April 20, 2021

Interview with Tony Maritato

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RangeMaster Rob 0:16 
So, just for the sake of introduction to those who haven't met you, I mean, I'm assuming everyone knows you, but probably not everyone, right?

Tony Maritato 0:25 
Sure.

RangeMaster Rob 0:26 
You're coming to us from where again?

Tony Maritato 0:29 
So I'm in Middletown, Ohio, we're about 40 minutes north of Cincinnati.

RangeMaster Rob 0:34 
And you have a practice there. But you've had multiple practices. Can you bring me up to speed on that? 

Tony Maritato 0:39 
Yeah, so I am a licensed physical therapist, my wife as well is a physical therapist, we started total therapy solutions back in 2002, in Sarasota, Florida. And just for context, so when we started, we had a little 800 square foot studio, it was all cash based, it was a personal training studio I had started the year before, turned it into a physical therapy clinic, we grew to three locations in Florida, we decided to get married, moved to Ohio, open to more locations. So at our largest, we were five locations, we had a team of clinical staff, admin staff, we brought our billing in house, we manage our marketing. And then over time, we decided, you know, we weren't going to grow to 20 locations and sell, we rather just consolidate and protect our time, raise our family. And so we sold a clinic we close to others and team that we're running them open their own clinics. And now we have two clinics here in Ohio. I get to teach therapists how to do Medicare billing and how to contract with Medicare. But I also treat patients still I was in the clinic this morning, treating a couple patients. And I get to meet people like you. So that that's that took 20 years to go from there to here. But this is where I am now.

RangeMaster Rob 2:05 
So totally for those who who don't know you say your last name and spell it if you would.

Tony Maritato 2:12 
Sure. It's Meritato. M A R I T A T O

RangeMaster Rob 2:19 
And I knew you first because you were you had a podcast, I believe on billing solutions for therapists. Yeah, where do people find you online these days.

Tony Maritato 2:32 
So Facebook is the best way to get ahold of me just look for Anthony Maritimo, although I go by Tony. And then on YouTube, I have the Learn Medicare billing YouTube channel. And then if anybody wants to see my clinical channel, it's total therapy solutions. That's both the name of my physical therapy practice. But that's also my YouTube channel, where we're just about to, we're up around 8000 plus subscribers on that channel and a couple of 1000 subscribers on the Medicare billing channel. So

RangeMaster Rob 3:06 
Well good for you. I said, I aspire to that level of engagement. But we will try to put a backlink with this to you. And I'll tell you the thing we've done latest, you know, shoulders you can't talk about shoulders very long without talking about posture. Yeah, right now on our website, my range master calm. We have a 30 day posture challenge. Yeah, we're taking both, you know, people on the street as well as therapists through 30 different Well, I think it probably adds up to take a day off. So maybe 20 different posture exercises, including some I I've never heard of, but obviously needed I think, yesterday I was on the floor doing something called the roach. And I won't go into the roads right now. But just you might enjoy taking a look at it and and if you think it's worthwhile, maybe backlink to us on that.

Tony Maritato 4:07 
Yeah, no, absolutely. I love it. I've been working with cameo we were trying to get the word out before you guys started. So I think it's a great challenge.

RangeMaster Rob 4:14 
Bless your heart. Thank you. Well, listen, um, if we could just talk a little bit about what you meant. When we were talking about range of motion exercise for the shoulder, and you made an offhand comment, that what you're really doing is changing the chemistry in the shoulder. And I'll preface what I why I'm asking because recently I've taken a deeper dive into exploring a general term would be biologics. Yeah. And that whole controversy around stem cell injection, but also platelet rich plasma. platelet rich plasma Sure, just basically, I met just yesterday with an orthopedist doing adipose fat in injections into inflamed shoulders to see if they could calm down the inflation before they decided what the next step was in the plan of care. So in relation to that, which is fine with me, if you say there's no relation to any of that. Let's go a little deeper into your take on changing the chemistry and an injured shoulder.

