained a traumatic injury and/or underwent surgery. Example of this would be a client with a ruptured anterior cruciate ligament in the knee or a disc herniation in the lumbar spine either of which has surgery to correct the injury. These clients need long-term supervised exercise after the completion of physical therapy or chiropractic care is done.

3) The client must have residual functional deficits that are present after the client has completed physical therapy and/or chiropractic care. At some point the client no longer needs PT or chiropractic but there are still functional deficits that impair the client's function. These include functional limits in ROM/flexibility, strength, power, endurance, balance, proprioception, joint stability, muscle recruitment and coordination. The post rehab exercise program addresses these deficits after discharge from physical therapy.

4) The client has a signed referral from his or her physician or physical therapist requesting a supervised functional conditioning program.

5) The client has received the maximum benefit from physical therapy and chiropractic care. The client has been through a course of physical therapy and/or chiropractic and reached the maximum level of function with these services and now is discharged. The client must be seen by a licensed medical professional prior to referral for post rehab services. This ensures the proper care and treatment are delivered in the acute and subacute stages following the injury.

The process of insurance reimbursement for post rehab services is more complicated then simply holding a post rehab certification such as the "Medical Exercise Specialist". I must admit we never thought we would see MES' or PRCS' receiving insurance reimbursement. Your best chances for reimbursement are far greater when working with clients that meet criteria. As you can see, the post rehab reimbursement criteria encompasses a wide range of clients. Medicare and Medicaid will not reimburse for post rehab services.

Click the link below and listen to my explanation of the post rehab criteria. We also have an audio-based workshop titled "Insurance Reimbursement for the Post Rehab Professional" that discusses the process and procedures for securing insurance reimbursement. The course takes you step by step through the insurance reimbursement process. For more information visit www.postrehabinsurancereimbursement.com.


Dr Mike

Member Spotlight - Bill Rothschild, BS, MES

Dr Mike interviews Bill Rothschild, BS, MES. Bill is the director of the Monterey Sports Center where his has developed a comprehensive "medical exercise/post rehab" program. Click the link below to listen.

Dr Mike

Post rehab conditioning is the story behind every Olympic star!!

Weren't the opening ceremonies of the Olympics fantastic!! The Beijing Olympic Committee did a magnificent job pulling off the opening ceremonies. My favorite part of the opening ceremony is the procession of the athletes into the stadium. I really enjoy seeing the athletes of lesser status meeting the more prolific athletes on the infield as the torch ceremony proceeds. As I watched tonight, I counted no less than 27 potential gold medalists with histories of recent major injuries, but they are now making a run for gold. I realized each of these athletes at some point followed up physical therapy or chiropractic care with a well developed post rehab conditioning program.

Many of you reading this blog have worked with high level athletes and you know the importance of using exercise to manage athletic injuries. So over the 17 days of the Beijing Olympic Games I will write each day about a common injury I have encountered as a physical therapist in my 23 years of managing athletic injuries. I will discuss the three keys to managing each condition and give you a flowchart from our PREPS - Post Rehab Exercise Protocols to help you better manage each condition from a post rehab perspective. Each day I will record the "3 keys to managing....." for you to listen to or download. After each session I will also give you a "post rehab challenge" for you to analyze and solve to enhance your post rehab critical thinking process. Answer all the challenges correctly and I will send you our Post Rehab Tips CD free of charge. This CD contains video clips, post rehab regional exercise guidelines and 101 post rehab tips you can use immediately with your clients. Join me tomorrow for our first condition and learn the 3 keys to managing the post rehab shoulder impingement client. CYA tomorrow.


Dr Mike

3 Keys to Managing the Post Rehab Impingement Client

Impingement syndrome is common in athletes. Usually seen in athletes involved in overhead activities. There are three key concepts to remember when managing the post rehab impingement syndrome client.

1) Increase the size of the subacromial space using the pendulum exercise.

2) Strengthen the rotator cuff muscles using resistance techniques.

3) Strengthen the periscapular muscles (rhomboids, traps and serratus anterior) to assist with stabilization of the scapula against the thoracic cage.

These are the 3 keys to managing impingement syndrome with exercise. The actual step by step exercise protocol is far more detailed with specific exercise techniques and progression guidelines. To get more information or to purchase the PREPS - post rehab exercise protocol for impingement syndrome go to www.postrehabprotocols.com.

If you follow these 3 key concepts you will produce positive functional outcomes with your impingement clients. To listen to my recording of the 3 keys to exercise management of the post rehab impingement client click the link below.

