Pain is no fun—in fact, pain could be considered the opposite of fun. Disappointment is no joyride, either. Pain and disappointment coupled together can make for some fairly unhappy patients. Chronic pain or severe disappointment—such as what an injured athlete suffers while training for a big event—can create some desperate patients.

Enter Sports and Orthopedic Leaders (SOL) Physical Therapy Inc, a sports injury and performance training facility in Oakland, Calif. SOL founder Tammara Moore, a PT and board-certified orthopedic clinical specialist, has built a practice to not only care for pain patients, but also to actually bring them relief.

"I would say 99.9% of our patients come to us because they are hurt. What’s a little different about us is that we don’t just treat them until they are out of pain, but until they have returned to as normal mechanical function as possible," Moore says.

Her philosophies are simple and can be summarized as: be nice, be open, and be the best. "The minute a patient walks through that door, they are the most important person," Moore says. Attitude is as important as treatment, with both focusing on the positive. SOL’s PTs aim to give patients hope as well as relief.

Their efforts include traditional and alternative methods; the approach is holistic. SOL therapists address lifestyle with their patients, reviewing the impact on pain of nutrition, exercise levels, and relaxation techniques. Thorough evaluations guide treatment programs that can include Active Release Techniques (ART; see sidebar on page 20), acupuncture, biofeedback, cold laser treatments, instrument-assisted soft-tissue mobilization, and/or photonic stimulation.

Of the available modalities, ART has provided a cornerstone for the practice. All SOL therapists are required to be certified in the technique, which can produce results in 4 to 6 weeks for nonsevere injuries, according to Moore. Word of mouth about this success has drawn patients to the practice. And some of them are willing to pay out of pocket, which has improved cash flow, Moore says.

Not all patients, however, will find resolution so quickly, but goals are set with the realistic intent of seeing fast improvement. "We realize that with the way insurance reimbursement is, we have to get people better in the available time frame—which means we have to bring out everything we can," Moore says. If patients have shown no improvement within 2 to 3 weeks, the program is reassessed. Collaboration with another PT is common.

"We share patients a lot. There is a mutual respect in our clinic for the different skills we all bring," Moore says. The staff works as a team, with weekly meetings to address upcoming issues and practice management. Moore believes that continuing education is critical to the PT’s role in medicine, and she works with a business coach to make weekly in-services economically feasible.

Moore also believes in setting an example, for both her therapists and her patients. She demands a lot from her staff, but nothing she doesn’t ask from herself.

Compassion Before Compression
Moore and her staff consider themselves role models. SOL’s therapists are active, participating in marathons and triathlons on a regular basis. Moore has completed four Ironman Triathlons herself. "What sets us apart is that we understand what it is like to be injured as athletes, and we know how to push ourselves. If you can understand the psychology and you’ve actually had that experience yourself, you’re much better at pushing people in the direction they need to go," says Moore, calling it a psychological advantage.

Part of that psychology is a positive attitude. "A lot of times, people come in and say, ‘I can’t do this,’ so we ask, ‘What can you do?’ You have to be positive and give people hope," Moore says. Focusing on the positive can also help to get a patient’s focus off the pain.

The practice’s atmosphere mirrors this attitude. Moore describes the setting as beautiful. The waiting room is accented with fresh flowers, and treatment rooms provide privacy for those who need it. "People have emotions related to their injuries, including grief and loss, and they have to be able to express them," says Moore, who believes that the PT needs to be there for patients emotionally, as well as physically.

"What sets you apart in private practice is having empathy and making a connection with a patient. If you can’t like that person, you probably shouldn’t be treating him. It’s important to be supportive in the healing process. The connection makes the treatment successful," Moore says.

Holistic Approach
Of course, connection isn’t the only thing. A treatment program based on a thorough analysis of the patient and realistic goals also contributes to treatment success. "The overall philosophy is to quickly hypothesize what the source of pain and the source of the dysfunction are. We do that with a thorough musculoskeletal assessment and biomechanical analysis," says Nina Patterson, MPT, OCS, director of SOL.

She promotes the holistic approach, which looks at the whole body and the way the body moves. "If someone comes in with neck or shoulder pain, we don’t discount the weak hip that may be causing them to overuse their shoulder," Patterson says.

The goal is to restore balance to the system and get the patient functional using all of his or her available skills, Patterson says. Objective measures must be determined to judge improvement.

"When we treat athletes, we have to be really clear about their expectations. Usually, these are very highly motivated people, and they need coaching to hold back a little bit. But we also know the power of setting a goal. It’s daunting but encouraging for your patients to set realistic goals and go after them. We’re all about getting people to look at the big picture and help them restore a more healthy lifestyle," Moore says.

For Moore, a healthy lifestyle includes aspects that a PT normally does not monitor, such as nutrition. "When patients come in with chronic pain, we want to look at their nutrition. Can we help them with recommendations for an anti-inflammatory-type diet? What supplements are they using? Are they drinking eight glasses of water a day?" Moore says.

Aerobic exercise is another aspect. "We work to make sure they are getting adequate aerobic exercises," says Moore, who notes that very few of the practice’s patients lead a sedentary lifestyle. Even so, exercises are done in the clinic. "Home programs do not work," Moore states flatly.

Stress and relaxation techniques are also addressed, from meditation and guided imagery to breathing techniques and enough rest. "A lot of time, people come in and are very stressed. If you can reduce their anxiety and give them ways to manage their stress, a lot of time their pain goes down. It’s a systems approach," Moore says.

That approach can also include acupuncture, which a therapist may recommend as part of the therapy—a suggestion that is first run by the patient’s physician, Moore says.

Alternative Modalities
Treatment programs can draw from a range of modalities. SOL’s tools include ART soft-tissue treatment, biofeedback, the Graston Technique, iontophoresis, joint mobilization and neuromuscular re-education, manual physical therapy, mobility and stabilization exercises, myofascial release, performance training, photonic stimulation, Pilates-evolved rehabilitation, and video-movement analysis. The facility also offers an underwater treadmill.

"It’s a normal treadmill enclosed in a Plexiglas tank that fills with water. The buoyancy permits a much more pain-free gait and is particularly beneficial for patients with spinal problems, leg weakness, or pain," Patterson says. A temperature between 90ºF and 95ºF also eases pain, particularly for arthritic patients. The motion introduced by water flowing under the belt causes the patient to work core muscles as he or she balances, bringing further benefit.

Cold laser treatments are another unique modality employed at SOL. The technique uses low-level laser therapy and is fairly new to physical therapy. The system SOL uses was approved by the US Food and Drug Administration in 2002 and represented the first of its class, says Moore, who was introduced to the technique after she suffered an injury of her own. "Two years ago, I was at the Olympic trial for track and field and developed an Achilles tendinitis problem. I had two and a half months left of my training for the Hawaii Ironman," Moore says.

A runner with Achilles tendinitis usually needs 3 months to return to running, according to Moore. Through word of mouth, she was directed to a clinic where she received cold laser therapy—four treatments over 3 days—and was back to running 3 to 5 miles with no pain. This past November, Moore bought a system and added the modality to the practice’s services. Now, Moore says, "I wouldn’t leave home without it in terms of traveling with some of our athletes."

Active Release and Patient Activity
Another modality Moore believes strongly about is ART. "We’ve had some miracle cures that have completely blown us away—we’ve treated a patient one or two times, and he’s out running," Moore says.

Patterson shares the case of a man in his 50s who had been suffering from chronic glute pain for 30 years. "He had torn his muscle running track in high school and never recovered. The area had pain, and the muscle strength was reduced by 50%," Patterson says. Using ART alone, Patterson eliminated his pain and fully restored the muscle strength. "He felt better after the first treatment, and his strength began to return after the fourth. I don’t think I saw him more than six or eight times," Patterson says.

Many of SOL’s treatment plans incorporate ART. Moore says it is particularly compatible with other manual therapies. "This is a very mechanical type of technique, and it goes along well with other manual techniques, such as spinal manipulation and joint mobilization," Moore says. The lack of controlled, randomized studies examining ART is unfortunate, according to Moore, but she has seen enough amazing results with the therapy that it does not matter.

These results justify the expense of getting certified. Moore and Patterson both note that ART certification is not cheap. According to the ART Web site, seminars start at $1,590. "Other therapists often tell me they would like to be certified but need to justify the expense. I tell them it’s the best investment they can make, and they often call me back and thank me. I know two PTs who have been able to start their practices because of their use of ART," Moore says.

In addition to using financial resources, ART also takes time. The technique requires a few years to master by Moore’s estimate. "It’s a very technical technique and not something that you can learn out of a book," says Moore, who notes that she is an ART instructor. The classes stress the difference between compression and tension. "It’s really about lengthening the structure or structures that are involved and being able to assess where the limitation in motion comes in," Moore says.

A lot of times, standard orthopedic tests do not show these types of muscle injuries, according to Moore. "The patient may test fine, but when you start palpating, you feel fibrous tissue. If there is a way to release that, you can improve their functioning," Moore says.

The technique has been part of the chiropractor’s toolbox for years, but it has recently been gaining popularity within physical therapy. At SOL, active rehabilitation is always implemented within the program so that it never stands alone, setting PTs apart from chiropractors. "I think chiropractors are really good at spinal manipulation, whereas PTs have a much stronger base of exercise. I never do Active Release as a stand-alone treatment but always implement exercise, because once we restore movement, we want to restore function. In terms of implementation, your outcomes are hands-down going to be better with Active Release," Moore says.

In addition to helping to restore function, ART can also reduce pain. "We don’t know all of the reasons why, but ART does release pain. If you can restore motion and function and you can improve circulation so that everything is moving better, then you will relieve pain," Moore says.

Active Release and Practice Activity
While this technique should not be used on patients who have a low tolerance for any manual therapy, it can help receptive patients recover faster, often responding within four to six treatments. The resulting word-of-mouth promotion is a practice builder. "If you get patients better in two or three visits and they go out and be active, they’ll refer four or five of their friends," Moore says.

