KEEPING UP WITH WASHINGTON

As many of our patients know, our Social Media Guru Anna is attending Washington University in St. Louis School of Medicine to complete her Physical Therapy program. Washington University, sitting at the forefront of medical innovation, and priding themselves on their emphasis in research, passes along an electronic newsletter/blog/journal called The Record to all students, staff, and faculty. 

The Record is a product of The Source, a news hub created and directed by Washington University, and provides access to all publications including: The Record, Newsroom, and Washington Magazine. 

The information passed along in these articles discusses new projects, research that has received awards, new medical information discovered or accelerated here on this very campus. If you're at all interested in keeping up with the medical accomplishments at Washington University, Barnes Jewish, or St. Louis Children's Hospital, please visit:

https://source.wustl.edu/

for more information. 

MUSCLE TIGHTNESS

Why do muscles feel tight? Does that mean they are short? That they can't relax? And what can you do about it?  

Tightness Is A Feeling, Not Just A Mechanical Condition  

When someone says they feel tight in a particular area, they might be referring to several different complaints. So I try to find out: 

Are they talking about poor range of motion? 
Or maybe range of motion is fine, but movement to the end range feels uncomfortable or takes excess effort.
Or maybe the problem isn’t really with movement, but just that the area never reels feels relaxed. 
Or maybe the area feels basically relaxed, but has some vague sense of discomfort - a feeling that is unpleasant but too mild to be called pain.  
This ambiguity means that the feeling of tightness is just that - a feeling - which is not the same thing as the physical or mechanical property of excess tension, or stiffness, or shortness. You can have one without the other. 

For example, I have many clients tell me their hamstrings feel tight, but they can easily put their palms to the floor in a forward bend. I also have clients whose hamstrings don't feel tight at all, and they can barely get their hands past their knees. So the feeling of tightness is not an accurate measurement of range of motion.

Nor is it an accurate reflection of the actual tension or hardness of a muscle, or the existence of "knots." When I palpate an area that feels tight to a client (let’s say the upper traps), they often ask - can you feel how tight that is?! 

I often say something like: 

Ummmmmm ...... no. It feels just like the surrounding tissues.
But I completely understand that it FEELS tight in this area and you don't like it. 
I don't like the feeling of tightness either so I want to help you get rid of it. But the feeling of being tight isn’t the same thing as that area actually being physically tight. Make sense? 
This actually does make sense to most people, and they find it mildly interesting. I want people to understand this because it might help them reconsider a misconceived plan they may have already developed for curing their tightness - such as aggressive stretching, fascia smashing, or adhesion breaking. So now they are willing to consider an approach that is a bit more subtle than driving a lacrosse ball halfway through their ribcage. 

Why Do Muscles Feel Tight If They Are Not Actually Tight?

So why would a muscle feel tight even if it physically loose? 

I think we can use pain as an analogy. Pain can exist even in the absence of tissue damage, because pain results from perception of threat, and perception does not always match reality. Pain is essentially an alarm, and alarms sometimes go off even when there is no real danger.

Perhaps a similar logic is involved in the feeling of tightness. The feeling happens when we unconsciously perceive (rightly or wrongly) that there is threatening condition in the muscles that needs a movement correction.

So what is the threatening condition that a feeling of tightness is trying to warn us about? Surely it is not just the presence of tension - muscles are made to create tension and we often feel tightness in muscles even when they are almost completely relaxed. 

So tension is not a threat, but the absence of adequate rest or blood flow is a threat, which could cause metabolic stress and activate chemical nociceptors. So the problem that a feeling of tightness is trying to warn us about is not the existence of tension, but the frequency of tension or the lack of blood flow (especially to nerves, which are very blood thirsty.) 

With this in mind, I think of the feeling of tightness as a variety of pain, perhaps a pain too mild to deserve being called pain. But it is definitely bothersome. And it has a certain flavor or character that motivates an interest in changing resting posture, or moving around or stretching. Which is different from certain pains, which often make you want to keep still. Maybe we could say that pain is warning us to not move a certain area, while tightness is warning us to get moving.  

How Can You Cure Muscle Tightness?

I think we can probably treat the feeling of tightness in the same way we treat pain - by changing one of the many "inputs" that cause the nervous system to perceive threat in the body, such as nociception, thoughts, emotions, memories, etc. 