Tony Maritato 5:39 
Yeah, I mean, so my background just for context. So I had an undergrad in kinesiology. I loved biomechanics, and the world was so much easier when everything was mechanical, right? When I could look at the shoulder, like a robotic model, and I could attribute everything to mechanics and even talking about posture, I could talk about how a rounded shoulder forward head, you know, is going to create compression here and distraction there, it's going to do all of these mechanical things. And I felt very smart. And it was very black and white, and therapists love black and white. But like most things in our profession, everything got up ended 180 degrees flipped over. And so with time and experience in history, you know, I started to realize like something's not right, there's just it's more complex than just mechanics and a classic example. So somebody would come in with, you know, rounded shoulders, elevated anterior tipping scapula, and forward head posture and fold in the back of their neck. And I would talk about how important their posture was and how we have to correct it. And that's why they're getting impingement and pain. But I never really stopped to say like, Well, wait a minute, the other shoulder is the same way, but it doesn't hurt. You know, like, why is this one hurting and the other ones not hurting in the same person. And then you'd hear the classic scenario where the patient were telling me I'd get up first thing in the morning, my shoulder be so stiff, and so sore, and I could barely reach behind me. But then I'd start moving. And by mid morning, I feel so much better. And I'd have more range of motion, but then by evening, it would start to hurt and throbbing ache. And you know, I hear these stories over and over and over again. And so that, like most things just makes me question, okay, do I really understand everything that's going on? Do I know as much as I think I know, or I thought I did. And then once I started looking for myself, outside of just biomechanics, and for myself, I was like, you know, I was the classic guy. I was in my late 30s, early 40s, gaining a couple pounds of weight every year trying to eat less every year, feeling hungry, not feeling healthy. And just the chemistry, you know. So then I started to research the immune system. This goes back to we have a son who's who's had tree allergies, and tree nut allergies, I should clarify. And so we were looking for, you know, what are the options and we looked at Oh, it oral immunotherapy. And just to think that, you know, a person could build a tolerance to certain allergens. They're never cured. It's not a cure for allergy, but understanding how the immune system will affect so many parts of our body. And so that came full circle to where I know for myself, I'm not Gloop. I'm not celiac. I'm not gluten intolerant. But I certainly know that between my right shoulder, my left knee and my left great toe. If I have a couple beers on the weekend and some sandwiches, I'm going to be in more pain. If I cut the foods that I'm sensitive to out of my diet, I'm going to be in less pain. You know, and since we're talking shoulders for me, it's consistently my right biceps tendon, long head of the biceps tendon. If I eat more inflammatory foods, if I have more stress in my life, if I do things that I know, wear down my immune system, my right biceps tendon will always tell me. But if I do things to change the chemistry systemically, maybe it's vitamins, maybe it's food, maybe it's exercise, whatever. That right, right bicep tendon will calm down. And I think so much of my patients, and you can stop me anytime. But I see patients who come into the clinic occasionally I see them pre op, they're scheduled to have a rotator cuff repair. And we've seen the data I'm sure you've seen the data on you know, it's not necessarily better than Sham in certain situations. And they've done those Studies and I really believe that the pain that they're feeling is independent of the mechanical damage that we might see on imaging. And if we can do things to relieve the pain, we can probably avoid the surgery. Where are you going to say?

RangeMaster Rob 10:18 
Wow. So ask a surgeon, ask the neurologist ask a physical therapist. Yeah. What do you think is causing pain in that shoulder? Do you think it's the tear in the rotator cuff tendon? And you'll get all kinds of different answers.

Tony Maritato 10:37 
Yeah,

RangeMaster Rob 10:38 
One of my favorite was from a neurologist down in Nashville. What's that university there. I'll say it for this little system there. I said, doctor what do you think is causing the pain in the shoulder? Well, she said, Remember this Rob, all pain starts in the brain? And then I said, Well, okay. But if there's not a lot of nerve tissue, in a fibrous rotator cuff tendon, do you think the pain is coming from the tear in the rotator cuff? And where we ended up in that discussion, and she wasn't going to make any absolutes. But she said, we've got two suspects here. One suspect is just plain old inflammation. Sure. And if you have a lot of inflammation anywhere, it's going to be equated with pain. The other thing is instability in the joint, because the bones themselves have a lot of nerve ends. And oh, if the terror is such that humeral head is, you know, not going around in there and bruise in the bone, and so on and so forth. If it's a straight rotator cuff tear, there's real chance that we've got some instability, if it's big enough, or if it's completely. Let me see the word. I'm digging into my journalism background here. If it's completely retracted from a rupture, then maybe you've got some loose ends down there. But I don't think there's a universal agreement that the terror itself is causing the pain. Is that what you said to me?

