Ramez Antoun is a guy I am lucky enough to work close to and be able to absorb knowledge from whenever he visits the Training Room in Somerville. I recently had the chance to put some questions to Ramez and get his feedback on physical therapy, his training philosophy and the biggest influences on his career thus far.
JC – For anyone who may be unfamiliar with what you do, can you talk about how you ended up becoming a Physical Therapist and where you currently practice?
RA – I thought I wanted to follow in my father’s footsteps and become a physician because growing up I was always fascinated by his understanding of the human body.
Luckily for me, while I was in high school, my dad thought it was important for me to see what a day in the life of a doctor was like, before I made the commitment of applying to pre-med programs.
So he had me talk to a good friend of his who was an orthopedic surgeon at the time, Dr. Fathallah. So I went to the doctors clinic where he told me how much he enjoyed his profession but was also brutally honest about the time commitment, and despite the fact that he was well into his 50’s, he still had to be “on-call” every other weekend for example.
I think he could tell through my body language and tone of voice that I wasn’t into that type of lifestyle.
Dr. Fathallah just so happened to rent space out to a physical therapist in the same building. So he introduced me to the therapist on staff and eventually the owner Todd Houghton. I started going in to observe Todd and the other therapist and I just got hooked.
From that point forward I really wanted to be a physical therapist. So I applied to Umass Lowell for Exercise Physiology because that was the path to get into PT school at the time.
I was already really into lifting weights and being a meat head so it was a perfect fit. Undergrad at UML really got me into strength and conditioning especially after doing my internship at The Institute of Performance and Fitness with Walter Norton. That’s around the time I really started to follow Mike Boyle, Eric Cressey and Charles Poliquin.
During PT school at UML I volunteered as a strength coach with the UML collegiate athletes under head strength coach Devan McConnell. Devan was one of the first people who introduced me to the Functional Movement Screen and Gray Cook’s system. And that, in my opinion, is one of the biggest milestones in my career because as soon as I picked up the book “Movement” by Gray Cook I was also in the midst of studying Orthopedic, Neurological, & Pediatric Physical Therapy courses. The reason why that timing was so perfect for me was because Gray Cook’s principles/philosophies behind his system, integrates all 3 of those course so brilliantly well and I no longer saw them as 3 separate courses but rather courses that complement one another. Gray Cook also references Proprioceptive Neuromuscular Facilitation (PNF) a lot in his work which is what eventually lead me to do a 9 month residency in PNF out in Vallejo, CA.
I currently practice out of my home office in Somerville, MA via my company Neuropedics Physical Therapy & Sports Medicine Consulting.
JC – What is your PT philosophy and your training philosophy and what has influenced them the most?
RA – On the rehab side of things I would say Proprioceptive Neuromuscular Facilitation (PNF) according to Maggie Knott & Dr. Herman Kabat, Dynamic Neuromuscular Stabilization (DNS) according to Pavel Kolar, Orthopedic Manual Therapy (OMT) according to Freddy Kaltenborn, and Gray Cook’s Functional Movement Systems continued to be the greatest influence.
From a training standpoint many of the principles and philosophies are actually very similar and as you keep reading you’ll understand why.
But to answer the question more directly I would say Mike Boyle, Eric Cressey, Brett Jones, Gray Cook, Charles Poliquin, Pavel Tsatsouline, and Dan John continue to be the biggest influence from a training standpoint.
Below I have 6 of my big philosophies spelled out (1-5 come from PNF and I quote Gray Cook in #6 but it is actually a combination of PNF, DNS and Gray’s material. If you want to read more detail about PNF philosophy 1-4, I have devoted a blog post to each of them.
- Every living thing has potential (http://www.neuropedicspt.com/blogforprofessionals/2015/8/30/philosophy-no-1-every-living-thing-has-potential).
- Treat/Train the whole person: Physical, emotional, Intellectual http://www.neuropedicspt.com/blogforprofessionals/2015/8/30/pnf-philosophy-2-treat-the-whole-human-being.
- Positive Approach http://www.neuropedicspt.com/blogforprofessionals/2015/8/30/pnf-philosophy-3-a-positive-approach
- Movement must be directed toward a functional goal http://www.neuropedicspt.com/blogforprofessionals/2015/8/30/pnf-philosophy-4-movement-must-be-specific-purposeful-and-directed-toward-a-functional-goal
- Use their strengths to influence their weaknesses.
If you are familiar with the Functional Movement Screen and programming implications based on the screen this is where “training the 2’s” (as Charlie Weingroff says) or the competent movement patterns. If you’re not familiar with the FMS what this basically means is if someone has an awkward looking dynamic single leg stance (Hurdle step test) but they look pretty good doing an in-line lunge, then lets train the lunge by loading it with weight or volume to give the client an actual training effect without compromising quality.