Some pains are very obviously related to movement or postural habits. We can know this if someone says something like: "It hurts when I do this, and it hurts even more when I do more of this, and it hurts less when I do less of this." In this case, changing movement or posture is likely to help because it will reduce the main driver of the pain – mechanical nociception caused by movement.

On the other hand, there are many other cases of pain, particularly chronic pain, that are more complex – the pain doesn't correlate very much with certain movements or postures, but instead with other variables like time of day, sleep duration, emotional state, stress level, diet, general exercise, or some random unknown factors. In this event, it is unlikely that mechanical nociception caused by movement is the main driver of the pain, and more likely that peripheral or central sensitization are playing more of a role.

I think we can look at the feeling of tightness in the same way.

In most simple cases of feeling tight, the cause is obvious – we  have been stuck in the same posture or movement pattern for too long, and our muscles need a rest or change of position to reduce the ischemia or metabolic stress that is causing nociception in certain areas. For example, if we spend hours in a car, or an airplane, or behind a computer, we will instinctively feel compelled to stretch and move, and this will usually alleviate any feelings of stiffness or yuckiness.

Of course, most clients who complain of chronic tightness have already tried and failed at this simple strategy. The feeling of stiffness remains for hours and days at a time, comes and goes as it pleases, and is less related to posture and movement. 

In these cases, the driver of the discomfort may have more to do with the nervous system becoming either peripherally or centrally sensitized to the need for more blood flow in certain areas. This could happen through local inflammation, adrenosenstivity, increased sensitivity at the dorsal horn, or maybe even learned associations between certain environments (say computers) and certain sensations (e.g feeling like crap). 

So how do we reduce this sensitivity? 

There isn't an easy answer to this question, because if there was, it would solve the problem of chronic pain, and no one is figured out how to do that yet. But if I'm right that the feeling of tightness is a mild form of pain, then it should at least be easier to deal with.

Below is a list of several methods people often use to address a chronic feeling of tightness, along with some thoughts about each strategy from the above perspective. You'll notice that some of the recommendations run exactly opposite to what people often do. 

STRETCHING

We instinctively stretch muscles that have remained in a short position for a while, and this usually makes us feel immediately better.

But, as noted above, most people who suffer from chronic tightness have already tried and failed at this strategy, which suggests the issue is less about bad mechanics and more about increased sensitivity.

The problem is that many people, and indeed many therapists, will think that the failure of a few simple stretches indicates the need for a far more aggressive program.
Damn hip flexors STILL feel tight.
Damn hip flexors STILL feel tight.

This would of course make sense if the root of the problem was short or adhered tissues. But if the root problem is in fact increased sensitivity, then aggressive stretching might just make the problem worse. On the other hand, stretching can often have an analgesic and relaxing effect.

SOFT TISSUE WORK FOR TIGHTNESS

There are various soft tissue treatments (deep tissue massage, foam rolling, Graston, ART, IASTM) intended to lengthen short tissues, break adhesions, or melt fascia, etc. This is very likely impossible, as I and many others have pointed out. 

But could these treatments decrease sensitivity and make someone feel less tight? For sure, by activating descending inhibition of nocicieption, which is a well-known effect of painful stimulation that is expected to bring health benefits.

But of course these treatments also create nociception, which tends to increase sensitivity. It's a fine balance that depends on the individual and many other variables. Again, if it feels good do it, but it's an option not a necessity, it's only temporary, and you should keep in mind the reason for doing it.

MOTOR CONTROL FOR MUSCLE TIGHTNESS

Many forms of movement therapy are essentially motor control approaches – they seek to change movement, postural and breathing habits so they are more efficient, eliminate parasitic tension, develop the skill of relaxation, etc.

Habits are hard to break, but this strategy is worth a shot, especially in cases where tightness seems related to certain postures or movements. Of course, where the situation is more complex, motor control shouldn't be expected to fix the problem on its own.

EXERCISE AND RESISTANCE TRAINING

People tend to associate strength training with becoming tighter. During exercise, muscles of course become very tense, and they may feel stiff the next day because of delayed onset muscle soreness. There is also the (false) idea that strength training makes muscles shorter and less flexible. 

These concerns are unfounded. In fact, full range of motion strength training can increase flexibility, perhaps more than stretching. It creates local adaptations in muscle that may improve endurance and make them less likely to suffer metabolic distress. And exercise also has an analgesic effect and can lower levels of inflammation that cause nervous system sensitivity. 

