November 2018 PULSE

NOVEMBER 2018

- COMING UP THIS MONTH -

Monday, November 5th from 6:30 - 7:30 pm Mike Antunes at Russell Library presenting “Overuse Injuries & Concussion Research” Thursday, November 8th at 10:00 am Tom Kassan at Elmood Community Center presenting “Oh My Aching Joints”

WORLD CLASS

While there were very few negative reviews, themes did emerge from the passives and detractors.

An exercise in understanding our patients and how we can grow.

A few comments included, “I didn’t get my home exercises” or “no one explained my injury.” This reminded me of the unique position we’re in to share our knowledge about the musculoskelI recently read a blog post about “negative physical therapy reviews” in etal system that most of our patients and even their physicians do not have. Most of our patients leave their first visit feeling which the author had studied hundreds of online reviews looking for patterns that could be used to better understand how patient feedback confident in their diagnosis and plan for rehabilitation, and they’ve expressed as much in many positive reviews, yet every can be used to provide better care. patient is different. Taking the time to explain to each and every PTSMC has been using the Net Promoter Score (NPS) for several years, patient their diagnosis and plan in a way they can understand and we have had thousands of responses. As a quick review, the NPS is a makes our patients comfortable and confident; creating PT for customer satisfaction score based on patients answering one question: Life relationships.

“How likely is it that you would recommend PTSMC Avon to a friend or “More time my clinician.” Overall, the vast majority of our reviews colleague?” show that we spend a lot of time with our clients; that’s why our The scale is from 0 – 10. Customers who select a 9 or 10 are considered score is at 90%! Our focus on one-on-one care is one that we all do well – it’s built right into the ethos of our organization—yet “promoters” – people who are extremely positive about their PTSMC experience and are willing to tell others! A rating of 7 or 8 falls into the it’s a helpful prompt that just one extra touch point or bit of communication can make a big difference in a patient’s “passive” category, representing those who didn’t have a great experience. experience or a terrible one. Last, we have the “detractors.” These individuals score between 0-6 and were clearly not happy with their Lastly, there was a minority of vocalized frustration in “not experience. getting better.” What may feel like progress to us may still feel frustrating to a patient who is working hard and expecting fast In the first three quarters of 2018, PTSMC netted a “world-class” NPS results. Not every patient will have the same journey or outcome, score of 90% based off 4,333 responses. For those of you who are and by working with our patients and encouraging them every wondering how great that score really is, consider this: the online time they visit us, we will help them to feel proud of the progress entertainment company with the highest score was Netflix… with a score of 50%! We should be proud that we are delivering on our mission they’re making. and that the vast majority of our customers are saying great things This exercise in finding value from the few detractor scores and about us. negative feedback is a great reminder that there is so much to be learned from every interaction and experience we have. While The comments section allows for individuals to express, in greater detail, why they chose a particular score. The amount of positive praise our positives far outweigh the negatives, there is always an opportunity to strive to be better each day. we’ve received is exceptional, and reading the comments affirms our commitment to those we serve. As awesome as it felt to read these A patient who is listened to, cared about, treated in a positive reviews, it wasn’t the reason I went looking. environment and respected will recommend us to family and Inspired by the blog post I read, I wanted to review the comments from friends. the “detractors” and “passives.” It’s important to keep in mind that Thank you for being World Class. someone willing to voice specific concerns or recommendations feels strongly enough to take the additional time to explain their score, and so we should take the time to read and think about what they’ve said.

Alan It can only help us to grow as an organization.

Was Casino Night a WINNER?

91.66% 100%

94.44%

We hope you enjoyed Casino Night!

According to the survey, of attendees said the theme was “Excellent” or “Very Good” of respondents liked the invitations and e-mail reminders of attendees would like to do another casino night While most attendees enjoyed the Hartford Yard Goats venue, about half of respondents said they disliked Hartford as a location, citing its inconvenience for shoreline clinics. For those who disliked the location, popular suggestions were in the Middletown or New Haven areas. One even suggested rotating regions where events are hosted. Some of the suggestions for future adult-only events included a dance party, a bowling night, trivia, and a brewery party.