Does this mean that we don’t attempt to implement corrective exercise to help foster a better hurdle step?
Of course not, that might be a part of the warm up but we need to be able to safely deliver a training effect.
Who’s to stay that training the lunge won’t indirectly help foster the other pattern?
- “Movement is behavioral, if we change perception (sensory input) we can change behavior (motor output).” Gray Cook
A beautiful quote from Cook re-emphasizing the importance of the sensory system in Orthopedics. Most of the time we are so worried about the output to the muscle that we don’t step back and ask if appropriate input is even being delivered to the sensorimotor system.
If you study motor control you quickly realize that our sensory system drives our motor system. To make it simple, sensory input can be thought of as a joint having adequate mobility.
If a joint doesn’t have adequate mobility then certain areas of that joint don’t get stimulate which means that certain mechanical receptors (in that joint) don’t get the stimulation they need to set off an electrical impulse (action potential) to the nervous system.
When mechanical receptors of a joint don’t get adequately stimulated, the brain doesn’t get that input and therefore movement strategies change, creating “compensations”.
The body seems to readily give up mobility for the sake of stability and this could help explain why people lose mobility in the first place.
The concept of “Reflex Stabilization” strategies vs. “Tonic Holding” strategies.
Tonic holding basically means that a muscle that is designed to help you move (hip flexor/hamstrings) increases its “resting” contraction level (tone) or goes into a mini spasm to help stabilize you.
We see very stereotypical tonic holding patterns in both neurological and orthopedic rehabilitation. If you dive into some of my blogs about the PNF basic principles you’ll realize how many other ways you can affect sensory input (Proprioceptive, Visual, Auditory) going to the brain with the intent to change movement patterns.
To give a clinical framework, the diagram above highlights the last 5 years of my continuing education including a 9 month residency in a neuro manual approach known as Proprioceptive Neuromuscular Facilitation (PNF) and a 2 year Fellowship in an Orthopedic manual therapy approach according to Freddy M. Kaltenborn.
The reason why the above diagram is organized the way it is, is because I used the Selective Functional Movement Assessment (SFMA) as a road map for my continuing education journey that helped me decide what courses/residencies to take.
The SFMA tells us that there are 3 possible diagnoses for movement dysfunction that stem from 2 fundamental movement issues:
- Mobility dysfunction or
- Stability/Motor Control dysfunction (SMCD).
If a movement problem is related to a mobility dysfunction it can be a:
- Joint Mobility Dysfunction (JMD) or a
- Tissue Extensibility Dysfunction (TED).
So based on these definitive diagnostic possibilities I went out and made sure that I had the skill set to be able to address each of these issues (joint/tissue mobility or motor control) if and when they came up with my clients.
I’d like to take this moment to make something clear that wasn’t so clear for me when I started my journey with the SFMA.
If someone is in pain and we’re trying to figure out why; medically related causes of pain like nerve involvement &/or an active inflammatory/pathological process needs to be identified or ruled out first. Basically we need to be able to answer this question:
“Are you in pain because you’re moving poorly?
Or are you moving poorly because you’re in pain?”
Gray Cook MSPT, OCS, CSCS
Put another way:
“Our first responsibility is to determine if we are primarily dealing with pathology or dysfunction.” Karl Lewit, MD
The SFMA system, can help us identify if pain is related to an active inflammatory process or not.
If pain is due to an active inflammatory/pathological process, I will try to protect before I correct. This means I will get into SPECIFIC recommendations and modifications for work station setup, sleep position, car seat adjustments etc. in order to respect the area of the body that is trying to heal.
I try to remove/modify aggravating factors which seem to be interfering with the healing process or things that keep “picking the scab”.
If pain does not seem to be associated with an active inflammatory process then I’m thinking “you’re in pain because you’re moving poorly”… Which places more mechanical stress in a given area of the body.
Now the prize winning questions start rolling through my head:
“Is this a mobility or a motor control problem?”.
“If it is a mobility problem; is it more of a joint or tissue mobility problem?”
“If it is a motor control problem; is it more of an unloaded or loaded control problem? Is it an isolated or regional control problem?”
Basically I ask myself:
1) Does it move? Yes or No? And if it does move;
2) Can you control it? Yes or No?
When pain doesn’t seem to be due to active inflammation/pathology, the clinical process can be a lot more creative and interesting with manual therapy and “corrective” exercises that usually end up on social media.
As a side note I might also get into specific lifestyle modifications even though the client doesn’t have an active pathology going on in order to protect the corrective approach that we’re attempting to improve.
JC – What would you say you are trying to improve in the industry with the approach you take to treating patients and getting them pain free long term?