"All of our PTs have been trained in ART. We all use it every day, and we are known to the doctors, athletes, and others in the area through word of mouth. I think it set us apart, and a lot of people come to us as a result," Patterson says. Successfully treating patients is the practice’s best marketing effort, according to the practice’s marketing materials.

"Success is determined by the patients. If the patients are achieving their goals and feeling satisfied, they’ll tell their friends, family, and doctors, and it will build on itself. I think the ultimate success is satisfaction of patients," Moore says.

Moore refuses to limit her time with patients, which would be required by a profitable business model based on insurance reimbursements alone. Moore obtains insurance reimbursement by billing the technique as a manual therapy procedure, but patients will also pay full price or additional copay for sessions. Moore estimates that 20% to 30% of SOL’s patients pay cash and have limited insurance reimbursement. "You have to be confident as a clinician to say, ‘I am worth this fee.’ If you aren’t, people aren’t going to value it," Moore says.

Mediocrity Not Allowed
Patients are even more satisfied with quick results. Higher insurance deductibles and copayments coupled with busy schedules create a demand for faster improvement. To keep patients happy and active, Moore seeks to keep SOL on the cutting edge of treatment.

"Private practice is not for complacency. It’s really a place for entrepreneurs and for practitioners who continually want to learn and improve their skill level," Moore says. She encourages as much continuing education for her therapists as possible and is herself completing a doctorate in physical therapy; she expects to be Dr Moore by the time this article is published.

"I think we strive to be the best. We are always looking at ways to improve our skills. Mediocrity is not allowed in the clinic," says Moore, who notes she is not easy to work for but by demanding high performance, she expects her staff to have high satisfaction. "There’s nothing better than having made a difference in a person’s life," Moore says. SOL’s patients would agree. The practice was voted "Best of the East Bay for Sports Injury" by citysports magazine.

Renee DiIulio is a contributing writer for Physical Therapy Products.

All About SOL
Tammara Moore first started Sports and Orthopedic Leaders (SOL) Physical Therapy, Oakland, Calif, in 1994, working out of rented spaces as small as 400 square feet. The solo effort followed 5 years of physical therapy practice working in orthopedic outpatient care, home health, and sports medicine. The experience exposed her to alternative practices, and Moore became the first PT to take courses for Active Release Technique (ART), she says. That was in 1993; 1 year later, she founded SOL and began operations debt-free.

Nina Patterson, SOL’s current director, was also working as a solo practitioner, alternating days with Moore at some of their rented facilities when Moore asked her to join SOL on a contract. However, Patterson first had to agree to obtain ART certification. She registered for three courses immediately.

Others have followed. SOL now employs six PTs (all of whom have ART certification), four certified athletic trainers, two massage therapists, one acupuncturist, two Pilates practitioners, and one occupational therapist. Together, they see about 60 patients per day. "We are not high volume," says Moore, who refuses to cut corners in her time with patients.

The facility features one main gym area, eight private treatment rooms, a Pilates studio, and a hydrotherapy area with an underwater treadmill.

Moore estimates that at least half of SOL’s patients are athletes, with many coming to SOL because of that need. Patients include recreational athletes, weekend warriors, elite athletes, collegiate athletes, and professional athletes. Few patients are sedentary. Moore estimates that about 90% of her patients work out during the week. Those who do not are limited by other health issues.

SOL’s therapists may also see more complex orthopedic cases who have not found success elsewhere. "We tend to get more complicated cases because we do things differently sometimes," Moore says. —RD

Active Release for Active Patients
Active Release Technique, or ART, is a patented, soft-tissue system developed by P. Michael Leahy, DC, CCSP. The movement-based massage technique treats muscles, tendons, ligaments, fascia, and nerves. Sessions incorporate examination and treatment delivered through the practitioner’s hands. Providers palpate the various structures to evaluate texture, tightness, and movement.

Tammara Moore, PT, OCS, founder of SOL and an ART instructor, explains that the philosophy behind ART suggests that scar tissue forms in response to cumulative trauma, whether it be a lack of oxygen or a repetitive stress injury. The cumulative injury cycle produces microtrauma that results in decreased oxygen to the tissue. Decreased oxygen, Moore continues, leads the body to lay down fibrinogen and collagen in an aberrant fashion that limits motion.

The technique treats these abnormal tissues with precisely directed tension and very specific patient movements. "The practitioner palpates for fibrosis and limitation in movement and then treats it with an appropriate lengthening maneuver using her hands to deliver the appropriate tension. It’s a very precise anatomical technique," says Moore, who notes that students review each individual structure, including nerves, muscles, and ligaments. The upper-extremities seminar alone features 105 protocols; there are more than 500 total.

Conditions that ART can resolve quickly and permanently include headaches, back pain, carpal tunnel syndrome, shin splints, shoulder pain, sciatica, plantar fasciitis, knee problems, and tennis elbow. Nina Patterson, PR, OCS, director of SOL, suggests that ART is particularly effective with repetitive stress injuries. "Repetitive stress injuries are very common in our world. The muscle has become fibrotic, with adhesions that the patient cannot break up on her own. ART allows the return of normal biomechanics so that the muscles glide smoothly over one another and permit freedom of movement. Once they can move, they can also be strengthened," Patterson says. —RD