Continuing Education Bits for PTs & PTAs

by Marilyn Pink, PT, Ph.D., MBA

Jobe banner

A patient sitting in his/her pre-op exam with Dr. Frank Jobe would hear about the surgery, and then they’d hear “—and that is only Jobe in scrubsthe first half of the job, the second half is your physical therapy”. On March 6, 2014, physical therapy lost a great friend and a firm believer in the profession with the passing of Dr. Jobe.

Given the great therapists he worked with, it is easy to see how he came to appreciate the benefits of PT. So, before going on with remembrances of Dr. Jobe, I, as a PT, would like to thank all of you PTs who affirmed Dr. Jobe’s belief in us: Haideh, Judy, Clive, Kevin, Pat, Brian, Matt, Stewart and many, many more. For those PTs who have not had the privilege to work with Dr. Jobe: we are making his EDUCATA course The Process of Progress (a collaboration between myself and Dr. Jobe) available for free this month of March 2014 in his honor. Click here and enter coupon code JOBE2014 at checkout if you’d like to hear and learn directly from this great clinician, surgeon, educator.

Like Hippocrates, Galen and Pare, Dr. Jobe went to war to learn about surgery. He joined the Army out of high school during World War II and served in the 101st Airborne Division during the Battle of the Bulge. One day, out of the blue, he told me a story about how his group was about to move to a new location the next day. As the medical supply sergeant, he stayed up all night packing supplies. The next day, once they’d arrived at their new destination and he had unpacked, he decided to take a nap.  So, he went into the forest and fell asleep – until he heard yelling, screaming and gunfire. He looked out from the dense forest, and saw the Germans had overtaken his camp. As a young man not knowing what exactly to do, he went deeper into the forest and became quite lost. Multiple days in the cold without food went by. Then he heard trucks. He decided it didn’t matter if those trucks were American or German, he was going to flag them down.

Lucky for him, and us, they were American trucks. Dr. Jobe became a medic and the Army doctors whom he saw performing surgery, keeping calm and focused with gunfire overhead, became his inspiration.

Indeed focus and keeping calm became landmarks of his personality.

The first lecture I did for Dr. Jobe was at a Baseball conference. After speaking and on stage, Dr. Jobe came up to shake my hand and leaned in, for what the audience probably assumed was a gentlemanly kiss on the check.  But, here’s the truth – he was whispering in my ear that I’d forgotten to distinguish between the upper and lower subscapularis!! So, Dr. Jobe: in the lecture on shoulder biomechanics that is currently in production at EDUCATA, I make a big deal out of the difference of those two RADICALLY DIFFERENT parts of the muscle.

Dodgers Fantasy Camp fixed

Baseball Fantasy Camp for MD’s and PTs. Dr. Jobe flanks one end and Marilyn Pink the other

Much has been said this past week about his breakthrough surgical procedures and the famous people he treated – mostly athletes. But I’d like to put in my two cents for his generosity to humanity. Here was a busy man who loved his work and the people around him. He helped us define our strengths and then gave us an opportunity to push a bit more. He knew what and when something was taking our minds off of work, he’d gently inquire about it and turn the focus to what we did well. He helped us believe in ourselves.

Jobe Manuel Bunelos

I’m at a lack of words for the greatness of this human being, but I’d like to close with this remembrance: frequently, at the end of a lecture, Dr. Jobe would turn to the audience and say “We aren’t done.  It isn’t over yet.  It is for you, the next generation, to take this knowledge to the next level.  I want YOU to do the research to make my words outdated.”

I take that to heart.  This past year we saw Dr. Perry pass away, as did Dr. McKenzie and now Dr. Jobe.  Who among us are the next leaders in clinical advancement?  What questions are we asking?  What do we look for and how can we consistently optimize treatment with our patients?  Equally pertinent is how do we deftly communicate our findings and promote learning in all of us?

So, thank you Dr. Jobe, Dr. Perry, Dr. McKenzie and many other leaders who have shown us not just the facts of medicine, but also the process of thinking through problems, deriving solutions and communicating results. Thank you too, for making it clear that we each have a responsibility to enjoy our work as we push it forward.   Thank you for being our inspiration.

Marilyn

Dr. Jobe and Marilyn

“A great surgeon but a better person” – Tommy John, retired Dodger’s pitcher.

Dr. Frank Jobe with Tommy John.

If you were asked to create and execute a PT program for a patient and his ECG graph looked like this:

Exercise this

Would you?

Tell us your choice and comment as to why you think you should or should not. We’ll let you know the results (and the correct answer) shortly.

By guest blogger, Susan Bamberger

The patient is better, but symptoms are not fully resolved. In determining the next step, considerations include the following:

  1. Analysis of the exercise:
    • Is he performing the exercises as prescribed?
    • Is he reaching end range?
    • Is the exercise correct?
  • He is performing the exercise correctly, and he is reaching end range. It is too premature to abandon the exercise. In one visit, he is demonstrating improvement, as he can run longer and with less pain.

2) Is he doing anything between the exercises that may aggravate his symptoms?

  • In his detailed journal, he had stopped all the other stretches as requested, and had not really changed his regular routine. He was not doing anything in his life that might aggravate the hip.

3) Was there anything about the posture of running that might aggravate his symptoms?

  • In this case it made sense to assess his running posture. This was not a running gait analysis, but rather an evaluation of the hip posture in relation to the understanding that his range of motion decreases and pain is produced when running. A derangement causes a mechanical obstruction, and therefore I wanted to see what it was about his running that was causing the mechanical obstruction.
    Example of the running posture he was assuming:

McKenzie runner b

With the forward flexed posture, it was reasonable to conclude this may contribute to his pain presentation. He was experiencing 2/10 pain when running during this demonstration, as he had just run over for the visit. So, I asked him to stand more upright by engaging his hip extensors. With this positional modification, his pain went away.

Visit three

Two days later, the patient returned, reporting he could run longer- 15 minutes, vs 10 minutes before, He reported he was learning to run upright, but was not able to maintain his upright posture, When he experienced pain, if he corrected his posture, the pain went away immediately.

Correcting posture with activities can be a process that takes a long time to correct. It is best to correct the pain before the pain comes on, but at first this may be challenging. With diligence, he should be able to permanently fix his running posture and avoid aggravation of his symptoms.

Since we were on visit three and he still could only run 15 minutes, it made sense to reassess the effects of the exercise. It was not completely clear that the stretch prescribed was enough to fully reduce his symptoms. At this point, it made sense to intentionally aggravate the symptoms through progressive mechanical loading to determine what it takes to fully reduce the symptoms.

Pt had 0/10 pain prior to the start of the start of this test. The patient performed unloaded hip flexion, or walking marches: there was no effect. I then had him perform walking marches into a full lunge, which reproduced his symptoms to a 3/10 and reduced his range of motion .I then had his perform his prescribed exercise, which reduced his pain to 2/10, but did not abolish it. I then encouraged him to hold his stretch 5-7 seconds longer, which abolished his symptoms altogether.

His instructions were to hold his stretch a little longer, and to gradually increase his running, integrating the prescribed exercise into his running, Some minor adjustments of the exercises gave him the results he wanted- a full resolution of symptoms.

He was given guidelines for getting back to running up to 30 minutes at a time. He was given the guidelines for pain production. He was instructed not to be afraid of the pain, but to respect it and be sure to move it when he feels it, so as to not aggravate it as he had during the marathon. He was instructed on what to do if his hip does truly worsen to the point that it causes constant pain; to perform the stretch regularly and take a few days off from running.

Visit 4: 2.5 weeks later

The patient was pleased that he was able to run up to 30 minutes without exacerbation of symptoms. He was so pleased with this progress that one day he tried running faster with some of his running buddies, which pushed his hip harder and further than he had been. During that run, he got the same 5/10 pain he had at the marathon. After the run, he immediately went back to the hip extension exercise. While they helped, they did not immediately abolish his pain as they had before.

An exacerbation of symptoms can be used as a learning tool for the patient; to see if they understand the principles of self management. McKenzie and May state in The Lumbar Spine: Mechanical Diagnosis and Therapy (2004) “At the first sign of recurrence, the patient should immediately commence the procedures that led to recovery”. Learning how to manage symptoms when they recur is a key to long term recovery and prevention of disability.

To determine if he understood these principles, I asked him what he did. He understood that he had run too fast and too far, and was not ready for it yet. He immediately went back to an increased frequency of hip extension in half kneeling, and stuck with them regularly for 2 days. He also stopped running altogether for a few days. Within a few days he felt much better, and was ready to start running again.