Thanksgiving Day, Thursday, November 22nd Orange at Orange Rotary Turkey Trot at 8:00 am Southbury at Southbury Turkey Trot at 8:30 am Branford at Branford Rotary & YMCA Thanksgiving 5k at 9:00 am

10th Annual Holiday Food Drive November 12th - December 14th

Support your local communities by bringing in non-perishable food items and encouraging patients to do the same!

StriveHub Fab 5 “Kevin and his staff do an amazing job with my kids.

My daughters are athletic kids and have various injuries that Kevin has done an incredible job helping them heal. I tell everyone I know about him.” - Plainville ”Everyone is very pleasant and friendly. Drew always answers questions and checks on progress and comfort. Clean, never in a hurry, comfortable atmosphere.” - Southbury “The staff was very helpful, and they were all nice to me. It’s a great environment in there. Everyone is trying to help the patients and have a little fun too.”

- Groton “The physical therapy team was excellent at returning my life back to me after my injury. Thank you to your dedicated staff!” - Westbrook “Therapists are extremely knowledgeable and very friendly. They listen to you and are helpful in every way.” - Wallingford

CLINICIAN’S CORNER

BY MARY CLARK, PT, M. OF ED, LMT PHYSICAL THERAPY FOR THE PREGNANT POPULATION

During pregnancy, women often experience discomfort, low back pain and pelvic girdle pain (PGP). Physicians who treat them often tell them this is normal and will go away after birth, but research shows this isn’t the case. Women with high pain intensity during pregnancy had a greater risk for back pain in the postpartum period1 and 65% of women with combined PGP and LBP reported recurrent PGP and LBP 14 months after birth2. Symptoms during pregnancy, birth and the postpartum period can affect a woman throughout her lifespan, and although incidences of LBP and PGP in pregnancy are common, relatively few patients report symptoms to physicians and even if they do, are often not referred for care. In pregnancy, women are more predisposed to these conditions because of ligamentous laxity that results from hormonal changes, and because a woman’s center of gravity and body mass are changing. If a woman has any muscle weakness or joint instability going into the pregnancy there is greater difficulty meeting the increased demands of her body’s changes.

Treatment should also include NMR – reeducating the core muscles - specifically TrAb and pelvic stabilizers. Several authors report that strengthening these muscles are essential to maintaining SI joint stability and can help to prevent DRA during pregnancy and postpartum. Principles to remember when teaching your patient these exercises are to maintain normal breathing; perform slow, controlled, minimal contraction to avoid recruitment of global muscles; maintain neutral spine (NOT a pelvic tilt). As the patient progresses with core stabilization, the goal would be to train them to use these core muscles during functional movements including transitional movements, lifting, etc.

Another component of treatment would be to educate the patient in good body mechanics to avoid further stresses and strains on the back and pelvis. General body mechanics principles are to be applied such as supported sitting, bending with knees bent, etc. Specifically for pregnancy, women should avoid leg crossing at the knees or ankles, standing with all the body weight on one leg, carrying large bags on one side, bending with twisting, large range lunges or splits, and hopping on one leg.

As experts on the musculoskeletal system and its functions, PTs are essential to providing pain relief and optimizing function during the perinatal period.

Expert-supervised, core-focused, progressive, and functional therapeutic exercise with a regular home exercise component reduces pain and improves function in women with pregnancy-related PGP3.

Modalities are mostly contraindicated for pregnant women, but ice or heat can be considered. If using moist heat, use extra toweling to prevent hyperthermia. Cold packs can also be used for good relief of acutely painful conditions. As most pregnant patients are not taking medications for pain relief, these thermal modalities may be useful tools to help reduce pain.

Here are some basic guidelines for treating these patients:

As trained physical therapists, we are in a unique position to help reduce pain and restore function in a pregnant patient. If a pregnant woman is referred to you, this information should help you feel more comfortable in treating this special population.