RA – In my mind helping clients become pain free long term needs to first start with educating the client on the difference between a functional diagnosis vs. Structural diagnosis. Many of them have already received a structural diagnosis i.e L4-5 degenerative disc disease, but that doesn’t provide them with a valuable plan of action to manage their problem. That often leaves them with very negative thoughts like “I have a bad back” or “I’m getting old and this is the way it is.”
A functional diagnosis identifies the movements, positions, daily activities that trigger the pain as well as movements that don’t hurt but fall below an acceptable standard of quality/quantity. An example of a functional diagnosis would be: Flexion intolerant (hurts when they round the spine) vs extension intolerant (hurts when they arch the spine). This provides us with valuable information to investigate postures and positions the client gets into throughout their day that are “picking the scab” if you will. Very often we find the people who are flexion sensitive are sitting at a desk and in their car in their sensitive position. That would be similar to injuring your wrist (Image A below) yet all day long you end up in that same position and putting weight through it (image B). We would have an epidemic of wrist pain.
Once the client is guided to identify which habits are actually hindering their progress then we can start to address areas of the body that aren’t moving so well (i.e the hips or thoracic spine) that could be placing more stress on the low back. At this point I make it a point to instill independence in my clients so that they know how to address the areas of their body that aren’t moving so well on their own. So they become comfortable with a daily routine of giving their body the proper dose of mobility and stability where they need it for long term wellness.
As a side note, If someone comes in with a history of chronic pain, I integrate pain education into my structural vs. functional diagnosis discussion. This is where I get into how nerve sensitivity can be manipulated by altering the way forces are being transmitted through the area of complaint.
JC – How important is it to have a line of communication with a client’s strength coach/trainer while treating them? Is there a disconnect in this area a lot of times based on your experience?
RA – This is extremely important in my opinion because many of my clients right now are being referred to be from their trainers. This makes the job a little more difficult sometimes depending on the experience/education of the trainer because program modifications are very often required based on the functional diagnosis of the client.
For example, if the assessment highlights that the client has limited posterior chain mobility bilaterally (active straight leg raise <70 deg), lumbar/lower thoracic spine that doesn’t flex in a unloaded position, and limited external rotation through their hips (real scenario) yet this individual is trapbar deadlifting from the floor in their program:
That’s a problem because the client does not have the prerequisite mobility to perform that version of the deadlift.
No matter what I do from a therapy stand point, if I don’t communicate with the strength coach that this person should be in a wider stance deadlifting from mid shin level, that client won’t get better.
There is absolutely a disconnect from my experience because screening for prerequisites and then appropriately prescribing exercise based on risk : benefit ratio in the fitness industry is still not where it needs to be.
JC – Changing gears, what are you reading at the moment?
RA – The Power of Habit by Charles Duhigg
JC – Do you have any podcasts that are a must listen for you during the week?
RA – Mike Roberson’s Physical Preparation podcast and sportsrehabexpert.com
JC – How large of a role does continuing education play for you in order to stay current?
RA – One the 8 core values of my company is “Growth” so this is the most important piece for me. I wouldn’t be anywhere close to where I am today if it wasn’t for my 9 month PNF residency in Vallejo, CA, 2 year OMT fellowship, and all the other con. Ed courses I’ve taken and will continue to take once I am done with my 2nd year of OMT this December!
JC – If you could sit down with three people from the PT/rehab/strength and conditioning industry, who would they be and what would you ask them?
RA – Gray Cook, Andreo Spina, Brett Jones.
“When you first started to branch off from the “status quo” of rehab/training what were some of your strategies to help your clients/referral sources understand your approach, and how did you manage that frustrating process?”
JC – Where do you see Neuropedics Physical Therapy in five years from now in an ideal scenario?
RA – I see Neuropedics being in a regular size facility where I can effectively deliver both rehab &/or training to provide long term wellness to my clients while having the time to travel and spend time with the people that I love.
JC – As a physical therapist do you have any advice for anyone currently in school who may be looking at going into PT after they graduate?
RA – Get out in the trenches and work with people. Find the environment that turns a not so good day into a pretty awesome day. Place developing relationships with people at your highest priority and do everything in your power to not burn bridges throughout your journey. This is a people business no matter how you spin it. The technical side of things is important but if you don’t know how to communicate and build relationships, technical knowledge won’t get you anywhere.
I’m not “correcting” anything, I’m helping you feel a new movement option #feldenkrais
— Ramez Antoun (@Ramez_PT) October 23, 2015
JC – I’m going to ask you for one quote that influences you daily or has influenced you in your career.
RA – “Seek first to understand before being understood” – Stephen Covey
I live firmly by this quote. As I interact with various fitness facilities I make it a priority to get to know how they think, what they believe, and how the train people. Even though I might have a many things that I would like to change, I don’t think anyone will ever listen to me if they don’t get the sense that I understand them first.
You can find Ramez online: