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12.1.08

A Master of Diagnoses

Through his physical therapy practice, Larry Greenberg has developed some interesting insights into how living, working, gardening, and hosting many a visitor on the Vineyard can affect the body.

When you enter Greenberg Physical and Hand Therapy Associates in the West Tisbury home of Larry Greenberg, his wife Debbie Shipkin, and their three children, the first health aid you experience won’t necessarily be from a clinician, a weight, or a machine. In a setting that combines the comfort of rural medicine with the modernity of a high-tech facility, you just might get the certified therapy dog – a golden retriever named Maisy roams the facility, sniffing around, producing merriment and laughter. “We’ve actually used dogs to relax patients,” physical therapist Larry Greenberg says. “It’s something unique about the Vineyard.”

The therapeutic dog might be one reason people have reported for more than 100,000 consultations in Larry’s thirty-year career, the last eight at the facility he runs with Debbie, an occupational therapist who specializes in hands. You get no end of stories from patients who have arrived in despair over their health and found relief in a matter of weeks with Larry. He’s the kind of guy people might call a magic man, with magic hands.

Larry has a bachelor’s in biology, one master’s degree in exercise physiology, and another in physical therapy (PT), all from Boston University, and he’s pursuing a doctorate in PT through courses at both Rocky Mountain and New England universities. “Physical therapists are licensed health-care professionals who diagnose and treat individuals of all ages,” says Larry, who is constantly reading literature and scanning the Internet for Evidence-Based Medicine, the latest clinical expertise and research available based on recent case studies. “Education is now master’s and doctoral level to become licensed practitioners. We’re considered the movement and exercise experts who treat injury dysfunction and derangements of the human neuromuscular system.”

Still a fit five foot nine and 180 pounds at age fifty-five, the former Wesleyan linebacker has a larger-than-life presence on the Island. One reason is that his credentials are hard to match. Another is that physical therapy itself has an outsized presence here. As Larry explains, “Laborers get hip, disk, back, and knee problems, and they can’t afford to stay out of work. Because so many people here are self-employed, often without much insurance or workman’s comp, there’s plenty of motivation to get them back on their feet and back to work.”

Where does it hurt?

As he speaks, Larry is tending to John Baliunas, a handsome, athletic, forty-six-year-old carpenter with bulging disks in the lumbar region of his back, which he believes were triggered by a fall several years earlier. After MRIs and visits with a chiropractor, he has found that ibuprofen gives him only temporary relief. John is visiting Larry for the second time.

The thousand-square-foot treatment room holds state-of-the-art equipment, and Larry trains plenty of it on his patient. He starts by putting John in back traction with a belt around his pelvis to stabilize him, and a belt around his waist that a bicycle-style pump pulls downward to create a space between his vertebra. Then he applies a cold, low-level laser for neuromuscular-pain management, using a stand with diodes and laser beams. After some manual mobilization of the spine, he applies ultrasound therapy and massage. Finally, there are exercises with a large rubber ball, straps, and weights.

Lying on his back, with weights on his ankles, his head on two pillows, and his legs at right angles to his torso, John pushes a large rubber ball with his feet to strengthen his core muscles and stabilize the lumbar section of his spine. The patient moves on to an exercise to stretch his hip flexors: Bending one knee at a 90-degree angle over a rolled-up towel, he pulls a strap stretch (a canvas strap attached to one ankle) toward his head. “We need to strengthen all the lower extremity pivots – ankles, knees, and hips – to stabilize and strengthen from the ground up,” Larry says. “You also need to stretch the hip flexors or otherwise you cannot decrease the forces acting on the spine.”

At last, John stands up, his hands rubbing his lower back. “That feels so good,” he says. John leaves the office but continues a prescribed regimen of strengthening and stretching with balls, Thera-Band straps, and weights.

“As important as the equipment is, it’s education, experience, and application of problem-solving that’s really the art behind the science,” says Larry, who is also a clinical instructor at Boston University Medical Center’s Orthopedic and Sports Medicine Department.

“We spend most of our time on bio-mechanics: sitting, driving, and walking,” Larry says, going on to address the Vineyard. “Our number one injury is gardening. People come here on Memorial Day after little or no exercise and start picking, mulching, digging, and shoveling. After thirty to forty hours of straight gardening, they knock themselves out – just like we used to see from snow shoveling. A typical injury is a worn-out kneecap or torn cartilage or bulging disks from being bent over.”