As with any patient you will do a musculoskeletal assessment. You may have to modify positions, but you should be able to do MMT, ROM (including lumbar and hip), postural assessment, palpation of landmarks, and most special tests for SI joint, lumbar mobility, etc. The main positions of concern are prone lying and there should be limited time in supine position after 24 weeks. Also, try to avoid positions that encourage vigorous stretching of the hip adductors, extreme asymmetrical lower extremity positions and extreme end-range of motion positions of the hips.

Treatment can consist of manual therapy which can include functional retraining, muscle energy techniques, myofascial release, joint mobilization, trigger-point release, and SCS (positional release). These techniques are used to reduce muscle guarding, improve joint function, and optimize musculoskeletal alignment.

Research shows that PT with a multimodal approach to low back and pelvic pain in mid-pregnancy benefits women more than standard obstetric care4.

1. Ostgaard, H.C., Zetherstrom, G., Ross-Hansson, E. (1997). Back pain in relation to pregnancy: a 6 year follow up. Spine,22(24), 2945-2950 2. Bergstrom, C., Persson, M., & Mogren, I. (2014). Pregnancy related low back pain and pelvic girdle pain approximately 14 months after pregnancy - pain status, self-related health and family situation. BMC Pregnancy and Childbirth, 14,48. doi: 10:1186/s12998-016-0088-9 3. Belogolovsky, I., Katzman, W., Christopherson, N., Rivera M., &Allen, D. (2015). The effectiveness of exercise in treatment of pregnancy-related lumbar and pelvic girdle pain: A meta-analysis and evidence-based review. Journal of Women’s Health Physical Therapy, 39(2), 53-64.

4. George, J.W., Skaggs, C.D., Thompson P.A., Nelson, D.M., Gavard, J. A., & Gross, G.A. (2013). A randomized controlled trial comparing a multimodal intervention and standard obstetrics care for low back and pelvic pain in pregnancy. American Journal of Obstetrics and Gynecology, 208(4), 295-e1-295-e7. Doi:10.10167/j.ajog.2012.10.869

Upcoming Event:

From Homework to Workforce

What: Event for DPT students, including any PTSMC employee in PT

school, to help them navigate the job search and make the transition from student to professional Where: PTSMC Wallingford When: November 14, 2018 at 7:00 pm Light food and beverages will be served. Interested PTSMC employees must RSVP to Mallory at mallory.mason@ptsmc.com by November 12th.

Upcoming Courses DEDICATION RESPONSIBILITY EDUCATION ATTITUDE MOTIVATION

Email coned@ptsmc to RSVP

Next month

Looking Ahead...

December 11th 4 pm - 8 pm Exam and Treatment of the Cervical Spine Presented by Steve Platt and Mike Gans in Guilford

Graston M1 March 2-3, 2019 Wallingford

Email coned@ptsmc.com to register

Student Program Update On November 9th at noon, Jessica Fontaine, Quinnipiac 1st year DPT student, will present her inservice on “ACL Prevention Program for Soccer Players” at the Watertown clinic.

On November 13th at 11:30 am, Kyle Wolf, Sacred Heart University 3rd year DPT student, will present “Tendinitis vs. Tendinosis vs.

Tendinopathy” at the Newington clinic.

STUDENT PROGRAM UPDATE

Myopain TDN1 March 8-10, 2019 Sacred Heart University

Beginning November 19th, Groton will host Sam McCullen, who will graduate from the URI DPT program in May 2019. Sam will be working with Steven deCastro.

The

Holiday Schedule All clinics will be closed on the following days in observance of the holidays

Dependent Care Savings Accounts/DCSA

Are you paying for dependent care for your children or elderly parent? Did you know that PTSMC offers a program where you can get reimbursed for those expenses with PRE-TAX dollars through payroll?

Employees meeting the following eligibility requirements can have PRE-TAX deductions from their paychecks so that they can be reimbursed for dependent care expenses tax free.

Eligibility Requirements • Employee has a child or disabled parent or spouse who needs daily care while you are at work.

• Incurring the expense allows you to work.

• Employee must be scheduled to work 20 or more hours per week • Eligible expenses may include the costs for dependent care at home or in a day care center or after school care for children under age 13.

• Employee may contribute up to $5000 in a calendar year to the dependent care savings account. if you are married and file a joint return, or if you are single and file as head of household.

There are a few government rules and regulations regarding this benefit. If you are interested, please contact Sandra Boccialetti sandra.boccialetti@ptsmc.com for specific details. All employees currently in the plan will receive the required paperwork from Sandra by November 16, 2018. Enrollment for January 2018 must be completed by December 14, 2018.

Thursday, November 22, 2018 Tuesday, December 25, 2018 Tuesday, January 1, 2019

Thanksgiving Day Christmas Day New Year’s Day

Thanksgiving Holiday Schedule All clinics will have the option of opening 7:00 am – 5:00 pm on either Wednesday, November 21st or Friday, November 23rd.

Christmas Eve Schedule All clinics will be open from 7:00 am – 1:00 pm on Monday, December 24th, Christmas Eve. All FT employees who are scheduled to work 8 hours a day and work form 7:00 am – 1:00 pm will be paid for 8 hours on this day. Timesheet entry would be 7 am – 3 pm. All employees who have requested time off on this day will use the total vacation hours requested.

New Year’s Eve Schedule All clinics will be open from 7:00 am – 3:00 pm on Monday, December 31st. Employees working 8 hours on this day can take a ½ hour paid lunch. Employees do not enter your ½ hour lunch time on your time sheet, however in the notes section enter ½ hour lunch taken.

401k

Employees who would like to make a change to their 401(k) biweekly contributions for the 1st quarter of 2019 must complete the request by Friday, December 14, 2018 to be effective with the January 2, 2019 payroll. Login to www.jhancockpensions.com and click on Manage and Contributions.

CURRENT JOB OPPORTUNITIES AT PTSMC Physical Therapist Avon Southbury Southington

Patient Services Coordinator Guilford New Haven

Physical Therapy Aide Branford Groton New London Wallingford Westbrook

Check PTSMC.com for our most up to date postings and feel free to share! We’re always interested in connecting with referrals of colleagues and friends.

Congratulations to the following employees who have achieved advancement in the PT Aide Skill Base Levels!

Stephen Dering, Guilford Renee Gallant, New Haven Jasmine Lumasag, Orange Derek Marinaro, Watertown Mia Martinez, Wallingford Mikayla Raffone, New Haven Olivia Tarca, Windsor Sylvia Yanez-Carlson, Watertown Meagan Harris, Southington Logan Edwards, Windsor Dan Delgado, Windsor

Meghan Blanusa, Guilford Jennifer Evans, New Haven Elton Purvis, Westbrook Arianna Cote, Westbrook

Extra MILE

Tips for EXCELLENCE in customer service with Alison Pearce, Customer Experience Coordinator Continuing our Customer Experience with a SMILE. Here is some feedback from one of our patients from Strive Reach: “Staff are well educated, personable, and cognizant of abilities during the healing stage. Would advise to open a bit earlier when offering 7am appointments to ensure office is open when patient arrives” It is important to be ready to start the day when the clinic opens. Front desk staff should be there to greet patients for even the earliest appointments. Arriving to work just a few minutes early sets the tone for the day and allows time to catch your breath and get settled before jumping in.

If you happen to be running a little behind and meet the patient in the elevator or at the front door ask, “How are you this morning?” (Let’s be honest - most of us, including patients, are still waking up!) Just that little extra warm welcome lets the patient know you care. I am sure most of us do this naturally anyway, and that is what makes our PSCs and PSAs the BEST!!

Would you like to join in the

FUN?

We are looking for employees to join our committee to plan for our 2019 Get Together events!

Have any fun ideas?

No need to travel!

All meetings will be via GoTo meetings.

If you are interested, please contact Sandra Boccialetti at sandra.boccialetti@ptsmc.com or 860-409-4595 ext 303.

