Healthy Wealthy & Smart

In this episode, we have Tom Goom with us again to join us with our running injuries and running rehab talk this March. Today we will be talking about acknowledging types of persistent pain in our athletes or runners. He talks about the bigger picture on persistent pain and its other connections, differentiate this persistent pain versus series of acute flare ups, where we should focus the treatment, and navigating injured athletes return to their sport and many more.   Key Takeaways we mustn't lose sight of the bigger picture. And actually, I think sometimes we do need to acknowledge that it is more of a persistent pain state, and not necessarily a series of flare ups of acute injury. Gritting your teeth and pushing on through isn't always the right answer… we do need to know when we need to back off a little bit. Focus on getting you well and ready to race rather than rushing you to get through a particular event when you've got a whole life of running ahead of you. Try and see if you can recognize when you are looking at a more persistent pain state and to try and really get to know that person and the bigger picture and what's driving that Suggested Keywords: Pain, athletes, running, persistent, bigger picture, acute injury, symptoms.   More about Tom Goom Tom is physiotherapist and international speaker with a passion for running injury management. He has gained a worldwide audience with his website running-physio.com and has become known as The Running Physio as a result! Tom remains an active clinician committed to providing high quality, evidence-based care. Social media handles: Twitter: @tomgoom Instagram: @running.physio Website: Running-physio.com   Resources: Running Injury and Rehab Webinar NetHealth Webinar   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:01): Hey, Tom, welcome back to the podcast. I'm excited to have you on today. Speaker 2 (00:06): Thanks for having me back. I really enjoyed it. Last time we took proximal hamstring. Didn't we last time it was a good chat Speaker 1 (00:13): We did. And now this time you are part of the month of March and this month we're talking all about running injuries and running rehab. So what we're going to talk about today is persistent pain in these athletes. And I know this is something that you're seeing more and more of. So let's dive in what let's talk about as physical therapists or physiotherapists. Do you feel that we're acknowledging these types of persistent pain in our athletes or in our runners? Or are we just thinking, Oh, well, you know, they have this tendinopathy or this strain and it's just keeps recurring. It's just like a, it gets better and then becomes an acute injury again or this back pain. Oh, same thing. It, it kind of goes away and comes back. So what, what is your opinion on that? Are we acknowledging persistent pain in these athletic populations? Speaker 2 (01:20): Yeah, that's a good question. I think maybe we D we do look at it a bit more, like you're saying, we just kind of see it as a sort of repeated acute injury may be large rather than seeing it as a persistent pain problem. And I think that's because in part, when we see people with persistent pain, part of our, of our advice and our management is for them to be active. So if you've got someone to come see seeing you, that is actually already sporty, they're already active that, you know, you kind of think, well, what else needs to be offered here? And I think sometimes we don't really think about the sort of psychosocial practice in sporty or active people, because they're not obviously fear avoidance, especially if they're keeping their sport going. So we, we tend to go down the route. That's perhaps a bit more biomedical isn't now we looked at biomechanics, we look at strength and conditioning and these all can be valuable, but we mustn't lose sight of the bigger picture. I don't actually think sometimes we do need to acknowledge that it is more of a persistent pain state and a, not necessarily a series of flare ups of acute injury. Speaker 1 (02:24): How do we differentiate this is persistent pain versus a series of acute flare ups. Speaker 2 (02:30): Yeah, I think there's going to be an overlap between those things. We know that people with persistent pain that isn't necessarily stable with change can change quite a lot. People go through periods of quite severe flare ups as well. I think it's about sort of looking at the bigger picture and looking at the connection between things like pain and load. So in, in an acute injury situation with something like tendinopathy, quite often, there is quite a clear load pain relationship. It hurts when I load it. It doesn't hurt when I don't, I'm in a more persistent pain state. We might actually see that that relationship becomes a lot more blurry that the pain may well flare up when load hasn't changed or the pain may remain present. When there isn't a great deal of loading going on. So we start to see a bit of a breakdown of that connection between load and pain. And perhaps you start to see other aspects influencing symptoms, you know, lack of sleep, stress, fear, et cetera. We see other sort of types of behavior creeping in there as well around maybe avoidance coming in. So now they are backing away from their sport. So I think that's something we need to have a lookout for particularly that lack of relationship between load and pain and then exaggerated pain response as well. Speaker 1 (03:48): And when we're looking at these more sporty athletic people are runners how do they differentiate from say maybe our non sporty or non-running population? Speaker 2 (04:01): I think that there will be some definitely some, you know, some crossover between different people in different groups. And I really would, you know, w I use the term athlete, but I, I have a really broad definition of that. Someone, someone who wants to be regularly sporty and active fits that category for me. So I'm not necessarily necessarily when I say athlete referring to an elite athlete, competing at a high level, this, this can be people that want to be running three or four times a week, that really comes in that category too. But I think they can have, you know, similar concerns to someone that's not sporty around pain and damage, for example. So they might have similar concerns there. They might both have quite high life load which is a term I quite like this, somebody mentioned in one of my courses recently. Speaker 2 (04:49): So, you know, this is where you've got lots of stress going on with, with work and family life this kind of Highlife load that plays upon your pain. And they may also both groups have poor recovery. So, you know, athletes may not be brilliant sleepers non-athletes may not be brilliant. Sleep is too, they might not get much downtime much emotional recovery. So there can be quite a lot of of overlap. I think perhaps where they differ is they may have quite different goals. So I think it's, I see Mike might have wanted to go back to running half marathons, marathons, ultra marathons, and beyond potentially. So that might be quite a different goal to non-athletes that want to be more functional with day to day activities or lower level activities, perhaps like walking distances and perhaps something that we do see in athletes. Speaker 2 (05:38): That can be different though. Again, we see this in non-athletes too, is they may be a bit more inclined to push through pain. Most of us that have done sports at any level will know that pain is quite often a normal part of sport. And to some degree we do have to work with it. If, if we stopped every time, something we we'd never really, really do sport for very long, but this isn't necessarily always the right approach, gritting your teeth and pushing on through. Isn't always the right answer. And it's not always obvious that that's the case, but sometimes actually we do need to know when we need to back off a little bit. I'm an athletes particularly really highly driven athletes may not be quite so good at recognizing when they need to back off. Speaker 1 (06:21): Yeah, that's for sure. Especially if, like you said, they've got this goal of, I want to run a half marathon and marathon or an ultra to be able to, to have to abandon that goal due to pain, persistent pain or injury is, can be very devastating. Right. So how do you, how do you navigate that with your athletes and with your runners, especially with a more persistent pain, how do you navigate that? Very, I would say very sensitive goal or topic with these, with these runners or athletes. Speaker 2 (06:58): Yeah. It's not, it's certainly not easy. I think it's it can be challenging. I think wherever possible, we want to try and invite them to review their expectations and goals. So that it's not necessarily us being prescriptive and saying, this isn't realistic, or you're not going to achieve this, but if we can help them have slightly more fluid expectations of themselves and slightly more realistic goals, the ideal world then is that they then come around to the idea that perhaps this marathon they've got on the horizon, if it's not realistic for them, that they can set a different goal with it. And th this is one of the things, again, sometimes with, with higher level athletes, certain personality types is that being, being able to persist is a good skill, a good good thing to have, you know, and you need it when you get to sort of modulating 19 in the marathon and your legs are heavy. Speaker 2 (07:50): And, you know, you've got to keep going to hit your target. Tom, you need that in the time. You've got to have that level of persistence. And, and for that to be at least a little bit rigid because you you've got to, if you're going to achieve that goal, you've got to keep going, but to keep going at a certain time. So at times that rigid persistence is useful, but if you apply that all the time when circumstances are changing and your expectations are rigid, it doesn't really work very well. So for example, with the situation's changed, you're now in quite a lot of pain, you're struggling with day-to-day activity. This marathon is, is a lot closer now than, than we would, would like it to be. Ideally we have to try and encourage them to be a bit more fluid there and say, okay, well perhaps what we need to do is change that goal a little bit. Speaker 2 (08:37): Let's push it a little bit further down the line, give ourselves a bit more time and helping them see the positives of that decision can help. So you all often say to them, well, you know, if we can, if we can move this, you know, a few months down the line or let's go for a half marathon or a 10 K, it's going to take the pressure off you. You're not going to feel like you're constantly chasing your tail because you're trying to catch up with the training. You're not able to do. You're going to be able to focus on the rehab side of things. You're not going to feel so much pressure, and we can really focus on getting you well and ready to race rather than rushing you to get through a particular event when you've got a whole life of running ahead of you. Speaker 1 (09:15): Fair, very fair. And, and I think that's great for clinicians to hear, because I think that wording is very sensitive to the, to your patient and also gives them the goal gives them that aspirational goal that they can eventually get to. So I think that wording was great. Thank you for that. Now here's a tough question. And, and I don't know all the answers to this one, but in your opinion, and in your experience, what do you feel may be driving persistent pain in these runners or athletes? Speaker 2 (09:53): Well, we had us, that's a good question. Isn't it? A million dollar question and I would acknowledge I don't, I certainly don't have all the answers with this, and I don't think the research does yet either because it's an area, you know persistent pain in athletes isn't brilliantly well researched. So I think there's a lot that we can, we can learn about this, but there's a few things that would, I think, would spring to mind here. So I think beliefs are important. So and this is, can be beliefs around what the pain means. And then they, you know, what the pain means is if it's, if it's a sign of damage if they think it means they need to stop their exercise altogether, how they feel their body's gonna respond to exercise when they have pain that continuing to run, for example, will that be more harmful for them? Speaker 2 (10:38): It can be around beliefs around training too. A lot of people will feel that unless they're pushing themselves a hundred percent in every session it's not worth doing. So that can be quite difficult then for them to pace themselves and modify their training because it kind of all or nothing really. I think one of the things that I'm realizing more and more over the years working with with people and athletes is if they are quite heavily reliant on the sport for their mental wellbeing, then that can have a bigger impact too, because they might be using that, that sport to help them with their mood or anxiety or depression. So if they can't do their sport, it increases the impact of the injury. And I think it increases the fear associated with that because they're losing this coping strategy, they're losing physical fitness, they start to worry about the future. Speaker 2 (11:27): And I think maybe that links in with pain science, because it increases the threat that this injury has, and that has the potential then to have a knock on effect in terms of the pain and increasing pain severity and things. And a lot of these things are interlinked. I think training behaviors go hand in hand with that, you know, tending to push yourself hard all the time, boom, or bust, things like that. I think there's also a lot of stuff that we might not necessarily, we see like negative messages from others. So other other athletes, sometimes coaches, health professionals, unfortunately I'm so pumped. Sometimes we can be responsible for that life. I've treated lots of runners. Who've been told that they should never run again, for example, by various different health professionals. So we need to be aware of that. I think Google might have a lot to answer for I don't, I'd love to know. I think you've been Dr. Google doc to goo exactly. I don't, I don't know many situations where someone's been worried about something and put it into Google and felt better. Speaker 2 (12:31): What you find is the worst case scenario from it, which does amplify, you know, it does amplify people's worries. And that's actually something as a clinician, I would check in with your patients about what what'd you do when you worried about this? Did you go and Google it? What'd you find when you Google it? How does it make you feel? Because quite often they'll find the worst case scenario and I feel a lot more worried. So we want to discourage them from doing that, come to us. If you've got questions about your care, that's what we're there for really. So there's a lot of things that also impact of the injury, perhaps not being fully addressed. So you know, looking beyond the kind of physical impact of the injury, but the loss of the social side of the sport, the loss of their identity around sport the effects, as we said, it might have on mental health. Speaker 2 (13:18): There's lots of other things that go alongside the injury that often don't get talked about. And if they're not addressed, I think they can amplify it as well. And then the final thought I would add to this is perhaps if not had really particularly appropriate rehab it may be, it's been very focused on pain and not really focused on function in maybe that it's not been progressive and it's not really looked to address their rehab needs, lots of stretching and foam rolling and, you know, ice and, but no real kind of planning and progression in that. Speaker 1 (13:50): Okay. So that leads me to the next question as clinicians, where should we be focusing our treatments? Good segue there. Speaker 2 (13:57): Yeah. I like the connection. You've done this before, I think. Yeah. Yeah. I think, I think he's got to start in the first session with trying to develop an understanding for that person, if we can help them to, to understand their injury. And it takes time to build on that, but really make that part of that first session and give them the opportunity to share their story in that first session and also to air their concerns. You know, I really think we want to make the focus of these treatment sessions on the patient and their needs, not necessarily a kind of a list of things we need to tick off to do in a session because there is actually research showing that quite often, people whose needs aren't really identified we can be quite dismissive as clinicians. So we want to get in there right in the early, early stages and say, you know, what would you really like to, to from, from your treatment? Speaker 2 (14:52): What are your concerns? What are you particularly worried about here? What would you really like us to help with? Because we can start with that. I think that helps us form a good, strong connection. We can really help them understand the injury and build on it from there. I think that alongside shared goal setting, I think big PA plan of I'm a big fan of collaborative working you know, so you're working towards their goals. How can we help them achieve those goals together? And again, get a good idea of those in the first sessions. And it is part of the reason I really love working with rhinos is because many of them have a goal. Even if it's just, they want to get back to running 5k, you know, great, brilliant. It's a measurable goal. We can start the planning towards that pretty much from, from session one. Speaker 2 (15:37): And then we do want to have some progressive rehab because they're all gonna be psychosocial factors. In many cases, we've talked about, you know, beliefs to address perhaps poor recovery load management to talk about that quite often, there are physical needs as well. So we need to address those if there's a lack of strength or control or range and address them in a progressive way, as opposed to just loads of stretching and rolling, and then we can start to do a graded return to sport when, when they feel like they're physically and psychologically ready to engage in that. Speaker 1 (16:10): And what are some, some examples that maybe you can give of the types of diagnoses or the types of patients that you're seeing coming to you with persistent pain, you don't have, we don't have to go into, you know, the specifics of how you treat XYZ, but what are some things that you might be seeing in your patients coming to you with persistent pain? Speaker 2 (16:36): So I, I do specialize to some degree in tendinopathy. So we will see a lot of patients with long-standing tendinopathy lots of patients with proximal hamstring tendinopathy, because that's particularly the area I've researched in. But it will say Achilles tendinopathy issues as well. See people with low back pain and hip pain as well, falling into this category people with persistent patellofemoral pain syndrome persistent bone stress injuries, like medial tibial stress syndrome. So it's do see quite a mix. And, and many of those will have been treated first and foremost in quite a kind of biomedical model. I think, Speaker 1 (17:16): Yeah, so I think I just wanted to ask, cause I think it's important that clinicians out there hear like, Oh wait, you can have a persistent tendinopathy problem. You know, you can have like, Oh, I, I wasn't aware. I thought, you know, after let's say proximal hamstring after a year of rehabbing, if that kind of comes back, Oh, it's probably just like a muscle strain. It's probably not that tendinopathy again or, or not again, but it continuation of that. Absolutely. Yeah. And Speaker 2 (17:50): To give you a clinical example then, because we talked a little bit about how the connection between load and pain can be blurry about how that may, we may see an exaggerated response. So to give you an example of that proximal, hamstring, tendinopathy patient that I've been working with who will not be able to sit for more than maybe 30 seconds because that will really cause a flare up in their symptoms. Now we can see then that's a, that's a really exaggerated pain response. And the average person sits for somewhere around six to seven hours a day. So not to be able to tolerate even 30 seconds of sitting because there's pressure around that that tendon is, is an exaggerated pain response. And that person's pain will fluctuate not necessarily in line with load. So there'll be days where her symptoms are much worse and she doesn't really know why it's not because she's run a long distance or done anything different. Speaker 2 (18:53): The fluctuations in activity levels might be small in the range of a few minutes here and there. And yet the pain response is really exaggerated. And again, I talked about sort of beliefs and things go going into, you know, going into this area. And when we talk to this particular person about her beliefs, you can see she's very concerned that sitting damages the tendon and therefore that adds to the threat value associated with the city. She's very fearful of sitting when you ask her to do it, you can see she's really reluctant, but also we need to acknowledge why it really hurts. It's really hard for a long time. So there should be no judgment and our pie, we should be reckless. Yeah. This is really difficult. This is having a huge impact on this person's life. Can't if you can't sit down and even to have a cup of tea or to watch a move at the end of a long day, what should we eat dinner? Like that's big. So I think we have to recognize that as a persistent pain picture and with aspects of tendinopathy in there that we can manage, but just seeing it, like you say, as, Oh, it's just another flare up of the proximal hamstring tendon. We were missing that bigger picture, I'd say. Speaker 1 (20:01): Yeah. And that was a great example. Thanks for that. And now, you know, when we talk about running, we talk about athletes. So one thing they all want to do is they want to return to their sport. So can you talk to us a little bit about how we navigate that, how we prepare these people to return to their sport and what that, what that sport may look like? Speaker 2 (20:24): Yeah. I think, I think maybe we start, if we can, by seeing if we can reduce irritability a bit where possible. So if we think back to that lady, I was talking about Verrier to boost symptoms at the moment. So if I go straight into a greater return to running, I think that's probably going to be a little bit too much to start with. So in many situations we may we say, okay, let's see what we can do to reduce the symptoms and irritability helping someone understand their pain and that it's not a sign of damage can help helping them work out a list of things that may help to reduce their pain. Maybe particular exercises that help simple things like, you know, using heat or ice if necessary, but trying to give them strategies and work with them. So they've got a little bit of a list of things that can turn that, that pain volume down a little bit, and we're placing them in a bit more control, reducing that threat value. Speaker 2 (21:17): And then we can start to work towards that graded return to sport. And again, if we want to plan together because we really want the person to be in the driving seat and us maybe just helping, you know, being a bit of a satnav along the way to keep them on track. So we've had this recently really lovely runner I've been working with who in the first session said to me you know, what she'd like to do is first of all, build some strength then increase her cardio fitness by bringing in a bit of cycling and swimming. Then she wanted to bring in some, some impact and some plyometric exercises before doing a graded return to running. And I thought immediately, brilliant, this is fantastic. This person has a great plan. Speaker 1 (21:57): And they find this woman, Speaker 2 (22:00): I met wonderful one, and this, this is someone with a lot of experience in sport. Who's also studied a sport of science, so knows the topic really well, but that's a fantastic plan. Let's go with that plan and just help the person with their plan there. So, and we might follow quite a similar plan to that for, for patients. You know, we try and calm things down where we can, we build some strength to try and address some of their physical needs. We bring in some cardiovascular exercise to build some fitness up. We start to introduce impact because it can build impact tolerance, but it also is often a a way of developing some power. So perhaps some plyometric exercise to restore power, which is often neglected in rehab. And then we start to do a graded return to running and that's then where we got to try and work with them around their goals and also work with them around pain. And that can be a bit of a barrier. Speaker 1 (22:53): Yeah. And so how much pain is acceptable? How much is too much? Yeah. Speaker 2 (22:59): Like our pain scales you know, sort of scoring pain out of 10. And I, I would say there's actually quite a few studies that have done that quite successfully. So I think there's some value in that. But what we've talked about with these pain groups is that the connection between load and pain, isn't very clear and the pain response is exaggerated. So if we're guided purely by pain, we are going to struggle a little bit, I would say with these patients. So I would tend to say that the patient needs to decide what they feel is acceptable, and we provide some, some guidance. And we need to try, and if we can look at longer term trends, then now patients quite understandably might get very focused on day-to-day pain fluctuations, but it's actually more the long-term in pain over the, over the weeks and months that we're a little bit more interested in. Speaker 2 (23:49): And we also perhaps need to recognize that there are almost two slightly separate goals here, improving function and improving pain. If you're seeing improvements in function and pain, hasn't changed, that's still a win because you're doing more. In fact, that's quite good when, because you're doing more and your pain doesn't get worse, but patients often won't see that as a win because understandably they may want that pain to go away, but we can often folks first will say, okay, well, let's start with what you feel is a manageable level of exercise. Let's work with it consistently. First of all, and then gradually build as long as you feel the pain is, is an acceptable level. And sometimes what we tend to see then is over time, they're able to do more and more, and then gradually that pain does subside because they're able to do more. Speaker 2 (24:39): They're more confident they're starting to get their life back. The threat value of the pain is starting to go down, but that takes quite a long time. So I think quite often, wherever possible, placed the focus a bit more in function and just save the patient a few phone that feel that it's manageable. It's acceptable. This is fine. If it's too much, if it's not manageable, we'll dial it down a little bit, but we want, if we can to stay consistent with exercise, because otherwise we're going to have a lot of beam, bus tear will build you up and stop they'll drop and stop. We want to just see, can we keep you ticking along, even if it's at quite a low level Speaker 1 (25:13): And do you have your patients keep a log or a journal or some way so that they can see, Oh, I was doing this. I started with Tom on March 1st and here it's April 1st. And this is what I was able to do Marsh. Now this is what I can do in April. My pain's around the same, but look at how much more I can do, or maybe my pains a little less. Or do you, how do you keep track of all that? Do you give that to the patient to help them with their own sort of locus of control? And are you using the pain scale? Are you saying well, what is your pain March 1st? Let's compare that to April 1st. Let's compare that to March 1st. Speaker 2 (26:01): Yeah. I would try and see if we can monitor that goal activity because it's important to be able to see that they're improving and they're progressing towards their goal. If you've got quite a specific goal, like running a 5k in order to get that, you've give it a C you know, how, how far you're able to run. And that's the simplest question. How far can you run now? But that can be it could be steps for day. If someone's wanting to build up their walking, it could be minutes rather than miles with any activity, really. So I think it's a good idea to try and monitor what people are doing. I do, I do use the pain scale a little bit. It depends on, on how comfortable the person is with it, whether they like using that. I tend to perhaps make it a little bit more simple and just say, is your pain mild, moderate, or severe sort of break it down into those into those three sort of different categories, really. Speaker 2 (26:58): But the thing is with pain is there's so many different aspects of it. Are we talking about average pain day to day? We talking about peak pain. What did the pain get up to is it's at its highest, we're talking about pain frequency. So how often you've had that pain during the day, are we talking about pain distress, which I think is almost a separate thing. How distressing are you finding that pain? So if you're especially worried about it, that pain often will be more distressing, even if the severity isn't necessarily higher. Do you see what I mean? So I think, I think where possible we focus on the golf function and we, we try and take that focus off pain a little bit because as well, you know, if patients are monitoring it every day, that drawing that focus on pain every day, and they're asking ourselves, how much does it hurt? Speaker 2 (27:47): Even some patients have no one used the term morning MRI. I used to get up in the morning and do it, do a sort of stretching test on his Achilles. That was what he called his morning MRI to test the Achilles out and see how he thought it would be that day. We don't really want to do that. To be honest, we want to focus on what your valued activities let's really try and bring them back in, build those up and keep a kind of a little casual, casual notice of pain, let pain tell us if it's too much, if it's breaking through, into your attention and in telling you it's too much, that's probably when we need to act, if you're looking for it, if you're, if you're kind of really questioning, is it worse today? I'm less concerned about it. Speaker 1 (28:26): Got it. Yeah. So you don't want them to, you don't want your patients to be waking up and be like, wait, do I feel, do I feel more pain today? Weight you're you're well aware that you have pain. Speaker 2 (28:38): Yes. Yeah, absolutely. I think that calling is focusing on the pain as well. It's quite, it's quite a normal thing to do. I think we've kind of pathologized it a little bit. But I think actually it's understandable for people to do that. There's another layer of context around the pain and what it might mean and what that might mean for your, for your future. So I'll give you an example from myself. So I have I have psoriasis and I have nail bed changes with psoriasis and that increases the likelihood of you developing cirrhotic arthritis. So a couple of weeks ago and surfing on Twitter and someone posts a link to a research paper that says new studies shows link between nail bed changes and severities, psoriatic arthritis. And I start thinking, yeah, my fingers are a bit sore today, you know, and that's one of the areas where you can get psoriasis, arthritis, changes in the joints and the fingers. Speaker 2 (29:41): And then I throw it comes back a little bit later that day and for a few more days afterwards, and now I'm sort of noticing like achy thumbs hands are a bit stiff in the morning. And if I allow myself to keep focusing on that and measuring that and worrying about that, it would be understandable that that could become really quite a worry for me, because then you think, well, is it cirrhotic arthritis? That's been, that's known to actually affect the joint and perhaps even damage the joint. And if I've got nail bed changes, that means it can be very severe. And what impact would that have on my life? And these are all just normal things that we have as, as people, as health professionals that know quite a bit about pain. So I think we can acknowledge for someone who's not a health professional. Speaker 2 (30:25): There's probably a lot of that going on, particularly the pain's been there a long time and pains is a real nuisance because it can, you can kind of like stop worrying about it. And then, then you have the pain and it kind of reminds you and goes on about you and that can start worrying prices over again. So it is hard. And I think sometimes it's health professionals, we think like, well, I talked to them about their pain and I reassured them that pain doesn't damage tech. But that if you think that that is enough to wipe out that concern, we are. Yeah, but we may need to be consistent with that message several times. And we might need to encounter that worry coming up several times and to try and help someone contextualize their symptoms and to see that not what they're fearing, but what really is going on. Speaker 2 (31:18): And to look at a bit the now of how symptoms are. So with my hands, you know, I don't have any of the classic signs of cirrhotic arthritis. I don't have swelling. I don't have a loss of joint range. I've actually been tested for psoriatic arthritis and it was negative. So it was trying to contextualize it and see the reality is I've just turned 40 and I've got slightly stiff fingers. That's the reality. So let's focus on the now and what is real for you now and not what you fear might be coming up in the future. Speaker 1 (31:47): Yeah. And that's something that I say to myself every time I wake up and my neck's a little stiffer sore, you know, my upper back feels a little sore instead of my, what I used to do is, Oh, okay. I better not go to work today. I better just relax. Let me get a heating pad. Let me just, I don't want to do anything. I should probably just lay down. And these are all the things I used to do. And so now when I wake up or if I do have a flare up of neck pain or something like that, now I'll just say, okay, I know nothing is seriously damaged. I have the MRIs to prove it multiple. And you know, these are just things that I have to continually say to myself. And I think I'm pretty well versed in, in the science behind pain and, and even working with people with persistent pain. I mean, I do it every, but even for myself, I have to continuously sort of recite these mantras to myself in order for me to get through the day when I have a little bit more discomfort or pain. So the struggle is there, you know, and I think imparting that and telling that to your patients, especially your runners with persistent pain. I think that can be very powerful. Speaker 2 (33:07): Yeah, absolutely. And, and recognizing, as I said, the bigger picture of knowing the person and, and the things that make them make up them as a person. And if they are, for example, running to their mental wellbeing, what, what, what is the, the thing that, that they're running to help? And how does that link to their pain? Are they running to help anxiety? In which case are they someone who is perhaps going to struggle with negative thoughts about chain, and they're going to be drawn into ruminating about those negative thoughts about pain, and they're going to be looking for reassurance that those thoughts, you know, jumping on Dr. Google, I'm finding actually it makes it worse because they see all the negative outcomes they're afraid of laid out on a web page. So if they are someone with, with that, then they, they may need more, more help with that. They may need to, you know, you may need to work with a mental health professional to help them work with those thoughts and to find ways perhaps to not get drawn into that ruminating pattern and to look for other coping strategies, we show it to them. The long-term can be useful because they're less reliant and upon the sport, because they actually learn perhaps a slightly different relationship with that, with their thoughts and from that, then can help that their mental wellbeing. Speaker 1 (34:22): Yes. I agree with that. And Nelson, before we kind of wrap things up is there anything that we missed or that maybe we flew by a little too quickly that you want to elaborate on? And if not, what would be your best advice to a clinician that is working with AF that is working with people with or athletes with persistent pain problems? Speaker 2 (34:54): I think in terms of things we might have missed, I just would say that there's a, there's a nice paper from Halon as torn in 2017 that's well worth a look, which is, is actually looking at things a little bit more in terms of pain in athletes. And there's, there's quite a nice quote in that that I'll just briefly read now if that's the case. So they say even low level inflammation, for example, linked to sleep deprivation, ongoing stress and load exceeding the tissues capacity can reduce the athlete's mechanical nociceptive threshold sufficiently to make normal mechanical demands of sport painful. So that sort of Lincoln into this bigger picture stuff saying here, actually, if we're not recovering enough, or the load is excessive on the tissues, it's actually going to have an effect potentially on sensitivity know nociceptive threshold. Speaker 2 (35:49): So this is where it's quite important for us to see the bigger picture. They also say in that paper that the, the link between tissue change and pain is thought to reduce over time. So if you've got someone with very persistent symptoms, years' worth of pain, you should already perhaps be suspecting that this is probably not just going to be driven by the tissues. I mean, when is there ever a situation where pain is, but, you know, it's probably going to be a bigger picture here that we need to identify. And I think that's probably one of the key messages to take from what we've talked about. Hey, really, you know, you, you start right with the first question is perhaps just to, to try and see if you can recognize when you are looking at a more persistent pain state and to try and really get to know that person and the bigger picture, and what's driving that because then I think you're going to get better results with them and then try and see if we can work gradually towards their goals and just keep them on track with it and give it time. Speaker 2 (36:45): It will take time, you know, this, the patients I'm seeing, we're looking at at least six months, probably a year of working together because there's so much to work through. I think we sometimes say, Oh, we reassured them about their pain. Give them some exercises away. They go, it's not really like that. You know, it's going to be lots of ups and downs. We're going to have to stick with them for a while and just keep chipping away, but you can get some really good results with people and you can get them back to the sport that they, that they love. And that can be a really, really big thing for them. Speaker 1 (37:13): Yeah. that's a great way to to end our conversation here. One, one question, what was the, who's the author of the paper from 2017? Speaker 2 (37:26): I think it's Hamline at all. I believe it was in the but I can find a link to it for you to put in the, in the show notes, if you would. Speaker 1 (37:36): Perfect. That would be great. And I will look it up as well. But thank you for that. Now before we finish our conversation, where can people find you? If they have questions? Speaker 2 (37:48): Yeah. Come and say hello on on Twitter, I'm at Tom goo or an Instagram ad running dot physic. Also I've got my website, which is running-physio.com. So yeah, come and say hello, ask questions and things. So it's good to chat. Speaker 1 (38:03): Perfect. And last question. What advice would you give to your younger self knowing where you are now? And I know we've, you said this before is, and I have to say something different. Now you get a chance to give yourself a second piece of advice. Speaker 2 (38:16): Oh, good question. Oh now that I'm thought 14 spending a bit on top, I'd, I'd say really enjoy your hair while it's there. Yeah. now I don't know, in all seriousness, I think I would probably sort of say you know, really make sure that you kind of value value, that things are important in life friends and the family, you know, always, always try and put those things first because ultimately they're, they're the things that are most important for us. And I think a lot of people already know that and I've learned it, especially during COVID, but I think there's a lot to be said about, you know, focusing on family and friends and things first you can still have a very fulfilling career and things, but I think that that's the important, the important stuff. That's what makes, makes life great. Really Speaker 1 (39:08): Excellent advice. Well, Tom, thank you so much for coming on to the podcast again and sharing all this great information with us. I really appreciate your time. Thanks for having me back here. And it's been really good pleasure, pleasure, and everyone. Thank you so much for listening. Have a great week and stay healthy, wealthy and smart.  