Here's a personal anecdote. Back in the days when I did yoga I had much more flexibility, but my hamstrings always felt tight. Then I quit yoga and started doing a lot of kettlebell swings. My forward bend decreased a bit, but the feeling of hamstring tightness was GONE, even though I was working the hamstrings HARD. In its place was a feeling of functional strength and capacity, which I imagine decreased any perception of threat related to lengthening my hamstrings.  

Of course if you overwork your muscles from strength training and don't let them recover, they will get sensitive, stiff and sore. But if you work them the right amount - enough to create an adaptation and not too much to cause injury or prevent full recovery - then you will make them healthier, stronger, and yes - less stiff.

WHY YOU SHOULDN'T EVER SKIP YOUR STRETCHES

Here at Champion Performance and Physical Therapy, we have a number of patients who, while they eat healthy, exercise consistently, and get plenty of nourishment and water, are in pain because they're missing one of the most under appreciated aspects of physical health in their daily lifestyles - stretching. 

It may seem like the most basic additive, but you must remember: the skeletal body is a lever system manipulated by musculature. In other words, your skeletal system will not move without the help of your muscular system, and each bone is almost entirely surrounded by muscles for this purpose.

During exercise (and after your warm up), your body is warm due to increased blood flow, the muscles are loose and firing.  Afterward, the muscles will cool, and if not properly stretched, will stiffen due to the biochemical aftereffects of exercise. While an effective fitness program should absolutely consist of cardiovascular training and strength training, the flexibility component is often overlooked. 

This is where skeletomuscular injuries come into play, specifically those relieved via physical therapy. When muscles tighten and stiffen, they pull just slightly on the bones in their direction. For example: runners often have tight hip flexors and quadriceps (the front of the thigh).  These muscles attach and originate along the anterior aspect (front) and inside of the pelvis. When they stiffen, they pull the pelvis slightly forward. Over a long period of time, the pelvis will shift so far forward that it will start to cause low back pain that can sometimes radiate into the hips, and SI - sacroiliac - joint, which is the point of attachment between the spine and pelvis. This can even radiate down the leg and into the knees, as the muscular insertion for the quadriceps are just below the knee on the tibia (shin bone).  Often times when patients come in with knee pain and all X-rays and MRI scans show no injury, it is because the muscles have pulled the skeletal system just out of sync enough for you to notice. 

Flexibility exercises are not only an essential part of recovering from aerobic activity, but can reduce your risk for further injury. The American Academy of Orthopaedic Surgeons (AAOS) encourages individuals to incorporate these exercises into their daily workouts.

EXPERT ADVICE
“Increasing your flexibility improves your ability to move easily,” said orthopaedic surgeon and AAOS spokesperson Raymond Rocco Monto, MD. “Some joints lose up to 50 percent of motion as we age. There are many ways to improve your joint flexibility including controlled stretches held for 10-30 seconds, stretches that rely on reflexes to produce deeper flexibility, as well as yoga and pilates.”

Before skipping flexibility exercises during your next workout, consider these five benefits of adding them to your workout regimen:

• Less back and joint pain: A 2011 study in the Archives of Internal Medicine found that regular stretching was effective in relieving chronic back pain. Other research has shown quadriceps stretches helped decrease knee pain.
• Better circulation: A 2009 study in the American Journal of Physiology discovered that torso stretches decreased stiffness and improved blood flow. This also may be why regular bedtime hamstring and calf stretches decrease the frequency and intensity of night-time leg cramps.
• Improved joint motion: Flexibility naturally decreases with age. Stretching can help restore lost joint motion and improve function.
• Better athletic performance: Like a good rubber band, muscles and tendons generate more force under tension when they are supple and compliant. 
• Improved muscle health: Mobility exercises can increase the amount of stress muscles can handle in high tension activities that involve jumping and cutting movements.

Get the most out of your flexibility training by following these simple guidelines:

• Always warm up before your stretch. Stretching cold muscles can cause injury.
• Stretch slowly and gently. Breathe into your stretch to avoid muscle tension. Relax and hold each stretch 10 to 30 seconds.
• Do not bounce your stretches. Ballistic (bouncy) stretching can cause injury.
• Stretching should not hurt. If you feel pain, take the stretch easier, breathe deeply and relax into it.
  