Post Rehab Challenge
Your client is a 21 year old swimmer. She specializes in the 100 meter butterfly. She was treated 3 months ago for right shoulder impingement. She was discharged after 7 visits with no pain with overhead activities or night pain and full shoulder strength and ROM. She is now competing in Beijing. How would you manage her exercise program during the 7 days before her event to ensure maintenance of her strength gains as well as avoiding any exacerbation of her shoulder. Please outline your program and post it in the comments section of our blog as well as emailing the program to DrMike@postrehab.com. Remember, if you correctly answer all 16 post rehab challenges during the Olympic Games, you will receive a free Post Rehab Tips CD.

Dr Mike

How do I write a post rehab progress report?

When writing your post rehab progress report make sure you include these 5 essential components:

1. Who is the client?
2. Why was the client referred?
3. What services are you performing?
4. How is the client progressing? (strength, ROM/flexibility, endurance, balance and functional activities)
5. What are your recommendations for the client's exercise program?

If you include these five components and don't make the mistake of adding useless information, this will make your reports easy to read for medical professionals and enhance your professionalism in their eyes. If more detailed information, samples of post rehab progress reports and to listen to the our podcasts on writing post rehab progress reports and post rehab assessment reports go to www.postrehabreports.com or www.postrehabforms.com.

Dr Mike

Medical exercise specialists - can you recognize PFS?

4 early signs your client has patello-femoral syndrome

Patello-Femoral Syndrome (PFS) can easily ruin a post rehab program and you may never pick up on the early signs. PFS is a very common development in clients with knee pathologies, especially in those clients having recently undergone a recent knee surgery and/or with chronic effusion (swelling) of the knee. Low grade anterior knee usually appears in these clients. It may show up after sitting and watching a full length movie in the theater or sitting during a coast to coast flight. The pain gradually increases to the point of limiting range of motion and function. Activities involving knee flexion or extension cause severe pain and make further rehabilitation almost impossible. Early signs of PFS include: 1) vague anterior knee pain; 2) the feeling of the knee giving way on stairs; 3) low grade swelling in the knee and 4) an underdeveloped vastus medialis. These are the four early signs of PFS. If you see any one of these signs, avoid continued resisted knee extension or flexion and encourage the client to ice the knee and perform standing terminal knee extension exercise to recruit/activate the vastus medialis. If the pain is severe and limits function, refer the client back to their physical therapist, chiropractor or physician.

Remember, PFS is always lurking for the client with chronic knee pain and effusion. The best way to manage PFS is prevention. With all clients suffering from knee disorders insert standing terminal knee extension (STKE) into the post rehab program as soon as the client is able to tolerate the exercise. Start with sets of 15 reps and gradual work up to 25-50 reps. STKE prepares the quadriceps for walking, absorbing the compression forces associated weight-bearing and the medialis for controlling the tracking of the knee. Calculate the number of steps you client takes with a standard daily activity such as walking to the rest room. Use this number as the basis for the STKE sets and reps. All the reps shouldn't be completed at once but through a series of sets over the course of the post rehab session. Click the link below to see a demonstration of the standing terminal knee extension exercise.

Dr Mike

Medical Exercise Specialist and Post Rehab Conditioning Specialist - Think Critical Job Demands When Establishing Sets and Reps

Think function and critical job demands when establishing sets and reps with post rehab and medical exercise program design. If the client's critical job demands require walking the equivalent of a football field two to three times during his or her shift, two to three sets of 10-15 reps won't prepare the client for return to work and certainly doesn't give the client a chance for a successful outcome. 30-45 reps doesn't give the client the necessary intensity to meet the critical job demands. Sets and reps take require a total of 150 to 200 reps might be closer to the demands placed on the client at work. Now we do not start the exercise program with 150 reps but we work toward that goal. Remember to recognize the need for sets and reps that mimic critical job demands. The concept of critical job demands applies to post rehab clients as well as industrial workers and athletes. So, are you preparing your client for a postive functional outcome when he or she returns to work?


Dr Mike

Get Booked Solid!!

Hi folks. I just finished reading two great books recently by Michael Post. Michael is a great small business and service professional marketing specialist. Michael has two great books, "Booked Solid" and "Beyond Book Solid". These two books are written for service professionals such as personal trainers. They do a great job giving your marketing concepts and ideas to help book yourself solid. If you are a Facebookie, as I am, add Michael Port as a friend on Facebook and find information on his weekly free teleseminar. While you are on Facebook you can add me as a friend also, Michael Jones....look forward to seeing you there.


Dr Mike

Post Rehab Tip #8 - The Use of the Thomas Test

The post rehab and/or corrective exercise assessment of the lower extremity commonly includes the the Thomas test. The Thomas test is often illustrated and demonstated incorrectly with the pelvis positioned far back on the surface supporting the client. The test should be performed with the ischial tubs placed on the edge of the surface supporting the client but the tubs are fully supported. The error in placement of the pelvis will cause inaccurate test findings. Please watch my demonstration of the Thomas test by clicking the link below.