In this episode, Founder and Host of Entrepreneurs on Fire, John Lee Dumas, talks about the 71000-word, 17-step, 273-page success roadmap that is his first traditionally published book. Today, JLD talks about the launch of his book, The Common Path to Uncommon Success, and we get to hear a few of the 17 foundational steps to success, and we hear about identifying what we want to achieve, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “The online experts in this world... will lead you to believe that the path to uncommon success is “secrets”, “hidden”, maybe it’s “complicated.” It’s none of those things. All of them [successful entrepreneurs] have taken what has turned out to be a very common path to uncommon success.” “Freedom is one simple word, but it’s so hard to attain.” A few of the 17 steps to uncommon success: Identify your big idea. “So many people are living and acting in a weak, pale imitation of somebody else’s big idea.” Discover your niche. “Identify, within your big idea, an unserved opportunity.” Create your content production plan.   Suggested Keywords Uncommon Success, Roadmap, Process, Entrepreneurship, Wealth, Prosperity, Freedom, JLD, Entrepreneurs on Fire,   More about John Lee Dumas John Lee Dumas is the Founder and Host of Entrepreneurs on Fire, an internationally-acclaimed award-winning podcast with over 1 million monthly listens and 7-figures of annual revenue. To date, he has interviewed over 3000 of the world’s leading entrepreneurs, including Gary Vaynerchuck, Barbara Corcoran, and Tony Robbins. His first traditionally published book, The Common Path to Uncommon Success, is an amalgamation of the lessons learnt from the over 3000 interviews he’s done. Get the book: https://uncommonsuccessbook.com   To learn more, follow JLD at: Facebook:       John Lee Dumas Instagram:       @johnleedumas Twitter:            @johnleedumas YouTube:        John Lee Dumas   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:01): Hey, JLD welcome to the podcast. I am so excited to have you on Speaker 2 (00:06): Fired up to be here. Thank you for having me and listen. You've got a beautiful cat. I've got a beautiful dog. They might make a Paris's in this interview who knows Speaker 1 (00:15): It is possible. And I have to say, this is like a full circle moment for me, because I have always as a podcast or looked up to you for your podcasting, for your show entrepreneur on fire 3000 interviews. I mean, that is, that is amazing. And, and for all the listeners out there that is not easy to do. And now you've got a new book coming out. Your first traditionally published book. How exciting is that? Speaker 2 (00:47): Listen, I'm fired up. This is a combination of the 3000 plus interviews I've done over the last decade. I've interviewed some of the world's most successful entrepreneurs over the years, and I've learned from every single one of them. I mean, every one has been my mentor and I've been able to distill their genius down into what has turned out to be 71,000 words of my blood, sweat, and tears. Cause it took me 480 writing hours to write the 71,000 words, the 273 pages that comprise this book. But I couldn't take a single word out. This is a definitive 17 step roadmap to financial freedom and fulfillment. So if that's interesting to you, this book is your guy, Speaker 1 (01:34): Which is amazing. So it's the common path to uncommon success, the road to financial freedom and fulfillment. And you know, you, as we know, have been very successful online entrepreneur, but let me ask you a question. Sticking in that online entrepreneur have people been lied to by the quote unquote experts in the online business world. Speaker 2 (01:59): Listen, the online experts in this world. There's a lot of fantastic ones that are doing amazing things out there. And there's some not so fantastic individuals out there who will lead you to believe that the path to uncommon success is secrets. It's hidden. Maybe it's complicated. Listen, it's none of those things I've seen over 3000 successful entrepreneurs and I've interviewed over 3006 successful entrepreneurs. And I've seen that all of them have taken what has turned out to be a very common path, a very common path to one comma success. Now, by the way, it's hard work. It is absolutely hard work, but it's a common path. It's not secret. It's not hidden. It's not complicated. It is a very, very clear, very common path. And it's not something that, again, these so-called gurus that will try to, you know, sell you some key for $1,997 and 97 cents. Like, listen, that's the answer. The answer is clear. The content is out there. I've done over 3000 interviews. You have individuals like Karen and others who have done interviews. There's great content out there to be had. And I could tell you right now, just go listen to all 3000 of my episodes, but that's tens of thousands of hours or is distilled down into one book, 17 steps, 273 pages. And it's there for you. That's the common path to uncommon success. Speaker 1 (03:29): And when you look at success and we look at financial freedom and fulfillment, what, what do we really want to achieve here? What does that mean? Speaker 2 (03:38): So this is what I've really identified. That individuals really desire in life. Freedom. Freedom's one simple word, but it's so hard to attain, but think about it when you're free every single day to wake up and to do these three things, do what you want, where you want with whom you want. What else is there in life? Like when you can literally say, I get to do what I want to do, where I want to do it with whom I want to do it. I have that freedom. That's happiness, that's success. That's what people want. And this is what so many people have been able to achieve. You know, unfortunately, a lot of people don't think that's possible and they will never be able to achieve as a result. But those type of people don't listen to podcasts like this. So I know I'm talking to the right individuals right now. It's there. It's possible. It's, it's, it's a, it's a common path to your version of uncommon success. Speaker 1 (04:38): Now, you know, you say in the book, it's a 17 step roadmap. Most people will give you five steps or maybe eight steps, right? So what, what is the 17 step roadmap? If you can give us a couple of little snippets or details. Speaker 2 (04:54): So here's the process it's like when I interviewed these 3000 plus now individuals, and I've been able to really boil down and distill down the core foundational elements that all successful, aren't new or share in common. There were 17 of them. Like I wish there were 18 or 16. I like even numbers, but listen, it was 17. I couldn't take one away. I couldn't add one. It was just simply 17 foundational steps. And I was able to put them in a chronological order. And before me, I had the 17 chapters of the book and a step-by-step format, 17 steps to financial freedom and fulfillment. And let's go over a couple right now. Number one, this is where most people get it wrong, by the way, identify your big idea. Keywords, your big idea. So many people, Karen, they are right now living and acting in a week pale imitation of somebody. Speaker 2 (05:53): Else's big idea. They're like, Oh, look what Karen did or John. And they're having success doing these things. Let me just do that. And then they wonder why they're not successful most because they're a week pale imitation of those people that are trying to copy. They're copying somebody. Else's big idea. That person, it's their big idea. It's their zone of fire. That's why they're successful because they're living in their zone, a fire. You need to sit down maybe for the first time in your life, by the way, and really give yourself the time, the space, the open bandwidth to really come up with and identify your big idea. And your big idea is out there. Your zone of fires out there and chapter one, listen, it's not just words on a page. There are exercises. I teach you how exactly you get to your big idea. Speaker 2 (06:42): And that is a super critical part. That by the way, most people will die. Never even knowing what their big idea is because they never took the time to sit down and identify it. And it doesn't even take much time, which is the sad and scary part. But here's the thing here. If it was just that simple to identify your big idea, it would be one chapter in my book. And there were just be one chapter in my book. There's 17 steps. So there's a lot more to it than I than identifying your big idea. Let's just jump to step two. And then we'll skip a little ways ahead to, to show you any part of the book as well. But once you have your big idea, people are like, Oh my God, I'm so excited. Like I have my big idea. Let me go all in on this. Speaker 2 (07:22): That's a huge mistake because guess what? Your big idea is a great idea. And other people have had it too. And there's competition. That's out there crushing your big idea, which is a good thing because that's proof of concepts. That means that your big idea really is proof of concepts, but you can't right now launch against entrenched competition that's out there. So instead you go to step two, which is discover your niche. That means you're going to identify within your big idea, an un-served opportunity, a void that needs to be filled, that you can be the best solution to that real problem within your big idea. That's how you win. Like Karen, when I launched a podcast, that was just this broad idea, but then I was like, well, I'll launch a business podcast. That's a little more niche. Okay. It's still kind of broad. Speaker 2 (08:14): There's a lot of people there. Well what about an interview business podcast? Okay. There's like seven or eight other interview business podcasts. What about a daily interview? Podcasts of the world's most successful entrepreneurs, zero other competition. The day I launched entrepreneurs on fire, it was the best daily podcast interviewing entrepreneurs. It was the worst daily podcast interviewing entrepreneurs. It was the only daily podcast interviewing entrepreneurs. Like can't you see, like, that's why I won at such a high level. How can you be the best? Sometimes it means being the only, or it means niching down till you look around your competition is terrible. So you can kill them immediately. You can beat them up. That's how you discover your niche. Then of course, there's step three, four, and I take you all the way through and beyond. Let's skip forward right now to step seven. Speaker 2 (09:09): So every chapter in this books, an average of a three to 5,000 words, this chapter I wrote and I wrote and I wrote, and I wrote 13,500 words. By the time I finished this chapter, step seven, chapter seven, creating your content production plan. That is why we've won financially at such a high level because our content production plan is amazing. And I say that because it took us 10 years to get here. It's stunk at first, but now it's amazing. And I poured it all into this chapter and it is phenomenal and it's listen, it's not easy to emulate, but it's all there for you. And you will see after reading this chapter, why we're winning at such a high level and frankly, you know why you might not be because likely your content production plan is nothing in the same realm of what we have just like ours. Speaker 2 (10:06): Wasn't in this realm, obviously when we launched back into, you know, almost 10 years ago now, so that's just a glimpse of three of the 17 steps. And we have actually a bonus chapter called the well of knowledge. And it's a really cool chapter is chapter 18, a bonus chapter. And that's just the best pieces of advice, mentorship, inspiration, motivation that I picked up over the years. I just dropped it into this chapter. And this meant for you to really just take your ladle, dip it into the well of knowledge every now and then when you need it, when you need a little bump, a little boost. And man, that chapter is really cool because it's not meant to just read all at once. Like go there, consume it. One passage to passage, get the kind of inspiration you need, then get back to work. That's the process Speaker 1 (10:56): Amazing. Well, I mean, I don't know about anyone else listening, but I am so excited to get my copy, which it releases on March 23rd. So tell us, tell all the listeners here a little bit more of the details of the book launch so they know where they can get their copy. Speaker 2 (11:11): So listen, all the magic is going to be happening over at uncommon success. Book.Com, uncommon success book.com. You can head over there. You'll see the personal endorsements from Seth Godin, Gary Vaynerchuk, Neil Patel, Erica Mandy, Dorie Clark. You'll see a video of me describing more details about the book. You'll see. The first chapter is there for free just to read, to consume it, to see kind of like, well, how my writing process is plus the five bonuses that come with the pre-orders. So do not wait until March 23rd. You want to pre-order this book because it is amazing what we've done for these five bonuses. Just one of them, by the way, I'm to your door. All three of my journals, the freedom mastery and podcast journal. I'm literally shipping to your door at my expense. Well, drop them all. If you live in the United States of America, outside of the U S I'm going to give you the digital pack of all three immediately they're beautiful fillable versions. They're awesome. And there's four other insane bonuses. You can learn more about those other bonuses@uncommonsuccessbook.com. Speaker 1 (12:21): And I, I ha I will say congratulations are in order already. Cause an Amazon I checked today is already a number one bestseller on Amazon and it's not even out yet. And for the listeners, I am going to be giving away five copies of the book and you'll find all the details on my Instagram page. So check that out. Cause I will be giving away to five lucky winners, five copies of this book, because if you just go on to the website and read even the first chapter, you're like, man, I get it. You know, and I, and I also love the fact that you're vulnerable, that you're saying, Hey, this didn't happen overnight. And that's what a lot of people think. And that's what a lot of people sell. And it's so refreshing to see people out there experts like yourself saying it's hard work, it's work, but you can do it. So you're welcome. So I want to thank you so much for coming on the podcast. And one more time, where can people find all the info, Speaker 2 (13:21): Uncommon success, book.com, check it out a lot of great stuff there. And once again, much appreciated. Speaker 1 (13:30): Thank you so much. And everyone thank you so much for listening. Have a great couple of days and stay healthy, wealthy and smart.