  Stretching is important and can be tough to master to maximum efficiency. The trouble is, it takes some time to stretch muscles back out to a healthy length. A combination of stretching, manual therapy to help relieve some tension in the joints that are being pulled on, and strengthening the opposing muscles to those inflicting pain should easily solve the problem and have you pain free within weeks. Here at Champion Performance and Physical Therapy, this is probably the most common cause of injury we see, and we approach it with a unique, biomechanically-based mechanism meant to relieve pain and tension through multiple planes of your body. Why?  Because your body doesn't move in just one plane. 
  
  Talk to your doctor today about what physical therapy can help do for you. For more information, visit us on the SW corner of 75th and State Line Road in Prairie Village, or by phone at 913-291-2290.

WHAT HAPPENS AFTER REHAB?

Many times, getting cleared from therapy can be bittersweet for patients.  On one hand, it's definitely a relief, as getting through therapy is a success on its own, but to an extent, it can be nerve-wrecking.  Quite a few people will struggle with venturing out on their own; doctors expect you to act as though you're as good as new, but you still feel as though you are not back to 100% - you've been through surgery, or therapy, or maybe both, and your body has changed.  The thing is, you're not wrong.  

The purpose of physical therapy is to return patients to a functional level; meaning you can drive, complete daily hygiene tasks, dress yourself, and perform household chores without modification of your movements.  Unfortunately, a functional level on a percentage scale means we're working to get you back to anywhere from 75-90%, with the last 10-25% being higher level activities, or sports (activities your body would still be functional without.)  

An example would be your right knee hurts when you put all your body weight on it when walking up stairs, so you only ascend stairs leading with your left knee. 

Another example would be your right shoulder pain is so severe when your arm is above your head, that you've begun washing and combing your hair with the left hand instead so as to avoid lifting the right arm above shoulder height. 

What does all of this mean?  

It means the last 10-25% is on your own.  This is the part that can be intimidating, especially for athletes who will likely be rehabbing to return to the sport during which they received the initial injury.

An example would be a high school student returning to volleyball when she went through five months of therapy to return from an ACL/MCL/meniscus repair while playing sand volleyball.

However, the point of us giving you the home exercise program is for you to progress on your own after in-clinic therapy is over. We give you the tools to continue your progression at home, and away from us.  However, we understand it's much more difficult to retrain the mind than it is to retrain the body.  For all of you who are nervous to return to higher level activity, or those of you who just do not trust themselves with the upkeep of their exercises, Champion Performance and Physical Therapy has your solution! 

Beginning in March, Champion Performance and Physical Therapy will be launching our FIT (Functional Independent Training) program.  FIT is an innovative approach to health, fitness, and continued patient care by increasing mobility, building strength, improving stability, improving vitality, and helping to prevent further injury. as it focuses on the need to continue triplane improvement, along with providing an education, that will help clients maintain therapy results, and improve overall quality of life.

The FIT program provides a comforting, medically oriented environment for clients to progress on their own but within earshot of a therapist.

The FIT Program requires an evaluation with a therapist if you have not been seen by a therapist in more than 30 days for a one-time charge of $40 out-of-pocket.  The purpose of the evaluation is review past medical history, review existing conditions and observe deficits that exist, whether or not the client is aware of them, and to create an individual workout program. 

Please call at 913-291-2290 or visit our website at kcchampionperformance.com for more information.

If you nervous about taking on your home program by yourself, or struggle to perform your exercises correctly on your own, or have trouble trusting your body to return to higher level activities without medical supervision, this just may be the perfect option for you!

BIRTHDAY WISHES!

Happy Birthday to our very own Hope Hillyard, Owner and Head PT!

31 never looked so good :) AND Happy belated National Boss' Day! 

In all seriousness, we love and appreciate you more than you realize. Smoothie King gift cards and Skittles will never be enough to express our gratitude - working for you is a pleasure! 

Love, 

All your employees 

BONE HEALTH IS A LIFE - LONG GOAL

As you age, it seems the risk of fractures starts and ends high. While parents are bombarded with information regarding the diet of a child as it relates to their growth, it's important that everyone understands the risk of a low calcium, low impact diet - at any age. 