Using the last visit as a baseline, we tested the irritability of his symptoms through progressive mechanical loading. I ran him through the same litany of tests as before. Standing hip flexion had no effect. Walking marches into a full lunges had no effect. He then performed many squats, lunges, lunges with torso twists, and side lunges over the course of 25 minutes. None of these symptoms reproduced his symptoms or created any mechanical change, indicating a vast improvement from the testing we had performed during the last visit. My instructions were to continue with self treatment and gradually increase his running program.

The patient came in three more times over the course of four weeks. During these visits, we would mechanically test the hip as we had previously done. His hip remained stable, as there were no mechanical symptomatic changes with progressive loading. At this point in the program we started to work on hip strengthening exercises. He wanted to return to the exercises he was doing before, so we reviewed what he was doing and discussed how he could integrate the hip extension exercise into his exercises: If he overdid the strengthening and his left hip pain resumed, he could utilize the hip extension exercise to self manage his symptoms.

By the time he was discharged, he was running pain free up to 10 miles at a time, at his desired pace. He was contacted a few months later for permission to publish this case study He reported he was gradually increasing his running, was still painfree, and was on track for his next marathon..

In 8 visits over 6 weeks, this runner progressed from not running at all to training for a marathon again without pain. As health care changes, we have to be poised to prove our value in providing cost effective care. Ask yourself:

  1. How can we set ourselves apart as leaders in health care? What services can we provide that patients find valuable in this information age?
  2. How can we maximize health care dollars and prove to our payers that physical therapy is a valuable tool?
  3. What tools are you going to use to prove you are effective and necessary?

Thank you for your attention to this case study. I have enjoyed hearing from so many of you and hope you have received value through this exchange. Feel free to leave any parting comments below. Warmly, Susan.

 

A FINAL NOTE FROM EDUCATA:

If you found this case study interesting, you might really enjoy delving deeper into the McKenzie Method. During the month of June, EDUCATA is making this 2 CE-Hour course available at 20% off its regular price. Simply click here, proceed to checkout and enter coupon code MTD613 to avail yourself of this very special offer.

McKenzie 6-2013 promo 3

 By guest blogger Susan Bamberger

Thank you all for your detailed and well thought comments on the first installment of this case study! At the end of the history, we should have some idea of what might be going on. Performing a detailed interview will help to create hypotheses that we can test in the physical examination.

Giving some thought to pathoanatomical causes, it is possible the he may have a tendonosis of the psoas. It is also possible that he has a mechanical impingement of the hip joint. He may also have a structural defect such as a labral tear. The symptoms could be coming from the lumbar spine or the hip, SIJ, knee or foot. It is also possible that he has a stress fracture. Each of these pathoanatomical possibilities are managed in different ways. How do you discern which to treat?

While the pathoanatomical possibilities are there, we do not have the ability to look inside and determine the exact cause. The most accurate information we have in front of us in this visit is the patient’s pain presentation and its behavior of symptoms. We can look at the behavior of symptoms and assess for change in these symptoms through the course of testing. This will become the most effective guide in developing a plan of care.

My assessment utilizes Mechanical Diagnosis and Therapy (MDT) which is used to target the problem based on symptom presentation and behavior. More common in the spine, MDT has proven to be reliable, valid and prognostic in multiple studies conducted over the last 40 years. However, the principles of assessment can easily be utilized in any joint of the body, including the hip.

As I begin to plan the physical exam I must consider all of the factors contributing to his recovery:

  • The pain is a 5/10 on a 0-10 scale, 0 being no pain and 10 being the worst pain ever imagined.
  • It comes on as soon as he begins running and it ramps up immediately. However, it goes away within a few minutes after stopping his run.
  • He does not notice the pain otherwise- he sleeps well, and does not feel the pain when going up and down stairs.

He has been trying to run every few days, without any noticeable change. Any objective baselines I find must be related to the exact pain he experiences when running. However, he was not prepared to run on this visit, so another baseline will need to be used.

To get a solid baseline, I may need to be pretty aggressive in my examination on day one. However, in order for trust to be established, I decided not to try and provoke his symptoms, but rather to educate him in the assessment process and the need for him to participate in the analysis.

The location of symptoms indicates the pain could be coming from the hip or the lumbar spine. The behavior of symptoms does not exclude the hip or lumbar spine. So a screen of the lumbar spine was necessary before exploring the hip in detail.