In this episode, sports physical therapist specialist, Dr. Alli Gokeler, talks about motor learning. Today, Alli tells us about the process of motor learning, how patient autonomy is advantageous to rehabilitation, and how to motivate patients. How does Alli measure motor learning outcomes? Alli elaborates on his on-field rehabilitation model, and the importance of incorporating cognition in ACL injury rehabilitation. Alli talks about RTS from a motor learning perspective, how to continue motor learning on the field, and he gives his younger self some advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways Alli defines motor learning: “In order to acquire motor learning, you need to practice. If you don’t practice, you can’t learn something.” “The learning process itself cannot be measured directly. It’s only something you can measure indirectly.” “What motor learning should result in is: it should lead to relatively permanent improvement of motor skills.” “Be careful how you interpret this process. Quite a few clinicians have a tendency to provide feedback because they intuitively try to correct a patient.” “Be a little bit patient with your patient, because learning takes time. Don’t interrupt the learning process too soon.” “Motor learning, as well as learning a language or math, is a non-linear process.” “One of the strong drivers of learning is intrinsic motivation.” “We provide our patients with a significant amount of autonomy, which means the patient gets a certain level of control over the exercises.” “Providing autonomy during rehab enhances learning.” “Around 70% of people prefer to receive feedback after a good performance of an exercise. What happens in most clinical situations, with all good intentions, we typically give corrective feedback, which typically means you didn’t do something according to the standards of the therapist. This may affect their motivation.” “If you look at the brain activity of someone that is instructed to do something, or the brain activity of a person who has some control over what they’re going to do, you have completely different brain patterns. When you give them some control, they are much more engaged, and this is a prerequisite in order to learn something.” “If you want to be certain that learning has taken place, you need to measure, otherwise you can’t be sure that the patient has learnt something.” “If you’re good at something, it’s not challenging anymore. If it’s too difficult, then it’s overreaching.” “One-on-one training is not what’s needed for a football player. They are team athletes.” Alli’s on-field rehabilitation model: Neurocognition: Reaction time, decision-making, selective attention, inhibition and working memory. Motor component: Strength, range of motion endurance, and speed. Sensory: Visual, auditory, and environmental factors. “We need cognition during our motor control, and if we only work on pre-planned activities, we miss something from the on-field situation.” “An ACL injury isn’t just a peripheral injury, but it’s also a neurophysiological lesion, and that needs to be considered in rehab.” “With colleagues that work with paediatric patients, some of the motor learning principles that they use could be very beneficial for us working with orthopaedic, sports-related injuries.”   Suggested Keywords Motor Learning, RTS, PDCA, ACL, Rehabilitation, Neurocognition, Therapy, Physiotherapy, PT, Training, Injuries, Sport, Wellness, Health, Recovery, Injury-Prevention,   More about Dr. Gokeler Dr. Alli Gokeler has 28 years of experience as a sports physical therapist specialist. In 1990, Alli graduated with a degree in Physical Therapy from the Rijkshogeschool Groningen. Following his graduation, he worked in both the US and Germany as a physical therapist. In 2003, he earned his Sports Physical Therapy Degree from the Utrecht University of Applied Science. In 2005, he started a PhD project at the University Medical Center Groningen, Center for Rehabilitation. He is a researcher-clinician and a clinician-researcher with a passion for multidisciplinary injury prevention. He has over 40 peer-reviewed publications, and he regularly gives lectures worldwide. In his free time, he loves to do mountain biking.   To learn more, follow Alli at: Facebook:       Motor Learning Institute Instagram:       @motorlearninginstitute Twitter:            @Motor_Learning YouTube:        Motor Learning Institute Website:          https://www.motorlearninginstitute.com ResearchGate:           https://www.researchgate.net/profile/Alli_Gokeler   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:07): Welcome to the healthy, wealthy, and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information. You need to live your best life. Healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, Dr. Karen Litzy. Hey everybody. Speaker 2 (00:37): Welcome back to the podcast. I am your host, Karen Litzy and today's episode is brought to you by net health. So net health is hosting a three-part mini webinars series on Tuesday, March 9th, entitled from purpose to profits. How to elevate your practice in an uncertain economy after 2020. I think you're going to want to sign up for this. So you're going to hear from a panel of guests that have over 50 years of combined experience working in the PT industry sign up will begin tomorrow, which is Tuesday the 23rd, February 23rd for this mini webinars series. So head over to net health.com/litzy to sign up once again, that's net health.com forward slash L I T Z Y. So check it out and sign up now. Oh, and it's free. Okay. So this whole month we've been talking about ACL injury and rehab. So today's episode is with Dr. [inaudible]. Speaker 2 (01:41): He has 28 years of experience as a sports physical therapist specialist. In 1990, he graduated with a degree in physical therapy from I'm not even going to pretend to try and pronounce this. So you can just go onto the podcast website to find out where he went to school. Cause I'm not even going to attempt it following his graduation. He worked in both the us and Germany as a physical therapist in 2003 here in does sports physical therapy degree from you trick university of applied science in 2005, he started a PhD project at the university university medical center, grown again, center for rehabilitation. He is a researcher, clinician, and a clinician researcher with a passion for multidisciplinary injury prevention. He has over 40 peer reviewed publications and he regularly gives lectures worldwide in his free time. He loves to mountain bike and you can check out more from him and his research@motorlearninginstitute.com. Speaker 2 (02:46): Okay. So today we talk about just that we talk about motor learning. So the process of motor learning, how patient autonomy is advantageous to rehab, how to motivate, how to measure low motor learning outcomes on field rehab models and the importance of cognition and ACL rehab. And we talk about Allie's brand new model for Mona motor learning, which will be out hopefully in a month or so. So a big thanks to Allie. And of course, thank you all for listening to this month on ACL injury and rehab. Hey, Alli, welcome back to the podcast. I am happy to have you on once again. Speaker 3 (03:31): Thank you for inviting me. Yeah. It's been awhile pleasure to be here today. Speaker 2 (03:34): Yes. And so, as people, if you've been listening to the podcast, you know, that this month has been all about ACL injury and rehab. And so what better person to have on the new to talk about kind of the rehab process after an ACL injury and your specialty, which sort of motor motor learning. So the first thing I want to ask you is can you define motor learning? Speaker 3 (04:02): Yeah, that's it, that's a very good question. And I I've taken three, I think important aspects of motor learning that I think are relevant for clinicians that listen to this podcast. The first one is in order to acquire motor learning, you need to practice. If you don't practice, you can't learn something and that may be pretty straight forward, but I still think it's important. The second one, and that's a little bit of a vague one, but the learning process itself cannot be measured directly. It's only been some been something that you can measure indirectly. And I I'll touch back on that a little bit later. What I mean by that? And the third point is what model learning should result in is that it should lead to relatively permanent improvement of motor skills. And last year I gave the example of writing how to ride a bicycle for this year. Speaker 3 (05:03): I thought, Hey, maybe skiing is a good example. And so if you've taking ski lessons as a teenager and you became quite proficient in skiing, it could be for many different reasons for job or any other reason that you haven't been going to the Rocky mountains, but at the age of, let's say 35, you have some time again, and you have some financial resources and you'd, Hey, let's spend the week again in Vermont or the Rockies and maybe a little bit of rusty at the beginning, but perhaps after a day or two, you get the hang of it again. So this is I think a great example of what motor learning means. It means that you acquire something and it sustains over time. Now that needs to be distinguished from performance. And this is, I think one of my key messages that I would like to point out to clinicians when you work with your patient in the clinic and you have your patient doing an exercise. Speaker 3 (06:11): And this relates to my second point is that motor learning is not directly observable. What you see in the here and now is performance. Now I get, I can give you two examples. So let's say you have a patient after an ACL injury six weeks post-op and you want to have your patient work on balance, not patient number one comes in and stands on one leg. And actually what you're seeing, you're very happy, very stable not any excessive movements is able to maintain balance for 30 seconds. Okay. You're you might be happy with that. Now, your second patient comes in from the same surgeon, also six weeks post-op and when you have this patient perform the same exercise, you see that a patient sometimes needs to take the hands of the hips or needs to hold onto something, or puts the other foot down to maintain balance. Speaker 3 (07:16): And from these two examples, you may draw the conclusion that the first patient has better motor skills and has better learning potential. And the second one has poor motor skills and is not such demonstrating good learning potential. We don't know. We only, we only know that performance in patient one is better for sure. Performance in patient B is not as good for sure, but that doesn't mean that the dis says anything about the learning potential. In fact, it may be that the learning potential in patient one is, or has already been reached because this is at the max of his abilities, various for the second patient with poor performance, there may be a large learning potential. So that that's that's I think very important. And what you need to consider as a clinician is be careful how you interpret this process, because what I know from my early days, and also when I teach courses, is that quite a few clinicians have a tendency to provide feedback because they would intuitive to literally try to correct patient too, because you see that it's not able to maintain balance. Speaker 3 (08:40): So we need to say something. So we will usually do that in with feedback. And we typically do this with corrective feedback. And my second take home message would be, be a little bit patient with your patient because learning takes time. So maybe unless you feel that there is an unsafe situation, but if that's not the case, let the patient practice and re evaluate in the week or in two weeks time. But don't interrupt the learning process too soon. Because when I go back to the skiing example, remember when you haven't been skiing for for like 15 years or when you started to ski, it, it, it was probably something like this first day, quite difficult. Second day, still difficult. You might even get frustrated third day, no improvement. However, on the fourth day snow not being able to ski ski lift is closed. Speaker 3 (09:55): And on the fifth day means there was no one day without any skiing lessons on the fifth. There you go out again, Hey, and all of a sudden you feel like, Hey, I I'm, I'm better than I was on day three, although you haven't practiced in the day in between. So this is what I mean, learning is not only happening as you practice, but there's also some processing afterwards going on in your brain that helps to acquire those motor skills now. And if you interrupt that process like vote by providing a lot of corrective feedback you may actually, although with all good intentions, I don't want to disqualify that, but maybe it's better to leave the process happening and evolve and then provide feedback later on. Speaker 2 (10:50): Yeah. It kind of reminds me of have you ever heard the term helicopter parent? So it's the parent that's always hovering over the child, making the decisions, not allowing them any autonomy for themselves. And so it reminds me of that helicopter therapist who's on top like, Oh, I see that if you use the example of balance, Oh, I see that you struggled a lot with your balance. Why don't you try and do this? Well, why don't you do this, try this, try this, try this. And, and in that as the therapist, are you taking away the autonomy for the patient and what kind of, how can that affect the outcomes for that patient? Speaker 3 (11:31): Yeah, that's an excellent point. Karen C motor learning, as well as learning a language or learning math is a nonlinear process, which means how you learn how to ride a bicycle was probably different from how I learned it. So, but what we typically do as clinicians, we have this, this, this clinical guidebook in our, in our mind map that we think based on our experience or based on our beliefs, how we need to guide our patients from simple skills to more advanced skills from single task skills to do a test skill, whatever. However, we don't know how this patient is actively engaged in this process, actually, by example, that you were provided the, the patient is directed by the, by the parent or, or the child is directed by the parent and is actually a passenger. Now, I think one of the strong drivers of learning is intrinsic motivation. Speaker 3 (12:41): So what role do you give your patient if you direct them, where to go, what to do, and also you give them corrective feedback are these all strong drivers for self-organized learning? I'm putting a question Mark behind it. So people need to think about them for themselves. I can tell you what we do in, in, in our clinical situation. And that's based also on our research we provide our patients or in ACL injury prevention, we provide a significant amount of autonomy, which means an athlete or a patient gets a certain level, not complete control, but a certain level of control over the exercises. So they can choose, for example, out of 10 exercises, they can pick three exercises that they would like to do on that particular day, in an order they would like to do. And we know from a substantial body of research that providing autonomy during during rehab enhances enhances learning. Speaker 3 (13:59): And I can tell you this from a research point, but it can also give you a brief insight from a recent survey that we've done among patients that completed their rehab. And we sent them an open questionnaire about their experience in in the entire process of rehabilitation. And one thing that two things that really stood out were a positive environment, a positive environment with relatedness of the therapist towards the patient, and not as a patient, but as a person that's quite important. So it's not a ne it's not an ACL patient. No, it's, it's, it's a person with an ACL injury. That's quite, quite, quite an important distinction. And the second thing that stood out was and you, you touched on that before is the autonomy some self-control over the rehabilitation process. And this was a qualitative study that we did my PhD student while surveilling ran the study. Speaker 3 (15:10): So it's not something that I'm just saying as a scientist, but this is also what we get back from our patients. And when we ask them so going back to the clinical situation this is what we apply also by providing our patient with the opportunity, instead of me always providing the feedback I'm asking them, or I'm giving them the opportunity please let me know when you want me to give you feedback. That is a great example of of autonomy, the thing, easy question. Yeah. And, and, you know, what's, what's, what's what's quite important to understand is if w if we think how humans preferably like to receive feedback if we, if we, if we ask a healthy population and the same applies to to an injured population, it turns out that around 70% of the power of the people prefer to receive feedback after a good performance of an exercise, what happens in most clinical situations with all good intentions? I really don't want to question that, but we typically give corrective feedback, which typically means you didn't do something according to the standards of the therapist. That means that maybe seven out of the 10 people that you provide feedback to may not really like this, and this may affect their motivation. This may affect their learning potential because they like to receive feedback when something went well, they, they conversely they already know when something didn't go well and they don't need us to rub it in or to remind them they already know. Speaker 2 (17:15): So you, you touched on a word that I was just going to ask you about, and that is motivation. So why is motivation key in motor learning? Speaker 3 (17:28): If you look for example, at the brain activity of a person that is instructed to do something, or you look at the brain activity of a person who has some control over what they're going to do, you have completely different brain patterns. And I can tell you that the second one, the second example, when you give them some, and when they can choose, they are much more engaged, and this is a prerequisite in order to learn something. Speaker 2 (17:59): Yeah. And, and I think we can probably all look back on our own personal experiences of learning, whether that be academic learning, or learning a physical task. I think we all like to have a little bit of control over that versus just have stuff thrown at us without our IM without our input or without our thoughts on it. So I think that makes perfect sense. And now, so we spoke about how motor learning is, non-linear why motivation and autonomy is so important. Now let's talk about, we've got this patient with who had an ACL repair and they want to get back to sport. They, they are, they are ready mentally. So we'll put that to one side. They're ready mentally. So let's talk about the return to sport from a motor learning perspective. Speaker 3 (19:02): In my opinion, return to sports is we first need to define what we mean. And I think the 2016 consensus meeting gave us some leeway in that direction. And I think one of the most important things that stood out is that it's a continuum. It is not one moment in time. And I think what I read in the literature often is is that it's such a that coma to choice yes or no at at six months or nine months, whatever you're, you're, you're, you're believing in. I think what we need to understand is certainly in light of the high number of secondary ACL injuries, particularly in the young population, in, in, in pivoting type sports, that's number one. But also the second one is that, you know, only, I think a disappointed percentage of people reach their pre-injury level. Speaker 3 (20:00): So their performance is not up to par. So do those two factors. When we, when we look at that, I think it all starts prior to the surgery. So the rehabilitation, I think is one of the key factors that we need to, that we need to consider anything that's left. Unaddressed will show up even in higher magnitude, after the ACL reconstruction, which was the second trauma to the knee. And, and then in, during the entire rehabilitation process, something very simple. And I can't stress that enough if, if walking is not normal and how do, how do many clinicians assess a normal gait pattern? They usually ballpark it, but, you know, even a slight deficit of five degrees is clinically meaningful. And now, now just follow some logical sense. If you're walking is not normal, what do you think will happen with the running? Speaker 3 (21:01): W what do you think, what would you expect? How, how the squat will be executed by the patient and how will the single leg up will be done or a drop foot, a good jump. So that's why I think that all these elements from a motor learning perspective, and also we'll touch back on that a little bit later, of course, sound strengthening program, you know, no question about it, very important, but I think it is, it is very important to also incorporate the model learning process so that we make sure that the patient is learning or relearning