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Dr. John Toerge
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Practice Focus

Our practice is informed by the comprehensive evaluation of the patient's history, background and concerns coupled with hands-on evaluation to guide the care plan and on-going treatment of the patient.

About the Practice

Our practice blends the specialty of Physical Medicine and Rehabilitation with the interactive, hands-on evaluation and treatment of the patient.  This approach promotes the fullest possible understanding of an individual's healthcare needs and the guidance of the most effective care planning and monitoring for that patient.

Physiatrist as Specialist:

Physical Medicine and Rehabilitation (PM&R) physicians, also known as physiatrists, treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. 

PM&R physicians are medical doctors who have completed training in the specialty of Physical Medicine and Rehabilitation (PM&R), and may be subspecialty certified in Brain Injury Medicine, Hospice and Palliative Medicine, Neuromuscular Medicine, Pain Medicine, Pediatric Rehabilitation Medicine, Spinal Cord Injury Medicine, and/or Sports Medicine.

Specifically, PM&R physicians:

  • Treat patients of all ages   

  • Focus treatment on function

  • Have a broad medical expertise that allows them to treat disabling conditions throughout a person’s lifetime 

  • Diagnose and treat pain as a result of an injury, illness, or disabling condition

  • Determine and lead a treatment/prevention plan

  • Lead a team of medical professionals, which may include physical therapists, occupational therapists, and physician extenders to optimize patient care

  • Work with other physicians, which may include primary care physicians, neurologists, orthopedic surgeons, and many others.

  • Treat the whole person, not just the problem area                                                     

Depending on the injury, illness, or disabling condition, some PM&R physicians may treat their patients using the following procedures/services:

  • EMG/Nerve Conduction Studies

  • Ultrasound guided procedures

  • Fluoroscopy guided procedures

  • Injections of spine

  • Discography, Disc Decompression and Vertebroplasy/Kyphoplasty

  • Nerve Stimulators, Blocks and Ablation procedures—Peripheral and Spinal

  • Injections of joints

  • Prolotherapy

  • Spasticity Treatment (Phenol and Botulinum toxin injections, intrathecal baclofen pump trial and implants)

  • Nerve and Muscle Biopsy

  • Manual Medicine/Osteopathic Treatment

  • Prosthetics and Orthotics

  • Complementary-alternative medicine (i.e. acupuncture, etc.)

  • Disability/impairment assessment

  • Medicolegal consulting                                                                                               

Osteopathic Physician:

Doctors of Osteopathic Medicine (DOs) are fully licensed physicians who practice in every medical specialty. They provide a full range of services, from prescribing drugs to performing surgery, and they use the latest medical tools. But DOs offer something special—their unique approach to patient care. Osteopathic physicians are trained to:

  • Teach patients how to prevent illness and injury by maintaining a healthy lifestyle.

  • Look at the whole person to reach a diagnosis without focusing just on symptoms.

  • Help the body to heal itself.

  • Believe that all parts of the body work together and influence one another. DOs are specially trained in the nervous system and the musculoskeletal system (muscles and bones).

  • Perform osteopathic manipulative treatment (OMT), a hands-on approach to diagnosing, treating, and preventing illness or injury.    


A typical office visit includes four parts: interview, exam, diagnosis, and treatment.

  • Interview: The DO will talk with you about your medical history. In addition, you will be asked about such factors as your home, work, and family life.

  • Exam: Your DO will do a complete physical exam. If necessary, tests will be ordered. The physician will do a structural exam, which starts by checking your posture, spine, and balance. The DO will then use fingers to feel your back, hands, and feet. Also, the physician will check your joints, muscles, tendons, and ligaments.

  • Diagnosis: The DO will consider the results of the interview and exam and will tell you what may be causing your symptoms.

  • Treatment: The DO will suggest a treatment plan. This may include such options as drugs and surgery. It may also include OMT. Depending on how severe your problem is, you may need more than one OMT session.                                                                                                                

Principles of Manual Medicine

Basic Concepts:
     The osteopathic profession subscribes to the following tenets:

  • The body is capable of self-regulation, self-healing, and health maintenance.

  • Illness is often caused by mechanical impediments to normal flow of body fluids and nerve activity.

  • The body is a unit, and the person represents a combination of body, mind and spirit.

  • The body is capable of self-regulation, self-healing, and health maintenance.

  • Structure and function are reciprocally interrelated.

  • The human body is a dynamic unit of function.                                                       

These points could be summarized by saying, "Dysfunctional structures result in impairment of normal function".

For example,

  • Hypertonic muscles may result in increased tension within the pelvic musculature that may result in a loss of the normal range of motion, pain, and/or discomfort.