Another patient common on the Vineyard is what Larry calls a “volunteer innkeeper.” “People in retirement for years run to the boat to pick up new guests, then change the linen, and do the laundry themselves,” he says. “They’re running a B& B, and they’re not getting paid for it. They’re like the chamber maid, and eventually they’re exhausted from bending over.”

“They’re chronic overdoers,” adds Debbie, who is as adept at completing her husband’s thoughts as she is at working with him. “It must be the type-A personalities that don’t sit still and relax. They do this activity without fitness training and conditioning, and they hurt their backs, hips, knees, and shoulders.”

When active gardener, entertainer, and educational therapist Judith Birsh arrived for the summer in 2007, she had suffered almost every imaginable back problem over the past twenty years, including disk protrusions, stenosis, and scoliosis. Doctors and physical therapists in New York City had given her medicines, epidural injections, electrical stimulation, manual traction, exercises, stress tests, angiograms, cardiograms, neuromuscular massage, you name it. “When I came here, I felt better from the last epidural steroid injections in my spine, groin, and hip,” says the seventy-two year old. “But I was on pain medication that gave me terrible reactions: dizziness, nausea, feeling completely zoned out. It helped my back, but I had pain going down my leg. ‘Pain fries your brain,’ I kept telling people.”

Judith asked a good friend for a recommendation and walked into Larry Greenberg’s office on June 25, 2007. “I brought my MRIs and X-rays. He put them on the viewer and went over everything with me. Then he showed me where he thought the pain was going on and prescribed an exercise program. I was very weak, which is counterproductive to dealing with pain. I got heat first, then weights, then work with the big ball, followed by resistance work, stretching, and massage. He threw everything at me, including electric stimulation and laser beams, to see what was wrong. I worked with him twice a week and did a series of exercises every day to build up my muscles.

“He works so hard,” she continues. “He’s in there, pushing and pulling, watching very carefully and increasing the intensity of exercises over time. I went from one-pound weights to four-pound weights, but if I was in trouble, we’d go back to a different level. Our styles mesh. I do the same things in academic therapy: Here’s the evaluation, here’s what you have to do. Larry listens, and he’s very patient. He’s a great teacher, which a PT has to be. He has to work on you and make you work until you have the mobility to run your life.”

Judith went on to use therapeutic pillows and cushions that Debbie found for her, a “reacher” to pick up things the way a grocer grabs products off a shelf, and a gizmo called a “sock donner” to spare her from bending over when dressing. She learned to bend her knees, not her back. She even learned the correct way to stand up from a chair: Inch toward the edge, then push up, using hands on your thighs or the side of the chair.

“Judy had bad disks and was deconditioned,” Larry says. “She’s a perfect example of our grind-it-out system: weights, treadmill, core strengthening, stretching.”

A gray-haired woman dressed in white, with gold-flecked sunglasses and earrings, Judith sits on her airy West Tisbury porch in sight of her tennis court and outdoor shower. A horse grazes in a neighbor’s field. Somewhere a donkey brays. She has her life back, and it shows.

“People say, ‘Oh, you look so different!’ My posture and body mechanics are better, and so is my awareness of how to handle my body. I’m in charge of it. It’s been a positive development of how I feel psychologically and emotionally. Delegating was hard for me, but I’ve learned to ask. I let people open doors, and I help others when I can. I also have a realistic, positive approach about how back pain impinges on life. One thing Larry told me that’s very important was, ‘Do one thing and then stop.’ So if I go in the garden, I don’t do anything else. I have a new life plan. As long as I can cook, read, and write, I’m okay. I can’t play much tennis, and I can’t take up golf because of its effect on the spine, but I can swim.”

Larry never looks at a muscle or joint in isolation, because he knows that a problem in one place may actually be referred pain from elsewhere. He thought from Judith’s spinal and disk problems that she had a degenerative hip and needed a total hip replacement. Sure enough, when Judith returned to New York in the fall, her doctor there confirmed the finding. As shocking as the news was, her experience at the Greenberg hacienda encouraged her to have the operation (which went smoothly) knowing she could get more PT from Larry if she needed it. In fact, she only needed to see him once this past summer and still does most of the exercises he recommended. “I still have the back issues but, it’s true, they are under control due to the work I’ve been doing with strength training and continuous exercising recommended by Larry,” she says.

Building a practice

Larry gets referrals from physicians not only on the Island but from all over the country. He says his best source on-Island is word-of-mouth. The problem is communicating with the off-Island doctors once physical therapy starts. “What happens is that the best surgeons are inaccessible because they’re in surgery or seeing patients,” Larry says. “You’re communicating through what we call physician extenders: receptionists, nurses, or assistants.”