those motor skills, but Mo and I can also stress enough. It's also important that we as clinicians really, really measure and boarding and, and I, we just completed and published a study among Flemish physiotherapist. And one of the things that came out of this study is that many don't use the evidence-based principles, meaning also they don't use two criteria as they don't assess and in order, and that's also coming down to model learning. If you want to a certain that learning has taken place, you need to measure, otherwise you can't, you can't be sure that the patient has learned something. Speaker 2 (22:22): And how do you, what are some examples that you can maybe give the listeners of how you measure these motor learning outcomes? Because I think that's important to let people kind of wrap their heads around that. And on that note, we're going to take a quick break to hear from our sponsor and be right back Speaker 4 (22:41): On Tuesday, March 9th, net health is putting on a three-part mini webinars series entitled from purpose to profits, how to elevate your practice in an uncertain economy after 2020, you're going to want to sign up for this. You're going to hear from a panel of experts that have over 50 years of combined experience working in the PT industry, signup will begin tomorrow for this mini webinars series. So head over to net health.com/litzy to sign up once again, that's net health.com forward slash L I T Z Y. Speaker 3 (23:16): Yeah. So I use, then that's something from, from the business that you probably know that the PDCA cycle, the plan do check act and the P and the plan, which means you do a baseline test. So first you need to let's say balance. So there's the patient have a balance deficit yes or no. You can use the star balance says you can use th the balance error scoring system. That's your baseline test. Now, it's up for you as, as a physiotherapist with your clinical reasoning. Does the patient need an intervention to target a balance? Yes or no, or are we happy with, but let's assume now there is a balance deficit. Now we go to the do, which means what is my intervention? So my intervention could be, I'm planning to do balance training for four weeks, with two therapy sessions in the clinic, and four sessions at home consisting of those and those exercises. Speaker 3 (24:21): And then AF in between I'm doing an interim evaluation, is the patient going on track as I'm expecting or not? I can still find tune my my intervention program, a training program. And then I do a final assessment after, after two weeks and preferably even one little bit later on as well to make sure that the effects of the balanced training are really sustained over time. Remember what I said about riding a bike or skiing and that's a very simple procedure you can use. It doesn't take a lot of time but it's, it needs to be integrated in your daily practice because if you don't measure, you don't know. Speaker 2 (25:09): Yeah, absolutely. And I love that. I think people can get behind that PDCA cycle and cause, you know, PTs love things that are regimented and you know, things that sort of follow a plan. So I think this is a really easy, and I think people can get behind it. And I also think that it will keep your patient on track and keep you on track and organized versus just like throwing whatever up against the wall and seeing what sticks, if you measure it, you're, you know, you're, you kinda know where this patient is going and that makes all the difference. Speaker 3 (25:51): Yeah. Which, which th that's a good point that you I, I forgot to mention it actually in the, in the, in the planning cycle, I'm incorporating my patient. So I'm discussing the baseline tests and I'm asking in my patients, so you have a balanced deficit. What do you think is needed for you to improve your score? What do you think is could be if you score eight out of 10, so zero would be no balanced error. 10 would be the maximum errors that you can acquire. So you have an eight, what do you think is reasonable to achieve in two weeks time, for example, and then the patient could say, yeah, I think I'm I can reach a seven. Hey, that's the interesting information. Why, why are you so conservative? Why can't, why can't you challenge yourself from, from an eight to a four, for example? Speaker 3 (26:42): So I always creating this interaction with my patient. You know, I can in conjunction with, with, with me and my patient, I can set goals that, and that's quite important as well. That need to be challenging for the patient, because if you, if you already a good or something, you're not challenging and it's not challenging anymore, if it's too difficult, then you then it's overreaching. But it, it has to be something that the patient sees. Okay. I really got to put some effort into this is again, which is, again, something for important for learning. Speaker 2 (27:22): I was just going to say that I said from a motor learning standpoint, if you do nothing that gives a substantial challenge to your patient, are they really going to see the benefits of those exercise or of your plan? Exactly. Yeah, yeah. Yeah. That makes perfect sense. Okay. Speaker 3 (27:45): And also going back to to the first example where the two patients with the balance exercise, if, if I give my patient an exercise, it is usually an exercise that creates difficulty for them. So if I see a perfect demonstration, then I'm kind of thinking, yeah, what is the learning potential here? So I purposely make the exercise a little bit more difficult right away. And I explained that to them, I'm explaining to them, don't expect to, to master this exercise today or tomorrow. And I always give that example of, of riding a bike and, and a lot of patients like that because, Oh yeah, I remember that I fell down quite a few times and and that that's in ACL rehab. It's, it's more or less the same process. Speaker 2 (28:37): Yeah. And, and I also want to switch, well, this isn't really switching gears just moving forward. So yes, we know that return to sport is a continuum you've got returned to sport and returned to performance, different things. And one of the things that I spoke about with Nicole [inaudible] is the importance of on-field rehab. So I know that's something that you're also passionate about. So do you want to kind of tie that into what, what therapists can do on field to continue to foster this motor learning within their sport, whatever that sport may be? Speaker 3 (29:20): Yeah. I think that's, that's something that's underappreciated and, and maybe that's because we haven't really integrated the motor learning processes in our rehab. And one of the things that we have to consider is when you observe your patient in the clinic and you a certain motor behavior, that's all what it means. It stems down to the interaction between the environment. The task at hand could be a jumping exercise, could be a single lag, actually, whatever. And, and, and, and to behavior that you're seeing. So there is a task athlete, environmental interaction, which means the movement that you see from that interaction only is valid for that interaction. You cannot extrapolate a jump landing strategy from a box in a physiotherapy clinic. And imagine how this athlete would play lacrosse or American football or soccer. It's completely different game, completely different worlds. Speaker 3 (30:37): So I think that's where one of the main reasons why single leg hop test and accessed by, by, by Kate Webster and, and, and Tim, you, it were shown not to be valid predictors of secondary ACL injury, because a hop test is something completely different than how an athlete performs on the field. So, in, in, in that regards I think we need to take the patient to the field and to see how the patient is performing based on that interaction that I just refer to the tasks, the environment, and the athlete interaction. And then you get meaningful information where the, where that patient is is add, which for example also means that one-on-one training is not what's needed for a football player. They are team ball athletes. So you need to do something with the ball. You need to be on the turf and you need to do something with teammates Speaker 2 (31:43): That yes, when you're working with someone with a team sport, you have to have those other I don't want to say distractions, but you know, other people, a ball scanning a field versus just going one to one with you. Speaker 3 (32:02): Yeah. And we, we've just completed an analysis of 47 non-contact ACL injuries in Italian professional football. Just this work that I've done with Francisco Della Villa from the ISO kinetic group. And what we did is we, we looked at the injury mechanism through a different lens and what we the lens we use was a neurocognition lens. So we looked at the inciting events that happened before the ACL injury took place, because so far the literature is predominated by the dynamic valgus collapse. And I totally agree. I totally agree. However, it doesn't tell you what led to the injury. It just tells you what the end point is. That's dynamic velvets now. And what we've done now is what are now some typical events occurring during a match play in which a non-contact ACL injuries took place. And we took two neurocognitive factors. One is the selective attention. So are you able to maintain attention to the relevant information in this regard and filter out irrelevant information? And the other one is, did we see some impulsive behavior of defenders? And they were running into a situation in which basically the attacker waiting for them to approach. And then at the last moment, they made a deceiving action that the defender did not entail. Speaker 2 (33:40): And now in the very small timeframe, Speaker 3 (33:43): The defender had to change the movements in a timeframe that you don't have enough time to coordinate those movements well. So if you think about this as a framework, how injuries may happen, we also need to consider this framework, how we integrate that in our rehabilitation process. And this is what I do from day one. And certainly this is what I do re related back to your question for the on-field this framework we use for the on-field rehabilitation. And I've created a model for that. Speaker 2 (34:19): Yeah. So I was just going to say, I know that you've created a model and it's going to be published soon. So let's talk about what that model is. And if you can kind of walk us through that, that would be great. Speaker 3 (34:31): So the model is consists of three main pillars. The first one is neurocognition and neurocognition, you need to think about reaction time. Decision-Making selective attention, as I mentioned before, but also your ability to control impulsive behavior. That's called inhibition. Can you, can you change your intended movement? Yeah. That's something to control your impulses. Very important. Working memory is another aspect. So those are the neurocognitive components. Then we have the motor component, and I think that's where most physios will be quite familiar with. So we think about strength, range of motion endurance speed, things like that. Yeah. That that's, that's I think pretty straightforward. Then we have the sensory part. So in the sensory part, we can have the visual components so we can alter the visual input, maybe quite relevant for ACL rehab as Dustin grooms has already shown. And also my colleague and part of borne, Tim layman has demonstrated that with EEG, that the patient may have some visual reliance, but also things like, do you have your patient do training with shoes on is, are you playing on the hard surface, soft surface lighting conditions, auditory information. Speaker 3 (36:06): Now those three factors, neurocognitive motor, and the sensory part. What I did in my model, I created like a gauge, so I can create an exercise combination in which I have a relatively simple motor skill. So not so demanding, standing on one leg, for example, but what happens now, if I, and more cognitive load, for example, by having them do math subtractions, or working on the synaptic sensory station by doing motion tracking. Now I can see what the influences is of an added neurocognitive load on my motor art, because those three shape my functional movement coordination. Likewise, I can turn back. My neurocognition lit and stay with the same exercise and do now something on the sensory part. And this is what we all do as clinicians. So we do a single leg balance exercise, and we have the patient stand on on the, on the foam surface, or we have them close their eyes. Speaker 3 (37:14): So we already doing this, but I think the model can help you. How do I plan my exercises within one rehab session? And I'm changing that from week two week. And why would this be important? Well, first of all, we all always need to consider that we have, we need cognition during our motor control. And if we only work on pre-planned activities that, that are often in happened, we miss something exactly what you pointed out already from the on-field situation. They have to perceive a lot of information. They have to process that information and then execute the movement. And here's where cognition comes in. And we do this by being aware of that, we can use these gauges. What we do is we actually create a rehab environment that we call in part a board. And we call that an enriched environment in which we constantly provide different stimuli to the patient. Speaker 3 (38:22): That means the rehab from week one to week two is not the same, which means variation, something new, something I haven't done before. Again, this could already motivation so significantly, and I can tell you from experience, patients love this. The second benefit would be since you're providing different stimuli, you actually confronting the brain every time with a new situation and the brain has to find solutions. And this is I think very important also from the motor learning perspective that we need to consider to enhance the neuroplasticity of the brain, because an ACL injury is not just a peripheral ligamentous injury. It is also a neurophysiological lesion and that's, I think, needs to be considered and rehab. Speaker 2 (39:19): I mean, I, I have to say for me, I really liked this model because it, it gives you a great way. Like you said, to plan out your session so you can maybe enlarge the motor component one day or take it back another day, do more, neurocognition move that back, do more sensory, do sensory motor, maybe not so much neuro do a little bit of all three. So it's sort of like, I just sort of see the Venn diagram, just expanding and contracting with all three of those bubbles, which I think is really great. And like you said, it gives you, it's almost from a therapist standpoint, a clinician standpoint, I feel like it gives me permission to play around and come up with some fun things and be a little more original. Speaker 3 (40:06): Yeah. And I think what it also does it, it, it may help you as a therapist to get a better understanding where some underlying deficits may be because we only, we T we typically like to measure the outcome. So let's say I'm doing an agility course, and I'm just looking at at the time. And then I see, Oh, the patient is not so fast. So I need to do more training. Well, what you could maybe do is try to untangle a little bit and to see if the patient from the motor perspective has all the necessary requirements in order to be fast. Maybe there's a deficit there, but let's assume it's not the case. So all, all the strength, all the rate of force development, all these parameters are satisfactory. That must mean that there's something else in the system that can't cope with the demands. And that could quite well be that there is an underlying neurocognitive deficit, and this may help you as a therapist to work more on those neurocognitive elements with the intended goal that the patient becomes faster, but maybe not so much, but we're doing more plyometrics and, and doing more speed now working on the neurocognitive aspect. Speaker 2 (41:30): Yeah. So it's, it's a, a treatment as well as an evaluative tool to kind of see where some deficits are and how you, you and your patient together can plan to move forward. Sounds great. When when will this be widely available? Speaker 3 (41:49): I hope we have it out in a month, the time from that pending on, on the, on the publication process, but please stay tuned. Speaker 2 (41:58): Okay, perfect. And we will let, we will let people know. I will put it on social media when that is out. So that sounds great. Well, I mean, thank you so much for coming on and talking about this, I've been taking copious notes. I think this was great. Before we get into where people can find you, I have one last question and I ask everyone this, and that's knowing where you are now in your life and in your career. What advice would you give to your, to your younger self? Speaker 3 (42:23): Good question. I think what would have helped me if I would have spent more time in the neurological field, I think in, in what I still see, or with colleagues that work with pediatric patients, I think some of the motor learning principles that they use could be very beneficial for us working with more orthopedic sports related injuries. That's something I did not understand back then, because my interests were solely in the, in the sports domain, but in retrospect, I should have spent more time in, in the neurological and pediatric field. Speaker 2 (43:04): Great advice and great advice for anyone who is maybe at that starting point in the sports or orthopedic rehab world and trying to figure out, Hey, what is there something I'm missing here? So I think that's great advice now, where can people find you and find all this great stuff, all your great info. Speaker 3 (43:24): All right. So we have a website from our company and our company's serves as the hopefully as the intermediary between academics and the clinical field. I, I work in both fields. I'm, I'm a clinician, I'm a researcher. And with our platform, actually our community model learning Institute, we want to create a bridge between the academic field and the clinical field, because I think we can all improve, but we need to find each other and we need to speak the same language and have respect mutual respect for one another. And if we engage in in such a culture by exploring, by facilitating one another, I think we can create a lot of new things and approaches with the overall purpose to help our patient. This website will be updated in a month from from now. So we will we will be offering completely new courses, which are also have the opportunity to get coaching from us. So it's not frontal education, but we offer for every course participant to receive life or written feedback on their progress during the course, because our premise is that we want to create a course in such a way that you can apply it into your setting after you've completed the course. Speaker 2 (44:58): That sounds amazing. And we will have links to to the website. We'll have also put the link up to your research gate profile so that if people want to look at some of the papers that you mentioned today, they can just go there and see all the papers that you have authored and co-authored do. I think it would be really helpful. And if people want to find you on social media, where's the best place to reach out to you there Speaker 3 (45:26): Would be Twitter, Instagram, or Facebook. Speaker 2 (45:30): Perfect. And what are the handles if you know them off hand motor learning Institute. Perfect. Perfect. Okay. So thank you so much. And like I said, I will have everything available up on the website at pod podcast at healthy, wealthy, smart.com. So Allie, thank you so much for coming on again. I really appreciate it. Speaker 3 (45:55): Thank you, Karen. And I really want to say, thank you so much for setting this up. I think this is exactly what we also stand for, that we create a platform in which we can exchange our ideas. We can ask one another question that that's the best way I think, to move forward. So really thankful for you to organize this and yeah. Speaker 2 (46:16): And so everyone, thank you so much for listening. Have a great couple. I have a great week and stay healthy, wealthy and smart. Well, a big thank you to Allie for coming on and sharing all this great information about motor learning as it relates to ACL injury and rehab. And of course thank you to our sponsor net health. So remember on Tuesday, March 9th, net health is putting on a three-part mini webinars series entitled from purpose to profits, how to elevate your practice in an uncertain economy. You're going to hear from a panel of guests that have over 50 years of combined experience working in the PT industry, signups will begin tomorrow, which is February 23rd for this mini webinars series. So head over to net health.com/ let's say to sign up once again, that's net help.com forward slash L I Speaker 1 (47:04): T Z Y. Thank you for listening and please subscribe to the podcast at podcast dot healthy, wealthy, smart.com. And don't forget to follow us on social media.  