We are THANKFUL for our employees!

Who was PTSMC’s FIRST employee?

Looking forward to hearing from employees from all regions!

A. Mike Durand B. Sandra Boccialetti C. Alan Balavender D. Tina Boccialetti

Test your knowledge of PTSMC! E-mail your answer to Mallory at mallory.mason@ptsmc.com by November 15th to be entered to win a Thanksgiving gift card to your local grocer!

Q3 Attendance Reward Recipients Dan Delgado Ted Fifield Ali Flier Kathryn Flodquist Mike Gans Melissa Lembo

Molly Maine Josh McAdams Liz Melvin Erik Olsen Danica Sadowski Michael Sousa

Life Beat

NEW EMPLOYEES

Welcome to PTSMC. We’re so happy to have you!

STRETCH AWAY THE PREWINTER BLUES

Are the cold, rain and darkness getting you down lately? Coffee not quite taking the edge off? Well forget the caffeine and try a bit of good old-fashioned stretching! Here are a few simple ways stretching can benefit your energy and brain power.

Savonnah Artis

Stephanie Brilla

New London PT Aide

Meaghan Cartier

Southington PT Aide

Windsor PT Aide

Start your morning strong: Beginning your day with a good stretch will get your blood going. Not only will this warm up your body after a cold November night, but it will also wake up your mind.

Purposefully doing a morning stretch will help you set the intention to have an energized and focused day.

Make the most of your work out: Stretching pre-workout can benefit you in a few ways. It will help you have better form in your exercises, thus getting more from the activity. You’ll get deeper in those squats and jump higher in those burpees!

Stretching before you get into your workout will also help switch your brain to “workout mode.” By focusing on stretching out your body, your brain will tune in more to the task at hand and let go of the rest of your day.

Jenna Glynn

Leigh Holahan

Nathan Gockel

Office Assistant

Avon PT Aide

Plainville PT Aide

Relieve stress: When you are all stressed out (preparing for the holidays or meeting a deadline) your body naturally tightens up. Stretching can help to relive that tension and allow you to physically and mentally relax. You’ll be able to focus on what you need to do rather than your constricted neck and shoulders.

Mid-afternoon “Stretch Break”: After lunch hours got you snoozin’ and running out to Starbucks? Skip the coffee break, save some change, and have a Stretch Break! With a few minutes of stretching you can increase blood flow through your body and to your brain to kick that feeling aside. So, hop back on that Energy Bus and crush the rest of your day with a little help from some stretching.

Michael Laviolette Avon PT

Jonathon Maposa

Sara Miller

New London PT Aide

PT Aide

Need some direction on getting a better stretch?

Check out Ali Condo’s stretching class in Avon on Saturdays at 9 am! To learn more or register for a class, give the Avon office a call at 860-674-1713 or visit PTSMC.com/stretching-class Allison Condo is a Certified Exercise Physiologist through the American College of Sports Medicine and graduated from Central Connecticut State University with a Bachelors in Exercise Science.

Andrew Perazella New Haven PT

Nicole Skirkanich Orange PSC

PTSMC Happenings Orange PT Stephanie Weyrauch (second from right) attended the Education Leadership Conference in Jacksonville, FL and presented with 3 other PTs on integrating podcasts in DPT Education.

Fred Havlicek visited SCSU to talk with students about a potential career in PT (right).

Fred also participated in Artspace New Haven City Wide Open Studios with other New Haven businesses. He’s pictured below with other New Haven business owners.

Westbrook attended the Chamard Vineyard Half Marathon.

Wallingford PTs Danielle Dunn and Ashley Tighe (right) participated at the Wallingford Senior Center Health Fair.

We helped as the stretcher crew for the USMNT’s game against Brazil.

Orange took a tour of New Haven via an Elm City Party Bike.

Naugatuck got into the spirit of the season with a spooky staff outing at Shelton's Legends of Fear Haunted Hayride.