Dr Mike

Medical Professionals Transition to Post Rehab

More medical professionals have contacted our office in the last few months with thoughts of transitioning from the clinical environment to the post rehab arena. Nurses, chiropractors, physical therapists and physical therapy assistants are finding the gains working with clients in a fitness setting are just as rewarding as those made with clients in a rehab setting. Though they may not have a large repertoire of exercise techniques to select from, their grasp of the medical based client helps these newcomers more than hold their own in the fitness setting. We would like to hear from medical professionals making the transition to post rehab fitness. Share your thoughts, concerns and success stories about your transition to fitness. Thanks!!

Dr Mike

Post Rehab Challenge

Here is an interesting case study you might like to figure out. You receive a post rehab referral from a local rheumatologist. The client is a 48 year old female with a history of rheumatoid arthritis and two recent motor vehicle accidents (the last accident was 5 months ago) with subsequent cervical injury. She completed a course of chiropractic care to manage the cervical pain. She no longer has cervical pain and she full cervical ROM but she complains of right shoulder pain. The shoulder pain occurs with overhead activity and movements across the midline of the body. She also has pain at rest along the lateral aspect of the right shoulder in the area of the deltoid. Her x-rays after the second accident show no fracture. The shoulder pain seems to occur with cervical right side-bending and right rotation. X-ray and MRI of the right shoulder show are unremarkable. What cervical nerve root innervates the lateral aspect of the shoulder? How does right cervical sidebending/rotation effect the client's shoulder pain? Please email your responses to this case study to DrMike@postrehab.com.

Dr Mike

Selling Post Rehab Fitness Using the Assessment

For medical exercise specialist and corrective exercise specialists selling personal training and post rehab sessions is becoming more challenging in this economic environment. I interviewed a former student, good friend and very successful post rehab professional, David Gilks, MES, MEPD of Nanaimo, BC. David shared his strategies for selling personal training and post rehab sessions using the post rehab assessment. Click the link below to listen in our this interview. I guarantee it will change your concept on the use of the post rehab assessment as a sales tool.

Dr Mike

My Post Rehab Story - Here's how the Medical Exercise Specialist certification started!

Hi, I am Dr Mike and in 1994 we offered the first post rehab certification for fitness professionals, the Medical Exercise Specialist workshop and certification. I am asked frequently how it started. So I would like to share this story. Please click the video link below to learn how the MES and our other post rehab certifications began more than 14 years ago. For more information on our certifications visit us at www.postrehab.com.

Post Rehab Tip 7 - The Components of Function

Medical Exercise Specialists and Post Rehab Conditioning Specialist are bombarded with information on "functional training" programs. It's important to understand the components of function and how exercise will impact on the overall functional capacity of the post rehab client. Functional improvement is the most important aspect of rehabilitation. The components to function include:

If any or all of the components of function improve with exercise, then the client's overall functional capacity will improve. Remember, its all about "function" with the post rehab client. Click the link below to listen to this post rehab tip.

Dr Mike

The post rehab fitnesss/medical exercise approach....do you have a system?

Managing the post rehab client requires a systematic approach to assessment and exercise program design. The first step is understanding the related clinical anatomy and pathology of the client's condition. The next step is understanding what NOT to do with regard to exercise for the client. Once you understand what not to do now you must determine the key areas that must be assessed to determine the client's exercise capacity and function. After you have completed the client assessment now you may proceed with establishing an exercise program. Each post rehab client must be approached using this step-by-step systematic approach.

1. Understand the related clinical anatomy and pathology.
2. Based on the client's condition what exercises and/or activities are contraindicated.
3. Determine the key assessment techniques, based on the client's condition, you must utilize to assess the client.
4. Develop a safe and effective post rehab exercise program based on your assessment findings.
   

If you can establish a systematic approach to developing the post rehab program, you will increase your clients success levels as well as establish yourself as the post rehab expert in your community. We use this same approach in our PREPS - Post Rehab Exercise Protocols. Visit www.PREPS-Protocols.com for more information and to download a sample protocol.


Dr Mike

Post Rehab Product Spotlight - TubeTrak

The TubeTrak is a great new post rehab product developed by Fran Scheel, MS, MES. The TubeTrak is a great tool you may use to provide rubber tubing resistance for several regions of the body. I tried the TubeTrak with a few clients and it's easy to use and provides a simple means of giving resistance in functional movement patterns for a wide range of joints and conditions. If you have a small studio and you need a way of providing resistance with rubber tubing, TubeTrak might be your answer. Go to www.tubetrakstation.com for more info.