In this episode, 3rd Year DPT Student at Rosalind Franklin University of Medicine and Science, Briana Zabierek, talks about her DPT Study Guide. Today, Briana tells us about her experiences in PT school and the frustrations that led her to start the DPT Study Guide. How is the DPT Study Guide helping students? How does Bri find the time to do it all while still studying? She elaborates on the future of the DPT Study Guide, what students can expect to find in the guide and current developments. Briana tells us about how the DPT Study Guide is compiled, finding her entrepreneurial interest, and she gives her younger self some valuable advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways How Bri manages her time: Change of pace: Set a timer for 45 minutes. Put all notifications off, and just zone in on your work. Master a topic, then move on: Be comfortable bouncing between topics. Master the main ideas before moving on to another topic. Don’t try to do a whole topic in one go. “The long-term goal is not just to provide products and merchandise, but to really make it a place where you know you’re stepping into a simplified version of PT school.” “If you have the passion for it, and this is something that you believe in, then you can make anything happen.” “You don’t have to be an entrepreneur to make these opportunities possible for yourself.” “Take more breaks and realize how valuable those can be for hitting reset with your mind and focus, and also make time to have some fun.”   Suggested Keywords PT, DPT, Study Guide, Health, Prioritizing, Studying, Entrepreneurship, Efficiency, Physiotherapy, Time Management,   To learn more about Briana: [caption id="attachment_9507" align="alignleft" width="150"] www.melissa-manzione.com[/caption] Bri was raised in Lockport, IL. In 2017, she graduated with a BSc from the University of Nebraska-Lincoln, Double Majoring in Nutrition, Exercise, and Health Science, and Nutrition Science with a Minor in Psychology. She is currently studying toward her PhD in Physical Therapy at the Rosalind Franklin University of Medicine and Science, with her graduation expected in May of 2021. Her mission statement: To serve, encourage, and equip patients and students in reaching their full potential.     Follow Briana at: Facebook:       @dptstudyguide Instagram:       @dptstudyguide LinkedIn:         Briana Zabierek SPT Twitter:            @dptstudyguide Website:          https://dptstudyguide.com                         https://dptstudyguide.com/downloads   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:01): Hi, Bree, welcome to the podcast. I am happy to have you on. Speaker 2 (00:05): Thank you. Thanks for having me. Sure. Speaker 1 (00:07): And we'll give a shout out to Dr. Sarah Hague for putting us into contact with each other and telling me all about the great work that you're doing with DPT study guide. And we're going to talk about that today. So before we talk about the guide itself, why don't you share with the listeners, your sort of personal experiences with PT school, which you are still in your third year student at Roslyn Franklin. So share a little bit about your personal experience with PT school and maybe some of the frustrations that came up for you. Speaker 2 (00:41): Yeah, yeah, absolutely. So first and foremost, I think every student kind of encounters a little bit of a roadblock just starting out between my roommates and just our class itself, we had some pretty good comradery to begin with. And so I always felt that that was a good option to at least discuss, you know, areas that I maybe was struggling with or they were struggling with and just kind of have this like melting pot of different ideas and different ways that we could all just get the job done and kind of figure out what we need to know for exams. But as time went on, I think we all kind of fell into our own little like habits and patterns and maybe a little bit what we're comfortable with. And then what I realized was when I think it was about like the middle of middle or towards the end of first year we had our neuro unit and that is kind of where everyone hit a wall with our study habits and just retaining the information and just kind of collectively as a class, we were making our own separate study guides and they would be like these super, super long word documents. Speaker 2 (01:56): And I'm talking like 50 plus pages full of yeah. Like eight point text. And I was kind of like attached to them. Like we all would get on like our Google docs and like start typing up information and it just became really overwhelming. And so what I realized was like, I kind of have an opportunity for myself and for my colleagues is to just simplify things a little bit like I was getting sick of kind of going through the PowerPoint slides that were, you know, 120, 150 slides long and just little snippets of information on each. And so I kind of just took a step back and, and saw an opportunity to really simplify things, not just for myself, but something that I thought would be helpful just to transform any student's education going forward. And it was in again, late in our first year when I was inspired by different cash based physical therapists and kind of exposed to that world and realized that there was an opportunity for me to step into like a neat niche position. We kind of get started there kind of with like a side hustle. So that's kind of where everything stemmed from, and right now it seems to be going pretty well. Just looking forward to kind of like sharing the experience. Speaker 1 (03:13): Yeah. And so tell me a little bit more about the guide itself. Can you kind of give an example of a section of it and how it helps other students? Right. Speaker 2 (03:26): So one thing that I definitely picked up on when I started posting the information on Instagram, which is my, my primary platform that I use was trying to get the main points of any kind of lecture or chapter into about like eight to 10 pictures on Instagram. And so what I wanted to do was share that information to simplify things for followers and students in general. But the guides themselves are focused around that idea. So kind of finding information that is most relevant to clinical practice and then finding information that's most relevant for board exams, meaning safety, or, you know, most basic like phases of cardiac rehab, pulmonary rehab and stuff like that. And I, I always felt like I mentioned kind of going through so many chapters, so many pages, so many slides it was getting exhausting, trying to figure out what I needed to know. And so the whole point of the study guides is to just really get to the meat and potatoes of everything. And then if you need to find something to reference later on, that's when we obviously go back to our PowerPoints in our articles. Speaker 1 (04:35): And how are you simplifying or sort of taking out those pieces that you described for the meat and potato pieces. Do you have a system as to how you extract that information from these lectures or is it a group effort? How is that being done? A little, Speaker 2 (04:54): A bit of both. I, like I said, we collaborate a lot as friends and classmates throughout the years. And then I really actually took the advice from Dr. Sarah Haig. So another shout out to her, she mentioned just go back to the objectives, whether it's the lecture that you're sitting in, in PT school or it's the textbook chapter that really lays out a good I don't know, six to 12 main ideas, and then I go back there and try and figure out, okay, what information from this chapter, can I really pull and fit it into these like umbrella topics? So that's kind of where I started at. And then some of the samples that I have up on the website to reflect like, okay, let's just put the fancy details away. And what do I need to know if I'm seeing a patient or if I'm seeing these questions on a board exam Speaker 1 (05:45): And what has the response been from your fellow students? Speaker 2 (05:50): So my class, my classmates are really excited about it. I post a lot of daily questions in, for board exams and they're excited to see it, they've moved their head ideas themselves to start an Instagram just for studying purposes. And then having that collaboration aspect has been really helpful. So I'll even get messages from a few of them saying that, Oh, well, you know, this is something that I haven't gone over yet. So I appreciate you kind of like pushing me to review it and, and stuff like that. But even from complete strangers, like how much support I've, I've gotten has been overwhelming almost, especially with trying to handle studying for boards and preparing for my final clinical rotation overwhelmingly positive. And I kind of attribute that to the field itself. I think going into a profession where we're, we're taught to care for others and put others first and all those ethical principles people are just really grateful to have an opportunity where they can see the information and either like bookmark it and kind of synthesize it right away instead of having to go through all like the dirty work themselves. Speaker 2 (06:58): So it's been overwhelmingly positive and I just want to shout out to everybody who's following along. I appreciate the support, Speaker 1 (07:05): And now you hit upon something that I want to dive a little bit deeper into, and that is time. So where are you finding the time? Because I know that I hear from a lot of students that they feel overwhelmed. There's not enough time in the day to begin with. So do you have any tips or tricks that maybe other students or even practicing clinicians can learn as to how you parcel out your time to be able to do all of this? Speaker 2 (07:33): That is a great point. It has taken me probably the last three to four years, even before PT school to figure out what works best for me. And kind of even coming to the realization of, you know, you, you do need to manage your time before I would be a little bit of a procrastinator. As in like I would, I would start a project and then I wouldn't really finish it. And I was like, okay, well I've already started it. So I'll get to it later. It's almost like more of a, a productive procrastinator, I guess. And so what really has helped me is a change of pace. So I know I don't remember the exact name of the timer, but you either set 45 minutes or 30 minutes where you're just zoned in notifications are off. And you're just focusing on that topic for a little bit. Speaker 2 (08:21): And then also mixing in a variety. So in the beginning of PT school, I would try and get through all of my lectures that we had that day, the same evening. And that was just that wasn't going to happen. I tried my hardest, but it was just wasn't going to happen. So what ended up doing was bouncing between topics, even if it feels a little bit unnatural. What I've noticed with my classmates and with myself is we want to just master a topic first, before we move on. And I think the most helpful tip that I can give is to really just be comfortable with bouncing between things and just mastering the, the main ideas before moving on to another topic, because the more that you get caught up in the details, the more you're going to kind of lag and again, procrastinate going to other topics. So that is first and foremost, give it some variety, mix things up and then really set a timer. And then lastly, like I said, just taking a peek at the objectives of the lecture and the chapter is really going to tie together, you know, what you need to pull away for clinical practice or, or board examinations. Speaker 1 (09:28): Yeah, because I think so often we can sometimes get lost in the weeds and we don't pick our heads up to see those bigger pictures. So I think that's really great great advice for students and for physical therapists alike. So now we know why you started DPT guide and now have a better idea of what it is. So my next question is what, what is the goal for you of the DPT study guide Speaker 2 (09:58): First and foremost, I, I want to make it a community. I think the longterm goal is to be not just to provide products and merchandise, but to really make it a place where students and practitioners alike can come and just review without any, I dunno, egos or preconceived notions or anything like that. Just coming into a place where like, you know, you're, you're stepping into just a, a simplified version of PT school or PT practice. So that's the ultimate goal is just making a community for people to come together and not, not entirely making it about DPT study guide, but making it about the appreciation and respect for physical therapy itself. I do a lot right now on the page about daily, weekly posts covering a variety of topics, as well as sharing a lot of other students, other clinicians work that they are doing to promote the profession, promote their small businesses. And so that's, that's kinda, my, my longterm goal is to just make it this safe space, I guess, for PT students and clinicians alike. Speaker 1 (11:12): And now is this something that is meant to help people pass their board exams? Cause I just want to make sure that we're kind of differentiating so that people, especially students that are listening if they want to get this guide or get these guides from you, is this something that's like, you're gonna pass your boards if you do this. Cause I don't want there to be any information there. Speaker 2 (11:36): Right? Absolutely. My first line of products is geared towards the board exam, especially the MPTE. I think long-term, I would like to branch out and see, especially in Canada, my boyfriend is Canadian. So you kind of giving some respect, a little shout out there too. But first and foremost, yeah, it's going to be focusing on the MPTE and then down the line I would like to extend it into just clinical practice, you know, how things have evolved from our standardized examination to how things are in the clinic or in the hospital. Speaker 1 (12:10): Got it, got it. Okay. So what can people expect? What if I, if I am a student and I want to download this, what can I expect to find, Speaker 2 (12:23): Do a lot of aesthetics? So I try to pull in like I said, the information that is relevant to both clinical practice and board examinations by kind of seeing where the attention is going to be in terms of like the mind's eye. So transitioning from what we made in school during our first year with those 50 to 60 page documents with just white background, black text, it's really hard to find the information that you think is going to be important. And kind of just simplifying it into basic examination procedures, basic interventions phases of rehab medical screening, laboratory values. And like I said, kind of the meat and potatoes of everything that PT is just so that students don't get overwhelmed with the details. It's going to be like bright and bold big ideas and then kind of like, Speaker 1 (13:21): Got it, got it. And, okay, so now we have a better idea of where you would like this to go. So tell me, what else do you have in development? What are you thinking that you can add to this? And it looks like, so what I mean, when you're on the website, it looks like it, the addition to it is, can be infinity. So I think it's important for people to know that it's not like you go onto your website and it's one big gigantic guide. Right, right. So where do you see this going? What do you have coming down the pipeline? Speaker 2 (14:08): So first and foremost is getting out both PDF copies and paper copies of the study guides. And then once I feel like that has a pretty steady response rate, then I want to transition into maybe even tutoring one-on-one video instructions or even student courses where they can go through maybe a differential diagnosis and orthopedics or differential diagnosis medication review in neurology and even down the line. This is like probably five years from now. I have a very invested passion and pain science, and so kind of pulling those things together and offing offering courses for professionals and students alike. So I, I have high hopes. I think it's going to be a little bit of a learning curve and seeing what the demand is for students and professionals when the time comes. But I, I have full intentions to continue to grow with the demands that are out there for students and professionals. Speaker 1 (15:16): Awesome. And now, you know, this is obviously very entrepreneurial and which is very exciting. So where did that spark come from? Because not everyone has that kind of entrepreneurial spirit and nor do you need to have it to be an excellent physical therapist, but where did that come from for you Speaker 2 (15:38): First and foremost? I have to, again, shout out to a dear friend of mine. His name is Travis. Robertson. He is, he was a third year student when I was a first year student. And like I mentioned, during that neuro unit where things kinda got a little hazy with studying, he mentioned to me that like, you know, why don't you just take a chance and see what the market is out there? He was very invested in cash based physical therapy at the time. And so then I started looking into, I mean, all the major ones, Aaron LeBauer was first and foremost, Danny Mada, Jared Carter. I actually even kind of more on like the female entrepreneur side of things is when I found obviously Karen Lyndsey and Dr. Hague more, just more opportunities to see what those people were doing in their own journeys. Speaker 2 (16:28): And so he really inspired me to just take a peek at what's out there. The more that I learned about cash based businesses, owning your own PTP clinic, the more I realized that there's different opportunities with side hustles with other income streams. And that's when I, I kind of took my passion for simplifying PT studies into like the study guide form and realizing it's going to take a little bit of effort upfront. But you know, if you have the passion for it and if you feel it's like, it's something that you believe in and fit that this is truly something that I believe in, then you can make anything happen. Like you said, you hit the nail on the head. You don't have to be an entrepreneur to make these opportunities possible for yourself. Speaker 1 (17:11): Yeah, no, definitely not. Definitely not. As long as you can stay organized and motivated and at some point reach out for help. I know not necessarily in the beginning, but you know, as time goes on reaching out for help when you need it is always a great thing as well. Well, it sounds like you've got, it sounds like you've got everything under control. I think you might be more organized and, and, and you've got your, you know, what together, more than I do. So I may, I'm a little so now what, where can people find you? Where can they find the guide? Yes. Speaker 2 (17:58): So the website is plain and simple DPT study guy at.com. I also run primarily the Instagram account, which is the handle is DPT study guide. And then that same handle you can find on Twitter and Facebook. If you're interested in connecting to me personally I do have a LinkedIn as well, and that would be my first and last name Breeza Barrick. So we can connect there too, but yeah, everything is easily accessible from the website and from Instagram page. Speaker 1 (18:30): Awesome. And, you know, just so you know, it's also very easy to download and it is very pretty and it's very organized and looks very it looks great. So I highly suggest if you're listening to this, especially if you're a student and even if you're not, if you want to brush up on your open and closed pack positions for all your joints, definitely a check out to DPT study guide.com. Now the last question is something I ask everyone it's knowing where you are now in your physical therapy student journey. Normally I say, in your life and career, what advice would you give to yourself right out of PT school, but why don't we say, what advice would you give to yourself maybe before you started physical therapy school to where you from, where you are now? Speaker 2 (19:16): Oh, that's a great one. Looking back, I would make more time for breaks. I feel like students are way too hard on themselves in terms of, I need to be studying 24 seven. If I'm taking a break, it makes me weaker. It makes me less smarter or whatever the case may be. Take more breaks and realize how valuable those can be for just hitting, like reset with your, your mind, your focus. And also just making time to have some fun. I, I really feel that our class emphasize that a lot because we were also motivated to perform as best we could on test exams and really trying not to sweat the small stuff. Obviously, like I said, the whole goal of it was to let's focus on the big picture and maybe try and make it a little bit easier on ourselves throughout the way. Speaker 1 (20:11): Excellent advice. Excellent. Well, Bri, thank you so much. You are absolutely wonderful and makes me very excited for the future of our profession, knowing we have people like you getting ready to graduate and enter the workforce. So thank you so much for coming on the podcast. Speaker 2 (20:29): Yeah. Thank you so much for having me. I really appreciate it. Speaker 1 (20:32): My pleasure, and everyone, thanks so much for listening. Have a great week and stay healthy, wealthy and smart.  