Social Media Sensation! PTSMC Employee Spotlight Joanna Fisher, Waterbury PT

Joanna has been at PTSMC Waterbury for over 2 years. Learn how an injury resulting from a horseback riding accident inspired her to pursue a career in PT and more in this month’s Employee Spotlight at www.PTSMC.com/videos.

EVERYONE!

Thanks for sharing your pumpkin pictures!

You really smashed our expectations!

NOVEMBER BIRTHDAYS Derek Marinaro Emily Hansen Nicole Skirkanich Andrea Murphy Ali Condo Liz Walton Victoria Carcova Cara McEvoy Emily Fillion Liz Saunders Heidi Klein-Robbenhaar Sandy Wickman Mason Mia Martinez Brian Vo Cindy Hales Ryan Balavender Todd Cacopardo Bailey Lyons Mike Antunes

2 3 3 5 7 7 8 10 11 13 13 13 14 16 16 16 16 18 18

Watertown Avon Orange East Hampton Newington Middletown Orange Branford Admin New London Wallingford Admin Wallingford Windsor Admin Admin East Hampton New Haven Middletown

Meagan Harris Jonathan Maposa Joe Mabry Christine Rasile

20 24 26 28

Southington New London Waterbury Admin

ANNIVERSARIES

Tina Boccialetti

Admin

Admin Receivables Coordinator

Jenna Hancock

New London

PT Aide

Congratulations!

Traci Riviere (New London) tied the knot on September 29th.

Laura Gallant (Avon) tied the knot on October 13th.

Melissa Lembo (Guilford) got engaged to Nabil Boutagy on October 13th.

Congratulations to Stef Cagno!

Congratulations and welcome soon, Stefanie Cagno to the Patient Benefits Department (PBD) team! Stefanie’s attention to detail as well as her experience with insurance verification will be of huge value to PTSMC clinics in her new role.

Stefanie joined PTSMC as a part time Patient Services Coordinator in our Naugatuck clinic in January 2016. She was referred to us by PTSMC employee and good friend Stevie Fell. By April 2016, Stef was full time in our Orange office, where she has been the primary PSC for one of our fastest growing locations. Stef’s thoughts on her move to the PBD, “I’m excited to begin this new chapter with PTSMC … health insurance can be intimidating and confusing, and I look forward to being an expert in the subject so I can help others navigate through it more easily.”

Stef enjoys carbs, sleeping in on weekends and caffeine! She is into selfies with Snapchat filters; perhaps a social media liaison for the Patient Benefits Department!

From PTSMC Residents John Galer, PT Guilford Channing Hardwood, PT Plainville Erik Schmitt, PT Westbrook

Orthopaedic Residency

Increasing Ankle Dorsiflexion with Dry Needling or Instruments?

P: Does trigger point dry needling result in greater increases in dorsiflexion range of motion (ROM) compared to instrument assisted soft tissue mobilization

(IASTM)? Lack of dorsiflexion ROM has been suggested as a predisposing factor for a variety of musculoskeletal injuries1,2. Determining the effectiveness of these interventions may lead to improved clinical reasoning and intervention prescription.

I: Dry needling (TDN) is a technique that uses fine needles to penetrate the skin and muscles with an attempt to purposefully mechanically disrupt tissue without the use of anesthetics. There are conflicting theories about the exact physiological mechanism underpinning the effects of TDN; however, it has been suggested that TDN may produce both local and central nervous responses to restore homeostasis at the site of the MTrPs, resulting in a reduction of both peripheral and central sensitization to pain3. The role of TDN to manage muscle tone abnormalities such as hypertonia or spasticity has been clinically developed during the last years, although existing scientific evidence is limited3,4. The effects of dry needling on increasing ankle dorsiflexion ROM has limited research and is the topic of focus.

C: IASTM uses specifically designed instruments to identify and treat myofascial restrictions5. Similar to TDN, there are conflicting theories on the efficacy of

IASTM. Graston is a popular, specific technique that combines IASTM with exercise. They use multiple stainless steel instruments of different sizes and beveled edges to tailor their treatment to different muscles6. They claim to treat fascial restrictions that will allow for better outcomes when the goal is improving ROM, eliminating pain, and restoring normal function.