The physical exam reveals an athletic man in no apparent distress. Left hip passive range of motion into flexion, abduction internal and extension rotation were tested in supine. IR and ER were tested supine in 90 degrees flexion. Extension was tested in side lying. Flexion ROM is approx 100 degrees and painful. Abduction is approx 25 degrees and painful. There is a minimal loss of internal and external rotation, with pain greater into external than internal rotation. Extension lacks approximately 5 degrees to end range.

Resisted motions are strong and painless in all directions except flexion and adduction, which are weak and painful. These tests were performed in supine. Resisted flexion in supine, in particular, produced his primary pain. This was the baseline to refer back to when I perform my mechanical testing later.

While special tests ( Hip scour, compression) could be performed, none were performed on visit one. The patient had been referred from his orthopedist, who was confident there was not an operable structural issue, and there was nothing yet in the history that indicated surgical referral. At this time, special tests did not have a practical use. If there was not a consistent response to the repeated motions, at that time special tests may be indicated for further clarification.

Screening for the lumbar spine did not reveal any significant lumbar component. This was done by first checking for lumbar range of motion in standing, flexion, extension and side gliding were  within normal limits. To determine if the lumbar spine was involved, 15 progressively loaded lumbar extension mobilizations were performed in prone, and then his primary baseline ( resisted hip flexion in supine) was retested for change. There was no change, indicating it was necessary to move to the hip for further testing.

The next step is the repeated movement examination, a key component of the MDT assessment process. Responses to symptomatic, mechanical and functional baselines give us the information needed to classify his condition and devise a directed and effective treatment plan. Repeated movements can be performed dynamically, with sustained positions or with resistance. If the baselines demonstrate an immediate and lasting change, the classification is derangement and the prognosis is excellent.

Repeated hip extension in half kneeling was the first movement chosen. Given the irritability of the symptoms, half kneeling would provide a great deal of force, and is a good start to providing movement that will provide immediate and lasting results. The direction of extension was chosen as this is often the direction most frequently seen for patients with hip derangements. The position of half kneeling was chosen as a relatively aggressive position, knowing that since an aggressive force was needed to produce the symptoms, that an aggressive force would be needed to reduce the symptoms.

The patient had 0/10 pain at the start of the repeated motions exam. There was some pain at the end of the range of the first repetition, in the same location as his primary pain. This pain progressively improved with subsequent movement, as did his ability to move further.

In retesting his primary baseline (5/10 pain with resisted hip flexion in supine), 10 repetitions of dynamic hip extension in half kneeling reduced his pain to 4/10, and 10 more reduced it further to a 2/10. His ROM in all planes were restored to symmetrical and within functional limits.

runner flexing

With an immediate and lasting change in range of motion and pain, the repeated motions exam confirmed a classification of derangement, indicating an excellent prognosis. As his pain decreased, his strength also improved, indicating the weakness with resisted hip flexion was more likely related to pain inhibition than true strength loss.

Since we have not actually tested running, we cannot conclude that this movement alone will resolve his primary pain. However, since we were able to find a baseline that reproduced his primary pain, and it changed with the repeated motions exam we have something to start his treatment plan.

The patient was sent home with instructions to assess the effects of this test over the next few days. He was instructed to discontinue any other stretches he was performing, and to perform just this one exercise until he came into the clinic again. This would help to determine the effect of this one stretch alone. Specifically, he was instructed to do hip extension in half kneeling, 10-15 times, 4-5 times throughout the day. In a few days, he was instructed to test running, to see if a few days of the repeated hip extension in half kneeling produced any positive results for running. Pt understood the mechanical issue, and experienced the immediate results during our assessment. He was eager to take a role in the analysis of his symptoms.

Visit two

Four days later, the patient presented to the clinic with a journal describing his pain behavior and exercises. There was a consistent effect with the exercise: immediate discomfort, then a loosening of the range of motion and a lessening of pain with each subsequent repetition.

He had tried running two days, and was encouraged as he could now run 10 minutes before experiencing pain. In addition, the pain was not as intense- it was a 2/10 instead of a 5/10 as before. He ran to the clinic for this visit, and was experiencing a 2/10 pain towards the end of his run to the clinic. He demonstrated the exercises, and was performing them correctly.

The patient is better, but is it enough to continue with the current plan of care?

What would you like to add to his home program at this time?

What would you do on this visit?

What other treatments would you want to apply, and why?