In this episode, Director of Rehabilitation at OL Reign, Dr. Nicole Surdyka, talks about on-field rehab after ACL injury. Nicole is currently the Director of Rehabilitation at OL Reign, one of the founding clubs of the National Women’s Soccer League, NWSL, which is one of the best professional women’s soccer leagues in the world. Today, Nicole shares her 5-phase on-field rehab strategy, and the decision-making process in return-to-play and return-to-performance. What are the criteria that Nicole looks at to determine progress to the next phase of rehab? She tells us about delaying return to sport to reduce second-injury risk, the return to sport continuum and how to define it, and the use of the StARRT framework for the return-to-sport decision-making. Nicole gives some valuable advice to her younger self, she tells us about integrating rehab with team activities, and communicating with athletes and coaches, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways Nicole implements on-field rehab in 5 phases. Phase 1: Simple, pre-planned, linear movements. The focus is on quality of movement and cleaning up movement technique before moving on. Typically includes walking marches, walking lunges, side shuffles, and jogging. Nicole starts this at 70-75 quad strength limb symmetry index. Phase 2: Pre-planned direction-changing movements. Typically includes accelerations, decelerations, sprinting, and change direction. Phase 3: Adding reactive tasks without a soccer ball. Direction-changing with an element of reacting to an external event. Nicole starts this with at least 80% quad strength limb symmetry index. Phase 4: Soccer-specific movements. The reactions are done in context – with a soccer ball. Phase 5: This phase should look like a modified training session. Delaying return to sport: each month that you delay that, there’s a 51% reduction in second-injury risk, up until the 9-month mark. Return-to-participation: When athletes are participating in their sport in a modified way – participation with certain limitations on activities. Return-to-sport: When there is no longer any medical reason to limit an athlete’s participation – “cleared to play”. Return-to-performance: There are no restrictions and athletes are training to become better at their sport. “Be patient. Every experience is valuable, and you can relate any experience to what you eventually end up doing.”   Suggested Keywords On-field Rehabilitation, StARRT, Injuries, ACL, Sport, Performance, Physiotherapy, PT, Therapy, Wellness, Health, Injury-Prevention, Recovery,   Recommended reading: Consensus statement on return to sport: https://pubmed.ncbi.nlm.nih.gov/27226389/ On-field rehabilitation Part 1: https://pubmed.ncbi.nlm.nih.gov/31291553/ On-field rehabilitation Part 2: https://pubmed.ncbi.nlm.nih.gov/31291556/   More about Dr. Surdyka:  Nicole is currently the Director of Rehabilitation at OL Reign, one of the founding clubs of the National Women’s Soccer League, NWSL, which is one of the best professional women’s soccer leagues in the world. Nicole is a physical therapist and strength and conditioning coach. She played Division 1 college soccer at St. John’s University and then went to Emory University where she got her Doctor of Physical Therapy Degree. Throughout college and PT school, Nicole coached youth soccer and worked as a personal trainer. After PT, school Nicole worked in various outpatient orthopaedic and sports medicine clinics before starting her own practice in 2018 where she worked with youth to professional athletes. Nicole specializes in on-field rehab for soccer players to help bridge the gap between rehab and sport performance. She is passionate about the return to sport process and how we can make better decisions for athletes returning to sport after an injury. Nicole has a website where she writes blog posts on rehab for soccer players, has eBooks available on specific injuries, teaches continuing education courses, and has presented at CSM and other national and international sports medicine conferences. To learn more, follow Nicole at: Website:          Nicole Surdyka Physio Facebook:       Nicole Surdyka Physio Instagram:       @dr.nicolept LinkedIn:         Nicole Surdyka PT Twitter:            @NSurdykaPhysio YouTube:        Nicole Surdyka   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the transcript here:  Speaker 1 (00:00): Hey, Nicole, welcome to the podcast. I am so excited to have you on. Speaker 2 (00:05): Thanks. I'm excited to be on. Speaker 1 (00:07): So this whole month we're talking about ACL injury and ACL rehab, and you are an expert in both. So I'm really excited to have you as one of the guests this month. And today we're going to be talking about something that is really your zone of genius, and that is the on-field rehab, a rehab techniques, I guess, that helped to bring that player back to performance. So can you talk about what is the on field rehab like? Speaker 2 (00:45): Yeah. So I guess it's a concept that I, you know, I was a soccer player. I was a youth soccer coach, and so I always kind of felt in the back of my mind when I was going through PT school, like, Oh, wow, I could blend. Like, if, if we're trying to get this adaptation or build up this physical attribute, we could do that through soccer. And so it just made, it was something that made sense to me trying to incorporate the sport as much as possible, but where it really all clicked and came together. For me, it was actually at the isokinetic conference that I went to a few years ago in Barcelona. And actually your previous guest on this in Arundale was the one who talked me into going. So that was great. And I saw a presentation by Matt Thorpe about on-field rehab. And of course he and Francesco via have published two different articles in WSPT on this, but kind of seeing that presentation really yeah, tied it all Speaker 1 (01:42): Together and made me have that aha moment Speaker 2 (01:44): Like, Oh, this is a thing I can make this happen. And so really what it is is it helps to bridge that gap between the gym-based rehab and then sending the athlete back for their sport. Because if you think about it, there's so much of a difference between doing a drop vertical jump in the gym and then landing from a head ball on the field. Like not even just physically that's different because the surface is different. Your shoe wear is different. The weather obviously is different, but there's also different things in your environment to make decisions based off of, and react to and respond to. So where are my teammates in space? Where is my opponent? Am I going to have a contact or an indirect contact, a perturbation while I'm in the air that I have to land on? Funny, where do I have to redirect my Ron to afterwards? Speaker 2 (02:34): And you can only prep for that so much in the gym. And at some point you really need to get them on the field and do in a controlled way, what they're going to have to do when they're playing with their team again. So on-field rehab. The way that I implement it is really based off of Matt, Matt backdoor, Ben for Jessica, Davey is research and there are papers on it, which is phase one, really simple pre-planned linear movements. And so that can start fairly early. They say in their paper that they want to start. When the athlete has 80% quad strength, limb symmetry index, I tend to start a little bit earlier than that. Typically, when I'm having athletes jog, then they can be doing phase one. So things like walking marches, walking lunges side shuffling is okay in this phase, jogging anything that the athlete is has pre-planned, it's a pre-planned movement and it's just linear. Speaker 2 (03:34): So no changes of direction yet. And in this phase, we really focus on quality of movement. And we start to address here before they move on to more complex tasks we address are they moving efficiently? And are there things we need to clean up with the technique of their movement? So something like a high skip or a walking March, are they getting a lot of trunk lean? Are they yeah. Are they kind of like looking like Gumby out there? And so we need to clean that up a little bit, and this is the phase that we can really take the time to do that. So again, I like to start this pretty early. Typically I want them to be at least 70 to 75% quad strength, limb symmetry index. But the, just as a caveat to that, the paper by Francesco and met, like they're up says 80%. Speaker 2 (04:27): So just be aware of that phase two, they then move on to being able to change direction. Everything is still pre-planned. So we can take those linear movements from phase one and make them a little bit more intense. So we can start working on reaching towards accelerations decelerations, maximum speed. So we start to work on sprinting here and exposing them to high-speed running on the multi-directional staff. We can have them do anything pre-planned so no reactive tasks yet, but they can start to cut decelerate, changed direction, all controlled everything throughout the unfilled rehab program is control first. Then we build volume and intensity. So after phase two, we can progress them to phase three. Now for this, I definitely want them to be at least 80% quad strength, limb symmetry index. And I would love for them even to be closer to 85% and depending on how they look functionally. Speaker 2 (05:29): And so this is when we start to add reactive tasks. So now change of direction tasks, but with a reactive component. So they're reacting to something external to them. So I like to mix up and I know Amy talks about internal versus external cues a little bit. And it's something that definitely is coming up a lot in ACL research with motor learning is that we want some external cues. And so that can be auditory. That can be visual. So I like to do kind of a combination of both. I'll use words that they're going to hear while they're on the field. So turn man on ball, you know, I'll use kind of those that verbiage. And then the visual is you can make it just simple. You pointing to where they have to cut to or change direction to. You can make it be, they have to follow the ball, they have to follow a runner. Speaker 2 (06:25): So they have to follow where the space is that you've set up with, however, you've set up the environment. So that's where we add the reactive components and they anything pre-planned they can now be doing at speed. Next, we're going to go into phase four, which is really going to be more soccer, specific movements. So now they can react with a soccer ball. So everything we didn't base three with the reactive movements is them without a ball at their feet. Now in phase four, we can add a soccer ball. So you have to turn and either dribble, dribble, or pass, or you know, you have to collect the ball and then make a decision based on what's going on around you or what the coach or the physio calls out. And then phase five really should just look like a training session, a modified training session. So I try to replicate what the team has done in their training session or what a typical team training session would look like as much as I possibly can within a more controlled environment. So that's kind of the five phases and then, yeah, and then I started to incorporate them into the team. Okay. Speaker 1 (07:32): So let's, I have a couple of questions. So we're just going to back up a little bit. So for most of these phases, certainly phase one phase two phase three is the player is the player alone on the field? Do they, are they working in tandem with another player on their team? Speaker 2 (07:50): So typically when I was, before I had my current role, I had my own practice and I would work with the athletes. So it would be me and the athlete. If they had a friend or a teammate who was available, it's always nice to add other players. Now here at LL rain. I have two athletes right now who are going through ACL rehab together, kind of they're at a little bit different spots, but I can still work together with them, which is really nice. And then I can always pull some of the other players. So, Hey, do you want to work on crossing and finishing today? Great, like come in for this session this time and I can pull other players and you can do it alone. Eventually you need to start adding other players because there's 22 people on a soccer field. And so they need to start being able to move and react to all of those different people on the field, around them. And you can still do that in a controlled fashion. Absolutely. Speaker 1 (08:51): I will say to, to play or one, I want you to run down to line and cut to the right as your athlete is within the midst of whatever you're asking them to do from a rehab standpoint. Correct. Speaker 2 (09:03): Exactly. You can say, okay, you're going to run up and defend them. I want you to force them to their right. You know, so that way I have that person has to go to their right, so you can control for it. Whereas in a game you can't tell them, or an even in a practice session with their team, you can't say to all the other players on the field, Hey, when you go and defend, so-and-so only for, for her to her right foot, okay. That's never going to happen, but in that nice in on-field rehab, you can control for those things. And Speaker 1 (09:31): The other question I have was what is the criteria for entering phase two? Speaker 2 (09:35): Good. So, and answering into any onto three high program. I mentioned the quad strength, limb symmetry index, but also there should be no joint pain or a fusion. They can have some muscle soreness at times if they had a patella tendon graft they can have some patella tendon pain. I'm okay with that. Hamstring graft, if they have hamstring pain, I'm okay with that. But, and then also no joint laxity. So I'll typically just do a Lockman's anterior drawer test, as long as those are negative and there's no joint fusion, then we're good to go. Now it's progressed through each stage, subsequent to that, as long as they're able to do those movements with control, and there's no increase in joint pain or a fusion during any of those stages, then I can progress them. Although I still want to bear in mind, like we're not just going to do walk like phase one stuff. Speaker 2 (10:27): And then it's like, Oh, they felt good. Okay. Now we can do phase two. Like I still want to make sure that we get a couple sessions in and it's always going to play back into the overall big picture of where they're at in their rehab. You know, we're still doing a gym-based strength program at the same time that we're complementing with on-field rehab. So it that's where it kind of the the art of coaching takes in a little bit. And you just need to understand where your athlete is and if they still need more time in that area before moving on. Got it. And Speaker 1 (10:59): I know this is a question that a lot of people constantly ask when it comes to ACL, what is the timeline? Right. You know, cause you're always here. You don't want to return to play for a year for 10 months, nine months, a year, two years. So as you are going through these phases, are you also taking into account where they are in that rehab continuum or in, you know, post-surgical so how do you question Speaker 2 (11:26): W so it's kind of the, the short answer to that question is we can go back to some of the research that's been done by the Delaware Oslo cohort, so that, Hey, grandam over at Oslo and Lynn center Mackler at Delaware, and they've shown that delaying return to sport each month that you delay that there's a 51% reduction in second injury risk. And really the whole thing of this is when we're sending out fleets back to sport after an ACL reconstruction, our goal is to not allow that to happen again, right? The rate of a secondary injury is so high that there's obviously a flaw in how we're sending athletes back. So I think that most athletes go back too soon. And so each month that we delay up until the nine month Mark and at nine months, we, after that, we don't really see that level of reduction in, in, in second injury risk. Speaker 2 (12:22): Now for a youth player, who's not really in a rush to get back. I will probably never let them go back before a year. I just, there was no reason it's not worth the risk. They're agreed so much more likely to have another injury. And like, why have two ACL injuries in high school before you even get to college? Right. If the goal is to, is to play in college, you're better off missing your entire junior year of high school to just rehab and then be really strong for your senior year. As opposed to feeling like, Oh, I have to show college coaches. I have to go to all these college showcase tournaments, which I know is, is pressure on the athletes, but what does it, do you any good if you go back and now you do it again and you miss all of senior year as well, right then by college, like that's not going to happen for you. Right. So more of the professional athletes, there's a little bit more pressure, it's their livelihood. Right. So I'm okay with moving or even college athletes. I'm okay with moving closer to nine months, but I will never go before that, unless I have somebody like an Adrian Peterson who is just one of those outliers, then they have to give me a really good reasons to let them go back. Speaker 1 (13:33): Okay. And this actually flows perfectly into the next topic I wanted to talk about. And that is that decision-making for return to performance, right? So we've got the return to play. And even if you want to talk a little bit about that distinction between return to play and return to performance and talk a little bit about what your your decision-making Speaker 2 (13:57): Is like. Yeah. So to talk about that continuum a little bit, and actually I just had a meeting with our coaching staff here about that to make sure you're on the