Tony Maritato 12:28 
Yeah, I agree. I mean, I think we've we've seen from clinical imaging, we see image studies that show major tears and no pain. We see images that show no tear and lots of pain. And we see everything in between, you know, and just as you said, I mean, the the science, so the science behind earlier, I said biomechanics, everything got flipped upside down. Pain, science flipped everything upside down for me. And so now I'm sitting here in a situation where on a daily basis, I'm talking to patients. And I'm trying, I don't claim to have the answer. I don't, I'm trying to ask better questions. And I'm saying, look, you know, I show you talking about pulleys. Let's do these pulleys. Let's do three minutes of pulley work. We do it the first 20 seconds, there's pain. After the three minutes, they're almost pain free. And range of motion is improved, almost universally on every patient. So it's like, well, what changed? What just changed? If the pain was coming from the tear, the tear is still there. But you have less pain, you know, the chemistry change. And so there's a term and I'm certainly not a physiologist, and this is way beyond my paygrade. But I do the best that I can so Myo kinds. We're familiar with psycho kine, which is a pro inflammatory protein. But a Mio kine tends to be an anti inflammatory protein produced by sub maximal muscle contraction. It's local, to whatever muscle is doing the work. But at least the limited research that I've seen suggests that there's crosstalk between the endocrine system and the muscular system and these Myo kinds that are produced locally. So were 20 years ago, when I knew everything. I would say, you know, well, these yellow Thera bands and pulleys, they're not really doing anything, it's more just a waste of time. We'll know maybe there is something that's actually going on, and maybe all of these patients that are telling me Hey, when I started doing these light movements, I actually feel better. You know, so now my treatment programs have changed from Okay, we're going to do this you know, the strengthening exercises to strengthen the rotator cuff because you're you're weak in these positions that I've manually muscle tested you out. They're weak because it hurts, but we're gonna do Three to five minutes of pulleys, five to 10 times a day, we're not doing it to stretch the connective tissue, and we're not doing it to strengthen the musculature. We're doing it to produce a chemical change locally in the area of discomfort, to try and improve the environment, you know, to facilitate some fluid exchange, we know that we get the synovial fluid moving, but maybe we're producing this acute response of releasing Myo kinds, the body's natural anti inflammatory protein. And so you get 20 minutes, 30 minutes of relief, just like if I took an Advil, I get a couple hours of relief, but it wears off, I do three minutes of bullies get a little bit of relief, but I do it more frequently, until eventually, maybe the environment actually starts to change for the better. And the chemistry and you know, you talk about pain starts in the brain. That's a popular term. And I totally agree, I try to use the analogy with my patients of biting into a jalapeno pepper. And so I always explain, look, if I bet a jalapeno pepper right now, my lips would feel like they were on fire, my nose would be running my I would probably start perspiring, you could not convince me that the temperature of my skin on my lips isn't 9000 degrees. But if you check the temperature, the temperature is the same. My brain is perceiving the oils in the pepper as a threat. And it's creating a pain response to telling me that I need to get away from this. And the sensation is a burning hot temperature sensation. But it produces a physiologic response in my body. But the temperature of my skin didn't change. It's the way my brain is perceiving the information from the oils in the pepper, you know, and so as we start to try and come to grips with all of this stuff, you talked about nerves innervations, and stuff like that is like Yeah, well, there's no nerves in an amputated foot. But a person who doesn't have a foot could still have pain in the foot. So we just need to requestion what we've been doing.

RangeMaster Rob 17:20 
Well, I'm, you're you have triggered more investigation on my part, just to read up on my yokine.

Tony Maritato 17:30 
Yeah.

RangeMaster Rob 17:32 
And what just say the term again...

Tony Maritato 17:35 
It's it's an anti inflammatory protein produced by the muscle? And why Oh, my Oh, I think it's kinds I can't remember.

RangeMaster Rob 17:48 
Well, you know, as I alluded to, you know, I was formerly an investigative journalist, and I, you know, I, through a series of things, I ended up being, you know, a provider of shoulder police to the world. And, and then we call these people, let's find out how they're doing, you know, we, we get a random sample every week and discuss five patient case studies every week, in our team meeting. And by golly, you know, they just keep saying, I got my pulley, and 90% of them say, I'm feeling better. Yeah, then, you know, at a certain point, you've got to say, why is that? I mean, this is a rope, a pulley, two handles, and some people swear by it and say, I'm going to be using it for the rest of my life. So something is going on in there. Right, right. And I could be satisfied by say, gee, I've helped you with your pain. But the inquisitive part of my brain says why. Right. And so you go to these meetings, and that's Vanderbilt where I was at. And, and other seminars or national conventions? And it is really a question. We know that rehab, and if we can go all the way back to APTA, his signature word, which is move. There is something to be gained in the movement, you know, provided that we've cleared the patient to move that we don't have a fracture or dislocation that's, you know, going to pop out or something like that. Right. Well, in for the sake of brevity, that's what I wanted to visit with you about today. And I knew you'd have an answer for me because it was such a curious response when we talked about it before.