  • Muscle spasm, that is a consequence of guarding due to pain, may result in a loss of the normal range of motion, pain, and/or discomfort.

  • Abnormal reflex activity, originating in the lower intestinal tract, may result in increased tension within the pelvic musculature that may result in a loss of the normal range of motion, pain, and/or discomfort.

  • Abnormal reflex activity, originating in the pelvic musculature, may result in dysfunction in the descending colon and pelvic organs.

  • Restriction of the normal range of motion of the thoracic cage and the thoracoabdominal diaphragm during inspiration and expiration may result in diminished oxygen exchange, decreased motility within the bowels, and reduced lymphatic drainage.

  • Diminished return of lymphatic fluid to the venous system may result in edema and contribute to pulmonary congestion.

Somatic dysfunction may be defined as an impairment, or altered function, of related components of the somatic (body framework) system: skeletal, arthrodial, and myofascial structures, and related vascular, lymphatic, and neural elements (Foundations for Osteopathic Medicine, 2nd ed, pg. 1249).
Somatic Dysfunction may be diagnosed by the presence of some, but not necessarily all, of the following:

  • Tissue Texture Abnormalities -- Surrounding tissues may feel hypertonic, rigid, fibrosed, atrophied, or edematous.

  • Asymmetry of Bony Landmarks and/or Function -- Bones, muscles, or joints may lack symmetry when compared to related structures.

  • Restriction of Motion -- A joint with a somatic dysfunction will have abnormal characteristics of motion. During the diagnostic process you should be constantly asking yourself the following four questions:

              Is the total range of motion symmetric?
              Is the total range of motion reduced from normal?
              What is the quality of the motion?
              What is the characteristic feel at the end point of motion?

              Tenderness to Touch -- Pain may result from palpation of tissues associated with somatic dysfunction.


Osteopathic Manipulative Treatment (OMT) Techniques:

Osteopathic manipulative treatment, or OMT, is hands-on care. It involves using the hands to diagnose, treat, and prevent illness or injury. OMT can help people of all ages and backgrounds. The treatment can be used to ease pain, promote healing and increase overall mobility. OMT is often used to treat muscle pain.  When appropriate, OMT can complement, and even replace, drugs or surgery. In this way, OMT brings an important dimension to standard medical care.

Myofascial Release (Myofascial Release Techniques MRT)

Myofascial Release (Myofascial Release Techniques MRT) is a safe and very effective hands-on technique that involves applying gentle sustained pressure into the Myofascial connective tissue restrictions to eliminate pain and restore motion. This essential “time element” has to do with the viscous flow and the piezoelectric phenomenon: a low load (gentle pressure) applied slowly will allow a viscoelastic medium (fascia) to elongate.

Trauma, inflammatory responses, and/or surgical procedures create Myofascial restrictions that can produce tensile pressures of approximately 2,000 pounds per square inch on pain sensitive structures that do not show up in many of the standard tests (x-rays, myelograms, CAT scans, electromyography, etc.)

The use of Myofascial Release allows us to look at each patient as a unique individual. Our one-on-one therapy sessions are hands-on treatments during which our therapists use a multitude of Myofascial Release techniques and movement therapy. We promote independence through education in proper body mechanics and movement, self-treatment instruction, enhancement of strength, improved flexibility, and postural and movement awareness.

Hands-On Treatment:
Each Myofascial Release Treatment session is performed directly on skin without oils, creams or machinery. This enables the therapist to accurately detect fascial restrictions and apply the appropriate amount of sustained pressure to facilitate release of the fascia.

Muscle Energy Technique (MET)

The Muscle Energy Technique was developed by Fred Mitchell, Sr., D.O., in the 1950’s as an osteopathic alternative to high velocity manipulation. It is basically a neuromuscular mobilization system for all motion segments of the body. That is, it engages and regulates the sensorimotor impulses and any musculature that moves a particular body joint. We had the good fortune to learn this technique from Dr. Ed Stiles, D.O., who was part of the first small group of osteopaths that Dr. Mitchell later instructed in his approach.

MET uses precise, three-dimensional positioning of joints, followed by specific isometric muscle contractions of a patient against the manual resistance of a therapist. By employing the principles of Post-Isometric Relaxation and Reciprocal Inhibition on the relevant hypertonic musculature, dysfunctional joint mechanics and their associated mechanoreceptor hyperactivity can be normalized.
Immediate results include:

  • return to healthy ROM,

  • spontaneous strengthening of inhibited muscles,

  • lessening of localized irritation and associated micro-edema,

  • decreased sympathetic overload and

  • increase of structural and functional integrity along the movement chain.                                                                                                                                                    

Active Isolated Stretch Technique (AIS)

The Active Isolated Stretching (AIS) method of muscle lengthening and fascial release is a type of Athletic Stretching Technique that provides effective, dynamic, facilitated stretching of major muscle groups, but more importantly, AIS provides functional and physiological restoration of superficial and deep fascial planes.