The bones of the body do not reach their maximum density until mid-late 20's - or in other words - your bones are not the strongest until you're around 30 years old. While many factors improve the mechanical properties of bone (stiffness, strength, ductility, etc.), it's important that all of them be addressed as a part of a healthy lifestyle. 

During childhood:

Nourishment is key - as activity is likely already being managed. Between recess, after school activities, and the introduction to sports, the activity levels during childhood should maintain the consistent forces bone requires to maintain stability and strength. So why so many fractures during childhood? 

Children have smaller, younger bones. Compact bone is not fully compact, minerals provided in the diet are harder to obtain and maintain (especially with picky eaters), and the mechanical properties of bone are not at full potential. For example: hollow bones with wider cross-sections (like those found in adults), have a higher resistance to torsion forces, or twisting and bending, than do children. So what happens when they fall and land incorrectly? Boom - higher risk of fractures.

During retirement and beyond: 

Bone density naturally decreases in almost all individuals with age. The body no longer regenerates cells as quickly, absorbs nutrients as efficiently, and therefore leads to decreased bone being produced and less calcium being absorbed to maintain the materials required to reproduce bone. Other external factors, like decrease in activity due to a slowing lifestyle, as well as a higher risk of other health problems causing a decrease in activity like arthritis will lead to a decrease in activity, and therefore, an increased risk for fractures. 

Not to mention as you age, your muscles naturally attempt to protect cells that have high endurance levels, the ability to react quickly (quick reflexes) diminishes. Therefore, if you were to trip, you're less likely to catch yourself, more likely to fall, and as a result, at a higher risk for fractures. 

What can you do? 

It's never too late to get active, and add calciums and proteins to your diet. It's never too late to find alternate sources for your children, either. 

The muscles and skeleton coincide with each other, and the health of one is codependent on the health of the other.  Keeping vitamins and minerals in your diet, taking daily supplements, and finding some source of natural proteins is crucial to the health of your skeleton. Activity levels help to maintain progress - and it's crucial that progress be maintained when it comes to bone density. 

Talk to your doctor for more information, or give us at CHAMPION a call for preventative measures you can take to protect you and your loved ones. 

GENU VALGUM IN YOUTH AND ADOLESCENCE

What is Genu Valgum? 

Valgum, more commonly referred to via medical terminology as "valgus" or "knock-knee" is a condition in which the knees angle inward toward each other, or the midline of the body, when the legs are fully straight.  The opposite occurrence is genu varum, otherwise known as "bowleggedness". 

Flexibility in the joints during childhood is completely normal, and is the reason why your children can sit cross-legged, or any other position you wonder how you were ever able to do.

Cases vary from slight to extreme, and are developed under a multitude of circumstances, including passively due to activity levels, hereditary, or retained as a result of a genetic disorder. Children who are "pigeon-toed" have an increased variability of retaining valgus into adulthood. According to , the average child has most prominent increase in valgus around age 4 at average 8 degrees, lessening each year with valgus averaging <6 degrees by age 11. Children in this study who's valgus was deemed within normal limits ranged from anywhere up to 12 degrees for ages 2-11. 

What does that mean?

Valgum is extremely common, more common in fact than it's counterpart in genu varum. During youth, it's nothing to be extremely concerned about. Often, as children age and become engaged in more strenuous physical activities ( ex: running while playing soccer), the musculature in the lower extremities will naturally reduce the angle of varum. In other words - many a times, valgum is corrected on it's own. 

What if it doesn't?

In most cases, physical therapy is an option to increase the strength on the lateral (outsides) aspect of the lower extremities, which will help to reduce the angle in a controlled environment. Teaching proper body mechanics through movement will increase the ability of the child to improve his/her valgum without the trained eye of a physical therapist, or the watchful eyes of their parents around. 

If the angle is more severe, other options can be provided and discussed with an orthopedic specialist and a primary care physician to determine the best course of action. 

Why should we correct it?

Genu valgum is not considered an emergency situation - nor should it be. It's a natural aspect of growing - simply something to be monitored. However, allowing valgum to stabilize and continue on into adulthood will create problems for the child later on in his/her lifetime. Multiple studies have shown that the presence of untreated valgum has an extremely high correlation with osteoarthritis of the knee and hip, misalignments of the pelvis and sacrum, which increase the risk of low back pain, leg length discrepancies, musculoskeletal issues, to name a few. 