Tony Maritato 19:55 
Well, I'd love to bring up one more component if we just have okay. So one of the things that I also always talk to my patients about and I always mentioned, like, think of the last time you had some sort of a cold, viral bacterial, some sort of infection. You know, I'm fortunate I've got a great immune system, I don't get sick often. But when I do, I find this pattern, I start feeling that muscle fatigue, that muscle soreness, my back starts to hurt. And then it's about a 12 to 24 hour time frame before all of a sudden, I realize, oh, I've got a runny nose, I've maybe I have a fever, like, I realized I have a cold. And even within right now. So this is March 25. I'm here in Ohio, allergies are just out of control. So this today was today, today's Wednesday, Thursday, Thursday, Sunday of this week, I started to notice my right SI joint, just hurt just hurt like crazy. Now I don't have back pain, I don't have normal si issues. But this is a normal signal for me. So my right si is hurting. It's not stopping me from doing anything. But certainly it's it's a nuisance, it's there, I noticed I'm moving differently. I'm just not as fluid and what I do. And I knew it, I knew what was going on. So Sunday, it hurt the most. By Monday morning, not so bad. By Monday evening, I was sneezing, my nose was running, I would have these fits. And it's because of the seasonal allergies. And so consistently, at least for me, and certainly I'm going to acknowledge I probably have biases at this point in my life to look for these things. But I really truly believe that my immune system started to ramp up because of the pollen and the seasonal allergies here in Ohio. The first response of my immune system that I realized was the right SI joint pain. And so I've been through it enough years, we've been here since 2006, that I kind of recognize, hey, this is what's going on. But I just I have a hard time when somebody tells me No, you know, it's purely mechanical. How can you differentiate dissociate like the rest of the body's systems, you know, my eyes are itchy. Right now, my nose has been running all day. When I research histamine responses, and I research other stuff associated with allergic responses, I know from my kids with the tree nut allergy and some other allergies, their skin, they started to get eczema certain times of year, they get a more kind of aggressive allergic response. And I even mood changes. You know, I'm grouchy. I know that I'm more grouchy this time of year, but I think that's associated with the histamine response. So when I look at an individual who's coming in with shoulder pain, or any other pain, and they tell me that they didn't do anything different, they didn't fall off a ladder, they didn't get hit by a car, they woke up one day, and they noticed that it started to hurt. And it progressively hurt worse. Maybe they did injections, and it didn't really help maybe they did this and you know, they go through the normal routine. I really just have to say, I don't have the answer. But maybe we need to look in different directions. And we need to ask better questions, you know, and look for these kinds of patterns. And then that's where you talk about like biologicals, like for me, I always go to food, I always go to sleep, I always go into mindfulness meditation, things that I can control relatively easily. And I feel like if we can bring more of that into the medical world, with some practicality and just say, Look, I'm not selling anything, I'm not making money off of you eating better. You know, I just think that, hey, what's the worst that'll happen? You get a little better quality food in your belly and a little better sleep at night. But maybe it'll keep you out of the operating room. You know,

RangeMaster Rob 24:05 
right. Well, the whole concept of integrated systems I don't think we can ignore. But I do think there's a bit of swimming upstream against the current in people in my generation, I'm 70. With my first response is, oh, man, my shoulder hurts. I wonder if I need surgery. Right? Yeah. Because that's sort of that was the fix all during now. Boy, I read the same studies as you that is not the fix all in the success rate is like tossing a coin in a lot of cases. And so, but I do see people going through tremendous amounts of pain for long periods of time, that something in the back of my mind says that may not have been necessary. And I'm not an orthopedic surgeon. And certainly there are cases where it's true, that there needs to be a surgical intervention, but Like you, I'd like to see folks exhaust quite a few other avenues before they really permanently, you know, got into a long term surgical recovery. Tony, thank you. You've just reminded us to listen to our bodies again. And to move good reminders, and to think about our total body systems as integrated. Yeah. appreciate that about you. How many shoulders you suppose you've done over the years have treated? 

Tony Maritato 25:36 
Oh, man, 20 years, lots of lots of shoulders higher? No, but the best part about it is I've gotten to meet lots and lots of people attached to those shoulders and hear lots and lots of stories, and hopefully glean a little bit of insight into the background of some of that stuff.

RangeMaster Rob 25:53 
Anything on the horizon? You want to tell us that you got to coming or?

Tony Maritato 25:57 
No, but I can't I want to keep building our relationship by Thank you. And everything that you and Camille is doing is amazing. And I just I know that there are so many therapists out there who are hungry for the kind of content that you guys are putting out.

RangeMaster Rob 26:12 
Well, thank you so much. And I look forward I'm sure we'll be talking again.

Tony Maritato 26:17 
I'm sure have a good one.

RangeMaster Rob 26:18 
All right. Bye bye.

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