Some notes from a presentation I gave about ruck marching prior to the 30 kilometer Norwegian Foot March: 

We all know that placement of the ruck is important and placement of the weight is important, but first I want to talk about what you’re doing with that weight. As we get tired and posture starts to deteriorate, that puts us at risk for a couple of key things…there’s back pain, neck pain, but also the potential for nerve irritation down the arms as we get hunched over and the straps increase stress on the nerves around this part of the body.
 
Here's an interesting nugget, there’s a lot of research out there on the factors contributing to injuries related to ruck marching, but one finding has been the effect of visual stability or gaze particularly during night time when a lot of these movements often occur. As we lose visual cues to orient ourselves when they get hidden by the dark, our gaze will tend to shift downward, which can pull our posture forward.
 
There’s also evidence that your ability to visually orient yourself can have a meaningful effect on trunk stability, which in turn has an effect on both joint health and performance. Fortunately, we’re only dealing with 25lbs, not 60-70 or even more, but this is all a nerdy roundabout way of saying your ability to maintain situational awareness can affect your posture. Or quite simply, remind yourself to maintain solid posture even when it really starts to suck in that 14-15 mile range. Obviously easier said than done, but every little bit counts.
 
Another key strategy is cadence. As we get tired, especially when running, the tendency for many people is to lengthen their stride in an attempt to stride it out. Which, if it gets you from point a to point b fastest then you gotta do what you gotta do. BUT along with this idea of mindfulness, monitoring your cadence so that it doesn’t drop. Because we know that with running, in general, a quicker cadence and shorter stride length will result in lower impact forces, which will ultimately decrease the risk of injury.
 
Final during event strategy is to be mindful of the slope on the side of the road. This can be a significant issue since the right leg ends up being higher than the left if we’re walking into traffic. If we have the whole road to use its not as big of an issue, but be aware that the repetitive stress of that slope will accumulate and can potentially cause some issues, maybe not during the event but quite likely afterward
 
A big part of avoiding injury actually has to do with what you do after the event. Theres a saying motion is lotion. Try to get some movement in the day after. That could be walking, bike elliptical are both good options. The pool as a zero gravity environment is possibly the best option, or a hotel pool if you’re headed out for the weekend.
 
It is important to recognize that depending on your fitness level and how fast you go in the event, your body may feel recovered before it is actually recovered. Let’s say you feel normal after 4-5 days, your muscles are still in a state of damage and need more time to repair. Still keep moving but just because you feel great doesn’t mean its time to go squatting heavy.
 
Massage is one of the best things you can do, but this isn’t the time to go super deep and aggressive. Same applies for self massage like theragun or foam roller.
 
Spinal decompression, whether on the inversion table or hanging from a bar, although I wouldn’t get carried away with those if you haven’t done the inversion table before. Regardless, because there a more compressive forces applied over the course of 18 miles the spine does need an opportunity to decompress.
 
Probably one of the most overlooked and underrated recovery techiniques is legs up the wall. So basically you’re on the ground, and prop your legs straight up against a wall and just lay there for 5-10 minutes. It’s very relaxing and soothing both for the tissues and the nervous system as a whole.  

StrongFirst – Our core philosophy at StrongFirst, "the school of strength": Strength is a skill. Strength also has a higher purpose. StrongFirst is a school of strength focused on the three core mediums of the kettlebell, bodyweight and the barbell. People who work with us are not “clients” but rather “students.” Students of strength. Although mostly known for the popularization of the kettlebell in the US by Pavel Tsatsouline more than twenty years ago, the teachings of StrongFirst apply to so much more. We simply have found that the kettlebell is perhaps the most effective way to teach fundamental lessons of strength in a way that transfers across many domains. Earning the SFG Level I kettlebell certification is a life changing event for many, and that includes myself.
 
Titleist Performance Institute – the leaders in golf fitness, yet so much more than golf. A core tenet of TPI is “there are millions of different ways to swing the golf club, but the most efficient was is based on what your body is physically capable of doing.” Sport or activity specific movement is based on what our body can do at a fundamental level. If you can’t turn your trunk 90 degrees on its own, you won’t be able to do it when making a golf swing.
 
Appreciating this reality shifts our focus away from forcing people into certain positions and postures based on what we think looks right and instead helping harmonize technique with physical abilities. This is a dynamic process and it begins with the understanding the “body-swing connection.” How you swing is dictated by how your body moves. We can apply this fundamental concept across any sport or activity by assessing whether the body has the underlying physical capability to perform the technical skill that is being asked of it.