“We’re fortunate here in that we get to speak with physicians,” adds Debbie.

“They’ll call us or we’ll call them on-Island, without support staff,” Larry says.

Because he sees his patients for a much longer time than physicians – typically twelve to fourteen visits for an hour or two each time – he often detects conditions that physicians miss. “A therapist has to recognize that a problem may be a systemic disease rather than biomechanics. When the puzzle isn’t fitting, you have to look for things like systemic Lyme disease,” he says. This past summer he had about half a dozen cases that tested positive. “It’s often the feedback from us that helps doctors solve the problem.”

It was Larry, not a doctor, who treated the bulging disks and acute elbow tendonitis, respectively, of the top male and female golfers at Farm Neck in Oak Bluffs just in time for the 2005 club championships. Both recovered enough to win titles in twenty-hole finals. It was Larry, not a doctor, who discovered that one of his patients, Harold Hill, of Oak Bluffs, had a back problem doctors later diagnosed as stenosis. “He’s the best on the Island,” says Harold, who subsequently had back fusion. “He’s saved my bacon more than once.”

Larry grew up in Meriden, Connecticut, where his father was a veterinarian, his mother a high school librarian, and Larry a varsity basketball player and star in football and golf. When he entered Wesleyan in 1971, he was impressed by the way his football teammate prepared for games: Future Patriots coach Bill Belichick was an offensive center and tight end who studied both offensive and defensive films for each week’s opponent.

Larry played linebacker in football and carried a four handicap for the golf team. After two years, he transferred to Boston University for its sports-medicine program. “Even though I’d had PT in high school and college, I’d thought I wanted to be a physician,” he says. “I was walking around my senior year at BU, having applied to medical schools, when I looked into the PT lab at the Graduate School of Allied Health and saw people physically working on each other. The light bulb went off....I decided I liked the aspect of physically helping people over an extended period of time.”

When both were employees at BU Medical Center, Larry met Debbie, who had graduated from BU with a Bachelor of Science in occupational therapy. She says she wanted to work in pediatrics, but there were no jobs at that time, so she started working in adult rehabilitation and liked it so much she stayed on that path. They were married in 1981. After working for ten years – she as an occupational and hand therapist, and he as a physical-rehabilitation specialist – in the Philadelphia area, they interviewed at Martha’s Vineyard Hospital in 1995 and discovered to their amazement that positions were open in both of their specialties. Since moving to their own office in 2001, they’ve routinely sent people to the Island hospital for X-rays and have referred some seven hundred patients to Boston doctors for consultations and surgeries.

Their treatment room has soft touches like Debbie’s photos of flowers and of boys on boats. Exemplars for their clients, Larry and Debbie work to stay in shape: “It wouldn’t help to have fat PTs,” says Larry, who cycles, does elliptical and weight training, and golfs. Debbie swims, power-walks, and lifts weights.

Stay an hour or more in the office and you’ll probably wind up discussing sports ethics. Larry has a photo and statistics for Hank Greenberg (no relation), the Hall-of-Fame baseball player who testified against the odious reserve clause (that gave teams control of players’ rights even after their contracts expired) and befriended Jackie Robinson when he integrated the major leagues. When he was growing up, Larry was constantly linked to his namesake. “Let’s go, Hank!” people would say to him. Larry welcomes the connection. “He fought anti-Semitism all his life and showed that Jews can be big, strong athletes like everyone else,” Larry says. “He’s an inspiration.”

Not surprisingly, Larry and Debbie have raised three scholar-athletes who each graduated among the top ten students in their high school classes: Sarah (a field hockey captain and basketball player) is a Tufts University senior who spent a semester in Argentina and another as an intern for U.S. Representative Bill Delahunt of Massachusetts; Dan (a track captain and football player) is a graduate of Bucknell University in Pennsylvania, now working for BlackRock Solutions, an investment management company in Princeton, New Jersey; and Stephen (a hockey captain and track athlete) is a sophomore at Boston College who plays club hockey and was just named a manager of BC’s NCAA champion varsity team. As a senior at MVRHS, Stephen received the Hobey Baker Memorial Award, given annually to one Massachusetts high school hockey player who demonstrates leadership, character, and scholarship, as well as talent.

In such a close-knit family, with aligned interests in sports, it makes sense that all three of their children have worked in Larry and Debbie’s office. “On the Vineyard, a home office is a throwback to a time when care was more individualized, more relaxed,” Larry says.

Especially when a golden retriever enters the room.

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