If that doesn't convince your young adult to improve their valgum condition, it may help to remind them that valgum is also correlated with an increase in non-contact ligamentous/soft tissue tears in the knee joint - those will end a season fairly quickly, and will increase their risk to tear a ligament simply performing a daily activity, such as jumping down off of a small ledge, or stepping off of a curb. 

Knowledge is power!

7 STAGGERING STATISTICS ABOUT AMERICA'S OPIOID EPIDEMIC

America's prescription opioid epidemic is a topic of national news.

How bad is the problem? Here are some statistics via The Centers for Disease Control and Prevention (CDC), which released guidelines in March 2016 encouraging health care providers to try safer alternatives like physical therapy for most pain management:

1. In 2012, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every American adult to have their own bottle of pills.

2. As many as 1 in 4 people who receive prescription opioids long term for noncancer pain in primary care settings struggles with addiction.

3. Sales of prescription opioids have nearly quadrupled since 1999.

4. Deaths related to prescription opioids have quadrupled.

5. Heroin-related overdose deaths more than quadrupled between 2002 and 2014, and people addicted to prescription opioids are 40 times more likely to be addicted to heroin.

6. More than 165,000 persons in the United States have died from opioid pain-medication-related overdoses since 1999.

7. Every day, more than 1,000 people are treated in emergency departments for misusing prescription opioids.

Do you know someone in pain? Encourage them to talk to their physician or physical therapist about safe ways to manage pain.

The American Physical Therapy Association launched a national campaign to raise awareness about the risks of opioids and the safe alternative of physical therapy for long-term pain management. Learn more at our #ChoosePT page.

MOVE FORWARD #CHOOSEPT

CHAMPION SUPPORTS SAFE PAIN MANAGEMENT

No one wants to live in pain. But no one should put their health at risk in an effort to be pain free.

Since 1999, Americans have increasingly been prescribed opioids—painkillers like Vicodin, OxyContin, Opana, and methodone, and combination drugs like Percocet.

In some situations, dosed appropriately, prescription opioids are an appropriate part of medical treatment. However, opioid risks include depression, overdose, and addiction, plus withdrawal symptoms when stopping use. And people addicted to prescription opioids are 40 times more likely to become addicted to heroin. Think that won't be you? Make sure you're right - and #CHOOSEPT. 

The Centers for Disease Control and Prevention (CDC) is urging health care providers to reduce the use of opioids in favor of safe alternatives like physical therapy.

Don't just mask the pain. Treat it.

Choose physical therapy to manage your pain without the risks and side effects of opioids.

ETHICS IN PHYSICAL THERAPY AS A PATIENT

WHAT AM I LOOKING FOR?

Ethics in physical therapy, from the perspective of a patient, is hard to recognize. There are a multitude of rules provided by the code of ethics established by the American Physical Therapy Association, or the APTA, and every type of physical therapy, whether it be inpatient, outpatient, acute, chronic, home-health, etc. is required to fulfill their ethical duties. 

Many of the guidelines are only recognizable from an employee perspective, but there definitely are aspects that patients may notice, as well. Rules and regulations may vary by state from a legality perspective, but from a licensing perspective, the APTA is law. Your health insurance also has some say in what is/is not allowed, as far as who you receive your treatment from. Talk to your physical therapist for more information. If you do not like who you work with, please tell your physical therapist so the issue can be resolved and you, more satisfied with your care.

For example, in the state of Kansas, if patients are working with a technician or a student, the supervising physical therapist must be within line of sight at all times (aside from reasonable deterrents, such as using the restroom). In an instance where the physical therapist leaves the room for longer than necessary (5-10 minutes, use judgement), that time was not directly supervised. 

Situations such as this have never happened here at CHAMPION, but many of our staff members have been employed at various locations elsewhere that were not as adamant about following this rule. 

SEE SOMETHING THAT SEEMS WRONG?

The APTA is accessible by anyone.

1. Take the opportunity to address the situation with someone at the clinic you're receiving treatment at that you trust, to see if the issue can be resolved.

2. In situations you do not feel comfortable speaking directly to a staff member, seek out the top dog to discuss problems you may have.

3. In extreme situations, it is an option for you to report problems with your treating therapist to the APTA. If the treating therapist is a student who is not being supervised efficiently by a clinical instructor (a licensed therapist at that clinic) you can contact their school or clinical advising team. 

Please visit the APTA website for more information.