Introduction by Marilyn Pink: from time to time EDUCATA has the privilege of hosting guest bloggers on this platform. This series is written and moderated by Susan Banberger, a PT since 1999. Susan is a Diplomate in Mechanical Diagnosis and Therapy and works at Advance Sports and Spine Therapy in Wilsonville, OR. She has contributed to several publications, including the International Journal for Mechanical Diagnosis and Therapy. 

The case study examines the experience of a runner who has recently dared long distances and comes to the PT with severe hip pain.Please feel free to participate and comment at the end of the article, as much is learned by all in the process of exchanging ideas.

A runner with hip pain – getting him back in the race

By guest blogger Susan Bamberger

When a runner comes to physical therapy with debilitating hip pain, there are a multitude of treatment options. The accessibility of information from the internet leaves patients confused as to which shoes they should wear, if they should wear shoes at all, if they should stretch, and if so, should they stretch before or after their run, or both? They come to us to help sort out this information and to determine what is best suited for them.

Physical Therapists have the responsibility to create an effective plan for each patient in a reasonable amount of time. Not every treatment works for every patient. Anyone can research stretches, strengthening and shoes on the internet. Our challenge is in proving that we hold unique knowledge and skills to deal with individual problems in this information age. This case study is an example of how skilled physical therapy provided excellent results and gave this runner the knowledge and treatment he needed to return to running, pain free.

physical therapy runner with hip pain

The patient is a 38 year old male plant manager and new long distance runner presenting with complaints of left anterolateral hip and thigh pain. He was referred to physical therapy from his orthopedist, who diagnosed him with greater trochanteric bursitis.

His onset of symptoms was 6 weeks prior to the initial evaluation, after running a marathon (26.2 miles). By the end of the race, he was in intense, constant pain, rated at a 5/10 that remained constant for 3 days after. His symptoms became intermittent, and have not changed much since that time. His plan was to run 4 marathons in the next year, but he has stopped running completely, as every time he runs the pain comes back to the same intensity it was immediately after the race.

Since becoming symptomatic he has tried many stretches and strengthening exercises he researched on the internet. He has also received advice from his massage therapist. However, the same pain comes back when he runs. He has good shoes, and changes them every 250-300 miles, per industry recommendations. Because of all of his research, he is concerned that this is an issue that is going to keep him from running altogether.

When asked if the patient had any imaging, he replied “only an xray”. Then he said, “Why, do you think I need an MRI?” Sensing fear of life-altering structural damage, the patient was assured that one of the goals of physical therapy is to determine the right place for them. With a careful assessment over 2-3 visits, we should know if further testing is necessary.

Given the history, which structures are you going to examine?

How can we establish functional baselines and how vigorous can we be in our examination?

What examination tests would you use, and why would you use them?

We look forward to your comments!

McKenzie obit

Robin McKenzie, world renowned physiotherapist, died peacefully on 13 May 2013 after a courageous battle with cancer.

Known and acknowledged around the world, he was the creator of the McKenzie Method of Mechanical Diagnosis and Therapy (MDT), a therapeutic approach now widely viewed as part of normal management for low back pain. His vision was that all patients with musculo-skeletal pain be taught how to manage their own pain. The two books he wrote specifically for patients: Treat Your Own Back and Treat Your Own Neck have sold over 6 million copies and are available in 17 languages.

photo3Robin McKenzie demonstrating MDT techniques

McKenzie treatment 2

His work will live on in the world of physical therapy, forwarded by the educational infrastructure of The McKenzie Institute International, which he created in 1982 and which has educated physiotherapists, doctors, chiropractors and other allied health professionals in 37 different countries.

Robin McKenzie led a rich professional life, that included:

  • Honorary Life Member of the American Physical Therapy Association “in recognition of distinguished and meritorious service to the art and science of physical therapy and to the welfare of mankind.”
  • Member of the International Society for the study of the Lumbar Spine
  • Fellow of the American Back Society, an Honorary Fellow of the New Zealand Society of Physiotherapists
  • Honorary Life member of the New Zealand Manipulative Therapists Association and an Honorary Fellow of the Chartered Society of Physiotherapists in the United Kingdom
  • Officer of the Most Excellent Order of the British Empire (1990)
  • Honorary Doctorate from the Russian Academy of Medical Science (1993)
  • New Year’s Honour’s List — in 2000 Her Majesty the Queen appointed Robin McKenzie as a Companion of the New Zealand Order of Merit

We will remember him for his accomplishments but above all for the deep caring for the well-being of all his patients. Thank you, Robin McKenzie, for your legacy to our profession.