Performing an Active Isolated Stretch of no longer than two seconds allows the target muscles to optimally lengthen without triggering the protective stretch reflex and subsequent reciprocal antagonistic muscle contraction as the isolated muscle achieves a state of relaxation. These stretches provide maximum benefit and can be accomplished without opposing tension or resulting trauma.

Strain-Counterstrain Technique (SCS)

Strain and Counterstrain, originally called “positional release technique,” was developed in 1955 by an osteopathic physician named Lawrence Jones. He is one of the co-founders of the Jones Institute. In observing a skilled Strain and Counterstrain practitioner you will immediately be impressed with how gentle and non-traumatic this technique is for treating the painful patient. A clinician is quickly able to assess the entire body for areas of pain and dysfunction and the involvement of the patient in assisting to guide the clinician’s movement of their body enhances the therapeutic benefit of the treatment. Let’s explore how this innovative system works and who can benefit from this gentle technique.

Strain and Counterstrain is a manual therapy technique, meaning the clinician uses only their hands, to treat muscle and joint pain and dysfunction. It uses passive body positioning of spasmed muscles and dysfunctional joints toward positions of comfort or tissue ease that compress or shorten the offending structure. The purpose of movement toward shortening is to relax aberrant reflexes that produce the muscle spasm forcing immediate reduction of tone to normal levels. This allows the joints influenced by the now relaxed muscle to function optimally increasing its range of motion and easing muscle pain. Strain and Counterstrain is an effective but extremely gentle technique because its action for treatment moves the patient’s body away from the painful, restricted directions of motion.

Maitland Grading of Mobilization Techniques (Grade I – V)

Grade I – small amplitude movement at the beginning of the available range of movement
Grade II – large amplitude movement at within the available range of movement
Grade III – large amplitude movement that reaches the end range of movement
Grade IV – small amplitude movement at the very end range of movement
Grade V – Joint manipulation; High Velocity, Low Amplitude (HVLA) technique

The grading scale has been separated into two due to their clinical indications: 

  • Lower grades (I + II) are used to reduce pain and irritability (use VAS + SIN scores).

  • Higher grades (III + IV) are used to stretch the joint capsule and passive tissues which support and stabilize the joint so increase range of movement.

Hengeveld E, Banks K.(ed) Maitland's Peripheral Manipulation. 4th ed. Elsevier: London. (2005) 
Kessler RM, Hertling. Management of Common Musculoskeletal Disorders: Physical Therapy, Principles and Methods. Philadelphia: Harper & Row, Publishers Inc. (1983)


Joint Manipulation – High Velocity Low Amplitude (HVLA) Technique (Grade V)

High velocity, low amplitude (HVLA) is a technique which employs a rapid, targeted, therapeutic force of brief duration that travels a short distance within the anatomic range of motion of a joint and engages the restrictive barrier in one or more places of motion to elicit release of restriction. 

"Glossary of Osteopathic Terminology, November 2011 Edition". AACOM. pp. 30–31. Retrieved 1 July 2012.

Lymphatic Pump or Drainage Technique

Lymphatic pump treatment (LPT) is a manual technique intended to encourage lymph flow in a person's lymphatic system. The first modern lymphatic pump technique was developed in 1920, although osteopathic physicians used various forms of lymphatic techniques as early as the late 19th century. 

Chikly, Bruno J. (2005). "Manual Techniques Addressing the Lymphatic System: Origins and Development". The Journal of the American Osteopathic Association. 105 (10): 457–64. PMID 16314678

Visceral Manipulation (VM)

VM assists functional and structural imbalances throughout the body including musculoskeletal, vascular, nervous, urogenital, respiratory, digestive and lymphatic dysfunction. It evaluates and treats the dynamics of motion and suspension in relation to organs, membranes, fascia and ligaments. VM increases proprioceptive communication within the body, thereby revitalizing a person and relieving symptoms of pain, dysfunction, and poor posture.

An integrative approach to evaluation and treatment of a patient requires assessment of the structural relationships between the viscera, and their fascial or ligamentous attachments to the musculoskeletal system. Strains in the connective tissue of the viscera can result from surgical scars, adhesions, illness, posture or injury. Tension patterns form through the fascial network deep within the body, creating a cascade of effects far from their sources for which the body will have to compensate. This creates fixed, abnormal points of tension that the body must move around, and this chronic irritation gives way to functional and structural problems. 


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