If you made it this far into the site, you probably have at least some interest in learning more about how I can help you and how I go about it. This upcoming series of posts will describe some of the systems that shape how I treat patients.  Of course many people couldn't care less about the minutiae as long as it works, but I know there are some readers out there who may be interested in learning more of the background that informs the treatment they might receive. 

Dynamic Neuromsucular Stabilization. (DNS)  – a treatment approach out of the Prague School of Rehabilitation based on developmental kinesiology. Basically DNS operates on the principle thatcertain movements are “pre-downloaded” into our nervous system. No one has to tell a baby how to suck its thumb, roll over, chew, swallow, move its eyes, stand, walk and many other key developmental milestones.
 
When problems arise later in life, the ability to access these “files” can provide incredible outcomes in recapturing movement and behavior that was seemingly lost. As such, during rehab, we’re not trying to force the body to do anything truly novel, we’re simply helping it reengage with something it already knows how to do. Learning DNS principles not only helps with the application of DNS methodology, it also explains why other successful approaches are also effective.

​Functional Movement Systems (Functional Movement Screen and Selective Functional Movement Assessment) – The FMS is a battery of seven screens based on key movement patterns within the developmental process that help identify where deficits may exist in how our body moves. Fundamentally, it looks at reaching, kicking, pressing, rotation, stepping, landing and changing levels. Identifying limitations in any of these domains allows us to address the individual’s weak links that may interfere with the training process or simply with quality of life.
 
At its most basic level, the FMS takes our focus away from parts and guides our attention toward patterns. After identifying patterns, we can then peel away the layers and focus on details, but only after an appreciation of how the body interacts with itself and its environment as a while.
 
The Selective Functional Movement Assessment is the clinical analog to the Functional Movement Screen. If someone presents with pain, then the SFMA is the proper channel to guide the process of reaching a functional diagnosis.
(Note the difference between a functional and structural diagnosis. Structural diagnosis might be patellar tendinitis. Functional diagnosis example would be limited ability to squat (change levels) as a result of insufficient ankle dorsiflexion.

​What is the effect and magnitude of training disruptions on marathon performance?
“Completing a marathon usually requires at least 12-16 weeks of consistent training, but busy lifestyles, illness or injury, and motivational issues can all conspire to disrupt training.”…
Some interesting findings from this study of over 300,000 runners..
Runners who experience longer training disruptions (greater than 7 days) suffer a finish-time cost of 5-8% compared to when the same runners experienced only short training disruptions (<7 days)
long training disruptions lead to a greater finish-time cost for males (5%) than females (3.5%)
Faster runners also experience a greater finish-time cost (5.4%) than slower runners (2.6%)
When disruptions occur late in training (close to race-day), they are associated with a greater finish-time cost (5.2%) than similar disruptions occurring earlier in training (4.4%)
—-
Feely C, Smyth B, Caulfield B, Lawlor A. Estimating the cost of training disruptions on marathon performance. Front Sports Act Living. 2023 Jan 10;4:1096124.

​Faster running can result in LOWER stress on the knees!⁣
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One recent study assessed twenty runners at four different paces from (2.5-4.2 m/s) and measured peak and cumulative force on the patellafemoral (knee) joint.⁣
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PEAK forces and stress were higher at the highest speeds ⁣
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But CUMULATIVE force and stress was LOWER at faster paces, with up to a 33% reduction from the slowest pace to fastest pace ⁣
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Authors conclude: “Running at faster speeds increases the magnitude of peak PFJ kinetics but conversely results in less accumulated force over a set distance. Selecting moderate running speeds (~3.1 m/s) with reduced training duration or an interval-based approach may be more effective for managing cumulative PFJ kinetics compared to running at slow speeds.”⁣
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In other words, intervals aren’t only for the track..Whether walk-run or fartlek, this can also be useful in a variety of contexts ⁣
…..
⁣
Doyle EW, Doyle TLA, Bonacci J, Beach AJ, Fuller JT. Cumulative patellofemoral force and stress are lower during faster running compared to slower running in recreational runners. Sports Biomech. 2023 Jun 26:1-13.

A lot of people don't realize that this skill set is part of the PT scope of practice (provided you attended a school or had some other form of training in the skill). There are differences between professions in how and why "cracking" joints is performed along with different terminology, but the main point to get out there is share how the techniques can enhance a rehab session in very powerful ways beyond just the "crack."