For a complete biography, click here

To see a photo gallery of Dr. McKenzie, click here

March brought several notable events to the Physical Therapy world. On Monday, March 11, my friend and mentor Dr. Jacquelin Perry passed away in her home at age 94.

Dr. Perry 001 tweaked-4

Dr. Perry had been diagnosed with Parkinson’s disease for quite some time, but that didn’t stop her. She kept traveling, wrote the second edition of her gait book with Judith Blumfield Ph.D., P.T, did some speaking engagements and continued to solve problems. So, herein I’d like to share a few of the life rules I learned from Dr. Perry:

Dr. Perry Rule #1 – Only bring issues forward that you truly want to solve, understand and improve

If you don’t want your personal or professional problem solved (i.e. if you just need to grovel in it for a bit) don’t bring it to Dr. Perry. She was a problem solver extraordinaire. The world was logical to Dr. Perry and she was always ready to figure it out.

One time I made the mistake of asking her for her opinion on a personal/professional issue. I rummaged around with it for a while. Finally she said “Marilyn, you just don’t WANT to solve it!” Then she got up and left my office!

Dr. Perry Rule #2 – There is no reason to ever stop

Dr. Perry flew around the world in her last years – there was no reason for her to stop. Many of you probably heard/saw her in those years. She didn’t miss many conferences that I know about!

As a minuscule example I’ll offer a memory of a dinner party: we were talking about an 8-year-old friend of mine who liked lizards – and lizards were cold blooded. I asked what was ‘cold blooded’. Without saying anything, she got up from the table with her walker, went to the library, brought back a physiology book and proceed to look it up and figure out what cold blooded meant.

Dr. Perry Rule #3 – The only roadblocks are those that you choose to see

I’d asked Dr. Perry once about what it was like when she graduated from UCSF in 1955 (which, I believe, is ten years BEFORE Rose Bird graduated from UC Berkley School of Law (Rose Bird was a former Chief Justice of California and the first female justice). I’d read a piece on how Ms. Bird, in her early years as an attorney, had to pretend she had a clerical rather than a legal mind. I asked Dr. Perry if she had similar experiences. She responded with “Oh no, not at all. I didn’t see any roadblocks, thus there weren’t any.”

Dr. Perry Rule #4 – Know the background, the science — and don’t fall asleep on the job

Dr. Perry was VERY approachable. You just had to know your stuff – know the literature from all sides and stand tall when you made your pitch.

Dr. Perry Rule #5 – Doing the hard work is only ½ of it. Clearly communicating the outcome is the other half.

Boy, did I learn a lot from Dr. Perry about being critical and concise with my communications! For some examples, please see the videos regarding how Scaption and Push-up+ came to be. She also coined VMO. We’d even talked about how the subscap should really be called 2 different muscles: the function and the innervations of the upper and lower subscap are different, so they should be communicated differently.

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I’m sure you can add to some of Dr. Perry’s rules to live by — and I would like to see your input on those rules. But, before I close, I want to address a couple of other characteristics of my friend:

Dr. Perry was the only child of a seamstress. She grew up in a one room apartment in downtown Los Angeles. She MADE her way – it wasn’t handed to her. And she never begrudged that. She was humble and believed in charity. She gave much to others with lesser abilities. As a matter of fact, EDUCATA and some of our partners,The Australian Physiotherapy Association, McKenzie, etc, are donating to one of Dr. Perry’s charities in her name.

Dr. Perry loved the outdoors. We’d go kayaking (and forget to take her Parkinson’s medicine with us, thus making it impossible to get out of the kayak at the end! Boy we had a lot of laughs about that one!). She loved analyzing movement — going to see Cirque de Soleil with her was a real experience.

Perhaps one of the things she loved best was bringing friends together. She did that superbly. Without Dr. Perry, I wouldn’t know her friends Jo or Judy or many others that I grew to respect and care about.

Thank you Dr. Perry for your gifts of intellect, friendship, acceptance, humility and encouragement!

Marilyn Pink, PT, Ph.D.

DID YOU HAVE THE CHANCE TO MEET OR INTERACT WITH DR. PERRY? I’d love to hear your experiences!

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