- How does working with you differ most from working with other clinicians?
Care begins with taking a specific verbal history. In terms of the verbal history, the questions I ask may differ from those of others. Part two is the physical exam; the biggest difference here is that I also may examine parts of the body that are distant from the location of complaints. The third part of my orthopedic evaluation is what differs most significantly. While I utilize quick orthopedic special tests (OSTs) on occasion (eg meniscal tests), and may recommend imaging tests, the test I rely on most is McKenzie’s repeated movement testing. Here, the patient performs repeated movements in the clinic and at home as we assess the effect of thorough specific movement on symptoms and the physical findings from part two. In most cases, the home program involves performing a movement roughly every two hours. Subsequent visits follow a similar pattern to the initial visit in that we continue to assess the effects of specific movements as needed, ultimately determining the diagnosis and therefore what treatment is most effective for the individual patient. - What exactly is mechanical diagnosis and therapy (MDT)?
Mechanical diagnosis and therapy (also known as MDT or the McKenzie method) is essentially an understanding of joint biomechanics. Clinicians who know the concepts of MDT therefore may find that a patient’s disorder is a mechanical joint problem that can be fixed with 1-2 movements. I think of it as getting the body back on track, and find 70-80% of orthopedic disorders fall into this category. If the diagnosis is not a mechanical joint disorder, we can more confidently make that separate diagnosis and apply the specific matched treatment. While I have a doctorate in “mainstream” physical therapy (and use that skill set, too, of course), MDT provides me with a more complete understanding of the musculoskeletal system that I argue most clinicians lack. That is, recognizing that joint mechanics play a pivotal role in musculoskeletal health – not just structures like bones, contractile tissues like tendons and muscles, nerves, or soft tissues like ligaments, labrums, menisci, or cartilage. Put another way, we must investigate physiology and not simply blame anatomy (even if sophisticated pictures show the anatomy is not perfect).
3. Can you diagnose my problem?
Yes; my education at the doctoral level and specialized post-doctoral orthopedic training give me the knowledge to diagnose as well as treat pathology. I examine more than just the area of symptoms when looking for the root cause and use a 70-minute evaluation combined with the results of thorough testing, usually continued at home. Diagnosing must be based on clinical reasoning and relevant, reliable testing – physically examining the integrity of a patient’s joints, muscles, nerves, etc. In other words, challenging the integrity of the body’s movement system by really moving it. This is in contrast to the prevailing idea that orthopedic disorders can be successfully diagnosed quickly based mainly on imaging and orthopedic special tests (OSTs). Should I determine that testing outside my office is needed such as x-rays, MRIs, bone scans, etc., I will make that recommendation. Lastly, should the diagnosis reveal that another intervention is needed (not physical therapy), I will make that recommendation as well.
4. How many visits will I need?
The amount of visits it will take depends on the diagnosis and the information gleaned from the evaluation and subsequent visits, but the average is six. One goal of mine is to empower patients to treat themselves and visits are minimized as much as possible. That being said, the number of necessary visits is also based on how compliant patients are able to be with the prescribed program. If physical therapy is not the best option for resolution of a disorder, that is determined through progressive testing usually not exceeding five visits.
5. How long will it take to get better?
As with question 4, this is better answered once I can determine a diagnosis. It varies widely. Sometimes a disorder is reversed in one week. On the other hand, in the event a patient has had symptoms for many months or years, in the case of certain diagnoses, or in the case of lack of compliance, the expectation could be that it will take months. In those instances, visits are spaced out and held at intervals based on necessity.
6. Will I be given a home program?
Absolutely. Most (not all) patients will need to perform one movement at least 6 times per day. It will take no more than 5 minutes each time, usually taking 1-2 minutes. In most cases, you will be instructed how to make helpful lifestyle postural changes in your daily life as well, which largely entails adjusting how you sit, but could include other situations. The effects of the home program inform decision-making and thus treatment.
7. What happens on the first visit?
I will first take a specific verbal history so that I have a clear understanding of the problem. Second, I will perform the physical exam, which entails taking baselines such as range of motion, strength, nerve extensibility, and functional movements. Baselines may be taken at the site of symptoms and/or other parts of the body. Part three is testing. For most patients (not all), the test we’ll focus on is repeated movement testing. In some cases, I employ other testing such as one or more OSTs or request imaging tests. I will explain what we find and how we will proceed. To wrap up, I will provide your home program and answer any questions.
8. Do you use …?
I do not utilize dry needling, cupping, Gua Sha or other soft tissue instruments, acupuncture, acupressure, electric stimulation, ultrasound, or laser for orthopedic disorders. If I think you need heat, ice, or something similar that can facilitate healing, I will ask you to do that at home. I focus on active movement and education because I believe it is the most effective way to address orthopedic disorders.
9. What is the training in mechanical diagnosis and therapy (MDT)?
Because Robin McKenzie’s work is not regularly taught in academia, McKenzie Institute branches exist around the world to teach clinicians his work. Interested clinicians can become certified or diplomaed in MDT. Certification involves attending courses and passing a written and manual exam. Becoming a diplomate requires certification, a semester of online study, working with mentors full-time in person for 9 weeks, and passing an oral exam. I did my in-person training in Austin, Texas and received my diploma in 2021, becoming the 505th clinician globally with this specialization.
10. Do you accept insurance?
I do not accept insurance. Patients pay me directly. I am exclusively out of network.
11. Will my insurance company reimburse me for these out-of-network visits?
Most commercial (not government) insurance companies do, but you will have to ask your specific insurance provider. As an example, some reimburse patients 70% of their out-of-network costs. I am happy to provide an itemized receipt (superbill) for office visits for those with a primary commercial insurance provider in the event that they do.
12. Do I need a referral or prescription?
In Washington, D.C., you do not. Patients have direct access to physical therapy in Washington, D.C. Insurance companies, however, may require one for your reimbursement purposes. If you plan on seeking reimbursement for visits with me, you should check with your insurance company for their rules. For more general information, you can go to the American Physical Therapy Association website.
13. Can I reach you between visits?
Yes. I am happy to personally respond to simple emails and take brief phone calls between visits during normal business hours. I do not text with patients. Clinical decision-making, however, is based on appointments, not emails or calls.
14. How can I pay?
I accept credit cards, checks, cash, Venmo, PayPal, and Zelle.
15. Do you accept health spending account or flex spending account credit cards?
Yes.
16. Do telehealth/video appointments work?
In my experience, yes. I have been doing video appointments for several years with good success. It has its challenges, but they’re typically surmountable. In fact, as repeated movement testing is based on active movement, this method is well suited to video appointments. I prefer patients use a laptop or tablet to allow for a larger camera view and to have some space to move around. Sometimes I may ask if there is someone else in the home that can assist us, but not always. Though in-person visits offer a more personal experience and are my preference if there’s the option, video appointments (either out of convenience or necessity) are usually equally effective, but not always.
17. Are evening and weekend appointments available?
Yes. In addition to normal business hours, I can see patients evenings and weekends if needed.