In physical therapy, the term we use is manipulation. With physical therapy sharing a lineage with osteopathy, manipulation of the spine or any other joint system is grounded in one of the core tenets of osteopathic medicine, which is the body has the innate ability to heal itself. Our role as practitioners is for the body to reach a homeostasis that enables this self healing ability. We're not putting joints "back in line" or fixing things "out of place." We're simply using a technique with the body that can make some change to create a more optimal environment for healing. 

If a physio manipulates your spine, for instance, you clearly feel a change to your body in the immediate aftermath. That's simply signaling that some change has occurred in the short term which creates conditions for the body to more effectively deal with any problems internally. 

So once we perform the manipulation, that's actually when we're getting started. We're squandering ripe opportunities for improvement if we stop there. Yes, we can still benefit if that's all the session entails, but the "magic" in the manipulation is how it allows us to move better to do the physical work and even psychological work during that SAME SESSION that will have the greatest long term change for the body.

I always say there are some things you just can't exercise your way out of, or at the very least that exercise alone without other techniques will make for a longer road toward healing. Adding manipulative therapy into a session literally allows us to supercharge EVERYTHING that we do.  What it also does is make our results more durable, meaning because we achieve such a potent effect with the combo of manipulation (and other manual techniques) plus exercise, you don't need to come in several times per week to see results. It's like taking your car to the mechanic and having them fix the problem, versus having to come in multiple times per week to keep topping off fluids leaking from the engine.

It also avoids the common scenario where you might get some wonderful treatment on the table and feel amazing, but then get in your car and drive around for a while or return to work at a desk for the body to revert closer to where it was before treatment. Then you go exercise in a separate session and you've lost some of the immediate benefit of the therapeutic technique. 

Bottom line: physios are trained to perform manipulative techniques (joint "cracking" in crude lexicon) and doing so allows the amazing results achieved within comprehensive treatment session to have the longest lasting effect. 

Wonderful summary here from Dr. Jenna Siracuse at On Pointe Wellness in Virginia. Every single one of these apply to how we care for patients at Ventana Physiotherapy. 

https://www.onpointewellness.com/post/top-10-reasons-why-you-should-consider-cash-based-physical-therapy

1. More one-on-one time with your therapist.
This is 100%, without a doubt, the most important piece to me (and most of my patients as well)! When you are not worried about billing insurance companies and being reimbursed for your time, you suddenly have much more of it to give to your patients. There are typically no aides or trainers involved in your session, it is all time spent with your therapist. Most PT's went into this business because they love working with and helping people. This therapy approach really allows us to get back to the reason we became PT's in the first place- and you reap the benefits!

2. More personalized attention.
When you are working one-on-one with your therapist, I can assure you the care you are getting is far more personalized then it would be otherwise. Your therapist won't be running back and forth between patients, the focus is 100% on you. This allows us to really assess each of your movements and make adjustments based on what is happening during each exercise. The end result is a completely individualized treatment plan to correct your specific muscle imbalances and help you get better faster!

3. Builds a strong patient-provider relationship.
Now, I know this one may sound a bit redundant but it sure is important. When you are being treated in a cash based PT setting you build a really strong relationship with your therapist. You are probably going to be spending a lot of quality time together and end up feeling more like friends in the end. Trusting your therapist has a huge impact on your healing, and having the opportunity to get to know each other one-on-one really allows for a deeper sense of trust to develop. All of my patients have my cell phone number and know I am always "on call" and they reach out whenever they need me. Most cash based PT's I know do exactly the same for their patients.
4. Yes, It may actually save you money in the long run.
Quality over quantity is an important concept here. More one-on-one time with your therapist means we don't need to see you as often. On average, I only see my patients 1x/wk but it is for a full hour. Sometimes we need 4 visits, sometimes its more. Either way, it gives you plenty of time between sessions to work on your program and start to see some results. More importantly, it empowers you to put in the work which = getting better, FASTER. With a less frequent PT schedule, this often works out to be much less than actually using your insurance.
Take this scenario for instance: a patient with a high copay of $60 per visit who needs to go to PT 2-3x/wk for 8 weeks will spend close to $1000 over the course of their care. During their visits, they are likely only spending ~20 minutes of actual one-on-one time with their PT. That's a lot of money and time for little reward. If that patient instead chooses a cash based PT practice that charges $150/visit and needs only 6 visits, you are looking at $900. The math is a no-brainer!!