O:There are a limited number of studies describing increases in DF AROM following TDN procedure. Studies included had small sample sizes, differences in

population, poor data reporting, and lacked a placebo control. The one study that included a control was also the only to repeat the TDN procedure, and did at a frequency of one time per week for four weeks. Their study demonstrated a significant improvement in DF AROM and pain immediately post and at four weeks post TDN intervention p<0.0017. In the other two studies, TDN procedure was performed once. Both studies had lower methodological quality and showed some, but insignificant increases in DF AROM post procedure8,9. Available evidence tells us there may be a benefit to repeating the TDN procedure more than one time to achieve maximum effect, and that effects are greatest when paired with a stretching program.

There are also a limited number of studies describing increases in DF AROM following IASTM procedure. All three studies included a healthy, active population of individuals in their early twenties. Two of the three studies were single treatment. Both showed some but not a significant increase in DF AROM10,11. One study also included a stretching program, and was able to demonstrate a significant increase in DF AROM p<0.01. They reported a modest 2.8 +/- 2.6 degree change in ankle DF after eight treatments of IASTM12. Available evidence tells us that there may be a benefit to repeating the IASTM procedure and adding a stretching program to improve DF AROM in a population of healthy, active, individuals in their twenties.

References

1. Backman L, Danielson P. Low range of ankle dorsiflexion predisposes for patellar tendinopathy in junior elite basketball players: a 1-year prospective study. American Journal of Sports Medicine. 2011;39(12):2626–2633 2. Willems TM, Witvrouw E, Delbaere K, etal. Intrinsic risk factors for inversion ankle sprains in females:a prospective study. Scandinavian Journal of Medicine and Science in Sports.2005;15(5):336–345 3. Gattie.The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. Journal of Orth paedic Sports Physical Therapy. 2017 Volume:47 Issue:3 Pages:133–149 DOI:10.2519/jospt.2017.7096 4. Jiménez-Sánchez, C. et al. Effectiveness of deep dry needling on muscle tone in healthy subjects. Physiotherapy , Volume 102 , e251 5. Stow R. Instrument-assisted soft tissue mobilization. International Journal of Athletic Training and Therapy. 2011;16(3):5–8 6. Stanek J, Sullivan T, Davis S. Comparison of compressive myofascial release and the graston technique for improving ankle dorsiflexion range of motion. Journal of Athletic Training.2018;53(2):160-167 7. Bina Eftekharsadat, Arash Babaei-Ghazani, Vahideh Zeinolabedinzadeh. Med J Islam Repub Iran. 2016; 30: 401. Published online 2016 Jul 23.PMCID: PMC5038993Dry needling in patients with chronic heel pain due to plantar fasciitis: A single-blinded randomized clinical trial 8. Grieve, Rob et al. Journal of Bodywork and Movement Therapies , Volume 17 , Issue 4 , 453 - 461 The immediate effect of triceps surae myofascial trigger point therapy on restricted active ankle joint dorsiflexion in recreational runners: A crossover randomised controlled trial 9. Ashley Davis Lake, PT, DPT, SCS1 Heather Myers, PT, DPT, SCS, LAT, ATC1 Brett Aefsky, PT, DPT, SCS, CSCS1 Robert Butler, PT, DPT, PhD1 Immediate and short term effect of dry needling on triceps surae range of motion and functional movement: A Randomized Trial.

10.Hammer WI. The effect of mechanical load on degenerated soft tissue. Journal of Bodywork and Movement Therapies. 2008;12(3):246–256.

11. Vardiman J, Siedlik J, Herda T et al. Instrument assisted soft tissue mobilization: Effects on the properties of human plantar flexors. International Journal of Sports Medi cine.2015;36:197-203 12. Palmer T, Wilson B, Kohn M. The effect of graston massage therapy on talocrural joint range of motion. International Journal of Athletic Training and Therapy.

2017;22(3):66-75