5. More freedom to address multiple issues at the same time.
While it is extremely unfair, insurance companies strongly dictate if you get better or not based on what they will approve. Did you know that under insurance PT's can only bill for treating one body part at a time? That means that you would need 2 separate evals and visits each week to be able to bill your insurance for your knee and your shoulder problem. In some cases, your PT may be able to justify it. They just better be prepared for a lot of extra paperwork, which really means less time for personalized patient care. Crazy right!? In the case of cash based PT-- not an issue! We can treat whatever issues you are having without you needing to worry about it being denied by your insurance. Again, the outcome is you getting better faster because you are actually getting the care your PT knows you need.

6. More freedom to explore the root cause of the problem.
With longer one-on-one appointments and not worrying about insurance approvals, your PT can perform a thorough assessment of strengths, weaknesses, imbalances and how you move. This means we have a full picture of what is going on. It may be your hip that is pinching, but WHY!? Maybe you don't have a strong core or your upper back mobility is limited. So we work on all of these areas and make sure to address the reason it happened in the first place. This results in you living pain free and preventing issues from returning in the future. No trying to explain this to an insurance company just to get denied.

7. Many insurance companies reimburse for out-of-network PT.
Depending on your out-of-network benefits, your insurance company may actually reimburse you for your visits! Just make sure you get a superbill from your PT that you can submit to your insurance company. At [Ventana], I always provide my patients with a superbill on request.

8. More flexible scheduling means getting more of your time back.
It is no secret that time is our most precious commodity, and we cant get it back. Only needing to see your PT once a week gives you more time back to do whatever you love! At [Ventana] Wellness I try to give you back even more of your time by giving you the option of home-based visits. You won't see your insurance company offering you this option very often!!

The last 2 are my favorite...

9. Empowering you to help heal yourself.
A good Physical Therapist will not "heal you" they will teach you to help heal yourself. Physical Therapists do not want you to use us as a crutch, we want you to take your health and wellness into your own hands. You have the power to help heal yourself, we just give you the guidance you need to get there. By choosing cash based PT, you have already taken a huge step towards empowering yourself, because you have made the commitment to invest in your health. The truth is, patients who pay out of pocket are far more committed to their treatment plan because they have paid their hard earned money for it.

10. Your health is worth any amount and is the BEST investment you could ever make.
It is simple, you only get one body and one chance-- take care of it!!

All of this really comes back to one main point. Cash based Physical Therapy has the ability to provide you with the highest quality of care. Aren't we all looking for a better experience with health care these days? I can promise you that high quality, affordable care still exists and your insurance company does not have to be the barrier.

I could not be happier with the choice that I made to leave traditional clinic life behind. As with most PT's who switch to a cash based model, my intentions have always been to put my patients first and give them the care they deserve. I can now say with certainty that I am able to provide them with a better patient experience than they would get anywhere else.

If you are considering cash based Physical Therapy for yourself, start with a simple Google search for PT's who may provide this in your area. I highly suggest taking advantage of a phone or in-person consultation so you can get a better feel for if this is the right way to go. In the end, its all about fulfilling your individual needs. Stay informed, do your homework and know that there are still so many health care providers out there who truly care about helping you live your best life!

RESET - make. an immediate change to the body, often through some form of manual therapy. Think of hitting the "delete" button or even doing a complete system restart of a device. Many degrees of resetting exist, which can be something as gentle as light stretching, to something more potent such as a spinal manipulation. Regardless of what technique we choose, we're trying to make a change to the body.

REINFORCE - but we can't stop there, although that is where many people do stop, being sent away from the clinic and just hoping that that therapy "sticks," or if not, making plans to keep coming back again and again to keep addressing the same problem over and over (think of those times you've been told you need to sign up for a plan of 2-3x per week for weeks on end...). Reinforcing stage is where we teach the body to move differently. If you typically round your back when you hinge forward, this is where we might teach you different mechanics to spare your spine. But remember, change is unlikely to happen unless we actually DO something, which is what the reinforcement stage is all about.

RELOAD - This is where we take our reinforcement strategies and hit the "SAVE" button. Ever have that feeling of getting great therapy but then within a day or so you feel like nothing much has changed? We can avoid this phenomenon by applying loading strategies to the body to remind it to make a change. Remember the example of changing how we bend forward? To transition from REINFORCE to RELOAD, we'd take that same pattern but make it more demanding such as by picking up a weight. This is how we avoid the problem of feeling great off the table and doing some light movement but then feeling like we take a few steps back when increasing the demand or intensity of the movement. This doesn't mean we challenge ourselves at a high intensity without proper progression; it simply means we need to provide something (such as a weight) that speaks to the body and reminds it to make some type of permanent change.