same page about these definitions. And so how I define them is based off of the return to sport a consensus statement for that Claire and was lead author on where the return to participation phase is when, or end of the continuum is when athletes are participating in their sport, but in a modified way. So I have a couple athletes now who I say, I look at what the daily session plan is for, for the training session. And I'll say, okay, this athlete can do the technical warmup and they can do the [inaudible], but I don't want them doing the two V twos because it's too much deceleration cutting, et cetera. So they, that counts as returned to participation because they're participating, but I'm still putting restrictions or limitations on them. Speaker 2 (14:53): So anytime there's any kind of modification or restriction or limitation there in returned to participation, when the medical, when there are no longer any medical reasons to hold an athlete back, that's when they're in return to sport. So that's what I would define as saying like you're quote, unquote, clear to play, right? Is that I'm not putting any restriction on you, if you are not being selected for playing time or for your starting position. That's because the coach isn't selecting you, not because I'm holding you back, but then beyond that, because sometimes an athlete's not going to really be satisfied with that outcome, right? If you're used to being the starting center forward and scoring a goal, a game, and now you're cleared, but you're not being selected into the starting lineup, or you're not being selected to the game day roster, or you are, but you haven't scored a goal in five games. Speaker 2 (15:44): Now you're not performing at where you were prior to your injury. So there's no medical reason to hold you back, but maybe you're not playing as much or playing as well as you would like to be. And that's where we transition into return to performance. So return to performance is there's no restrictions on you, no medical limitations or anything holding, holding you back from a rehab perspective. And now we're training to get you to being better at your sport. And I think those are really important distinctions to make, because a lot of times athletes or coaches, and actually it will be back and cleared to play, but coaches like, well, why isn't she as fast as she used to be? Why isn't she scoring goals? Like she used to be? Is she still hurt? It's like, no, it medically fine, but we're just not at return to performance yet. Speaker 2 (16:33): So then to to kind of decide when to send an athlete back for each of those things, I tend to look back to the on-field rehab program and how that is structured. So I'm a big fan of integrating the team, the athlete into team activities as often, and as much as you possibly can. So if they're able to do the technical warmup with the team, I'm putting them in there because, and that would technique that would typically be if they're in stage two, right. Cause it's going to be mostly pre-planned change of direction tasks, maybe some accelerations D cells, depending on, on what the warmup looks like. Sometimes there's reactive components. And so that sometimes takes just a conversation with the performance director or the SNC coach or the sport coaches, just to say, what is involved in this? And then, you know, but if you, if that athlete is able to do those things and they've done them with you and an on-field rehab program, send them back into the team. Speaker 2 (17:33): Cause that is just to me is another level of like the cognitive awareness and their ability to see what's going on on the field, around them and adding more athletes into the mix that they have to interact with. So I'm a big fan of that. So I'll typically have them in that return to participation phase for a fairly long time, like a few months before I say, okay, you're good. So, and the example right now, I have an athlete, who's doing portions of training sessions, but I probably won't like clear her quote unquote, clear her to play in a game until somewhere in the middle of April. Right. So she'll be, Speaker 1 (18:16): Is she about like six months then? Post ACL? Yeah. Yeah. Yeah. Okay. Yeah. And I think it's important to mention all of this because oftentimes a lot of physical therapists and I, this is not to throw our profession under the bus or anything, but a lot of physical therapists tend to be a little bit more restrained. They won't want them to go onto field. They won't want them to do this on-field rehab until they're at 90%. Right. And or until the doctor clears them to return to play well, you can't just be cleared to return to play. And you've only done a weight training program, proprioception, maybe some motor control stuff and then throw somebody on a field. Speaker 2 (18:56): Yeah. And I've seen that way too often. Speaker 1 (18:59): Yeah. Yeah. And so it's, I think that I'm really happy that you're saying like, Hey, you know, at six months they can be with the team, they can do some things. It just, it sounds to me like it's a lot of communication and collaboration from the, all of the stakeholders, right? Speaker 2 (19:14): It is, it does take a lot of communication. And we have twice a day meetings, constant emails, constant communication about where each athlete is. And then, you know, there is things that come up that we have to adapt to, like this was the training session plan. And this athlete was going to be able to do this amount of load that day. And then based on what was happening in the session, the plan changed. And so we have to adapt to that. And then we just supplement that with it with more on field work, you know, if they weren't able to do as much in the session with the team, then I just will take them to the side and do more work with them on the field. Now I will say that this is a lot easier to do in a team setting. And now I didn't work in a team setting for most, all of my career up until very recently. Speaker 2 (20:01): And so what I did in that situation, working in an outpatient clinic, that doesn't mean that this doesn't apply to you because you can still use this. And so what I used to do is whatever I would see my athlete do in the clinic with me or on the field with me, I would say, okay, I want you to go do this in practice with your team. So I want you to do the dynamic warmup with your team and then that's it. And then report back to me if that felt okay for them, then I'll say, okay, you can do any technical drill. You can do rondos, you can do, you know, possession style games but no contact. You can be neutral player. And I'll tell the athlete that depending on their age, I'll also tell their parents I do or did before I was in my current, always try to reach out to their club coach or their high school or college coach and let them know what the restrictions were. I understand sometimes we don't get responses when we reach out. I didn't always get responses when I reached out. But as long as you talk to the athlete and or their parent about that, and just make it very clear to them, like you can do this, you can not do that and then have them report back. But I, my rule of thumb was I wanted to see them do that type of activity with me before I had them do it with their team. Speaker 1 (21:18): Makes sense. And, and I think it's also important to note that just because you work in an outpatient clinic, doesn't mean you can't take these athletes onto a field. I live in New York city. I see patients in their home. I have a 14 year old who had a ACL rupture and subsequent surgery. And when she was 12 she's 14 now. Wow. Yeah. And we still got her out onto a field, got her. We went to the park, we did as much as we could on field. And sometimes that was just me having to be the defender or setting up cones and having her do stuff. But I think it's really important that if you work in an outpatient clinic, don't kind of wall yourself in with the walls literally. Yeah, exactly. You can take them out onto a field somewhere. I mean, if I feel like if I can do it in the middle of Manhattan, then people could probably have a much easier time doing it in places with more space. Speaker 2 (22:15): Yeah. And I would even get like, I've worked in clinics where the only space we had was the parking lot. And maybe that's where we did that. Or again, you can always say like, okay, I've, we've done the 11 plus warmup in our, in our gym based sessions. So you can go do that with your team now. Or we've done some volleying and passing and moving, you just need 10 yards of space. Right. We've done that in the clinic. So now I want you to try that with your team, or can you go in the backyard with your mom, dad, sister, brother, whomever, teammate, friend. And I want you to do these types of exercises in your backyard, you know, like have that be their AGP instead of having them do straight leg raises for six months. I mean, I have that either ETP. Speaker 1 (23:06): Yeah. I had my patient probably much, much to her. Neighbors' dismay, but we would be in the hallway of the building. Yeah. Or go into the basement of a building. I see a girl now for she's a softball pitcher. We go into an empty storefront. That's kind of attached to the building. I mean, you make it work, you know, you just have to Speaker 2 (23:29): Exactly. And like, if you can't find a way to make it work, you have to ask yourself, should I really be working with this type of athlete? Right. If you can't find a way to give the athlete what they need to get back safely and appropriately, then maybe that's not the setting, the athlete to be seeing you. Speaker 1 (23:47): Right. So it's you do the, I call it the blessing release. Oh yes. More, you need more space, you need XYZ. So I'm going to release you to someone that can, can finish the job if you will. Speaker 2 (24:01): Exactly. And that takes, like, I feel like in all walks of life, like just not having an ego is such an important skill set to have. And just saying, I know that there's so much more that can be done for you. And I know that there are too many limitations on me to be able to do this. So here's someone who can help you and you should move on to this person. Speaker 1 (24:22): Yeah. Yeah. And I think that's fair. And again, patient centered. And when you think about that return to sport, decision-making a lot of Claire, our Dern's work is that patient centered decision returned to sport decision-making. And so what you just said is exactly that. And so I think it's important for people listening that it may not always be you. Yes. That is such an important point. Yeah. Now, is there anything that we missed or that I glossed over that you're like, Oh man, I really wanted to make this point. Did we hit everything? Yeah. We hit everything. Speaker 2 (24:57): The only thing I would add is just as something for people to maybe go look up and learn more about is in that consensus statement, they talk about the start framework and that's what I use to guide my return to sport. Decision-Making right. So it's really just a simple needs analysis. What are the demands that this athlete is going to have to face and are they prepared for those? And yeah. So the start framework is a really great method. It's what it's literally what I use to help guide decision-making because it doesn't just look at, like, it looks at the tissue health, it looks at the demands. It also looks at what are some modifiers of those. So is it preseason? And so we can err on the side of being a little conservative or are we in the playoffs and this is one of our star athletes and we need them on the field. And so we're willing to take a little bit more risk. So yeah, I think that that's a really important framework to utilize because it provides you with that context that surrounds the kind of the risk reward ratio. Speaker 1 (25:59): Exactly. Yeah. And that's what I said to my, this 12 year old, who's now 14, but you know, she, we waited a year, at least a year for return to sport and then COVID hit and that night Oh yeah. Which I have to say, I wasn't mad about two years, you know, that's awesome. But you know, like what I told her was exactly what you she's like, Oh, do you think I can like play in this, you know, showcase she's an eighth grade. Yeah. No Roland showcase. And I was like, listen, here's the deal. Can you do this? Yes. Will you be at your best? No. Are you going to college? Is if this, what? And I said, it was like, if this was your senior year and it was the last game Speaker 2 (26:45): Sure. Have at it, you know, Speaker 1 (26:47): But it's not, so you're not going to do it. Are we in agreement there? And, and that's the hard part, right. Is trying to say to like a 12 or 13 was 13 or 14, 13 maybe was, do you want to play in high school? Yes. Would you like to play in college? Yes. Well then you don't need to do this exam because we're not taking any unnecessary risks and that's kind of, how did that start framework is looking at that context and I'm sure you have those difficult conversations all the time. Speaker 2 (27:15): All the time. Yeah. It, and especially after something like Nazi has already been cleared by a physician or previous physical therapist or athletic trainer or whomever, and then it's like, Oh no, I know that you were cleared, but we'll, you are certainly not ready. And just having that conversation can be difficult, but as super important, because all they're going to do is go right back. And the likelihood of them getting another ACL injury within the first year or two is pretty substantial. So sometimes scare tactics, work a little in that regard. Speaker 1 (27:46): And it's not, it's just, you're just being honest. Yeah. Like you can't like, you're the professional, you're the expert. They're the patient they're going to you because you're the expert. Yeah. Right. And so you have to be honest and you have to be upfront and you have to give them all of the options that they have and looking at things realistically, because just, you know, people say, Oh, runners, they just want to run. Well, it's the same with any sport soccer players. They just want to play soccer, football, I just want to play. And so there there's a lot of mental gymnastics that can happen in one's brains in order to justify doing that. Speaker 2 (28:21): Definitely. I think athletes actually appreciate that when you say like, like maybe in the moment they're frustrated, but it's not with you. It's just with the situation. And I think that makes it easier to swallow is that like, Hey, like they appreciate knowing that you're taking that context into consideration. Like, say like, Hey, if you're going to get re-injured, it's going to be in the championship game, not in a preseason friendly, like what sense does that make? And I think they do for the most part, appreciate that and understand it. Even if, again, in the moment it frustrates them a little bit. Yeah. Speaker 1 (28:51): I mean, there's a little bit of disappointment, but you know, something it's upsetting Speaker 2 (28:56): Templating moment. Get over it. You'll be fine. I feel the same. Exactly. I've never said that, but in my head I'm like, you'll be fine. You'll be to sign. Yeah. Like 10 years. That's fine. If you do it again and have to go through another year of this Speaker 1 (29:09): Exactly. Like 10 years from now, you're not going to be like, man, I didn't get to play in this showcase when I was in eighth grade. Speaker 2 (29:17): Yeah. Definitely not. It doesn't make sense. Speaker 1 (29:20): So I think thank you for bringing up that start framework and we'll try and get links to all of this and put them into the show notes so that everyone if you're looking for those papers on on-field rehab, the start framework and the consensus, we'll get all those and put them into the show notes. So you one click and everybody can read all of them. So Nicole, before we end our talk is the question I ask everyone. And that's knowing where you are now in life and career. What advice would you give to your younger self? Speaker 2 (29:51): I would definitely tell myself to be patient. I came out of school thinking like, okay, I just want to work with athletes. You know, I have to find a place where I can just do that. And anything else I do is a waste of time. And what I will say, what I would tell myself is that every experience is valuable and you can relate any experience to what you eventually ended up doing. Even working with a, you know, if it working with the elderly population that has nothing to do with working with athletes, but teaching them a new skill. If you can teach it an older person, who's never worked out a new skill, you can teach an athlete, a new skill, right. It's somebody who's like coordinated and strong and athletic as opposed to an older individual who's never worked out before. So I think that I would tell myself again, just be patient there's value in every experience and yeah, you'll, you'll eventually get to what you're looking for. Just take it, take things in stride and learn from each experience. Speaker 1 (30:56): Excellent advice. Now, where can people find you on social media? I think you've also got an ebook available. So give us all the goods. Speaker 2 (31:03): Yes. So you could to reach out to me. I'm I'm on social media. Instagram is at Dr. Nicole PT. My Twitter is at Encirca physio and my website is Nicole Serta, physio.com. I have a blog there that I grew up on this. I'm going to try to write more. I took a little hiatus. You had, Speaker 1 (31:28): I had a major change of life yourself from California to Portland and a new job. And so I think we, we understand we'll give you Speaker 2 (31:40): We're in the middle of a pandemic. So yeah, I think somewhere in the middle of the Vietnam, I just kind of lost a little motivation there Speaker 1 (31:48): With you all. Speaker 2 (31:51): Okay. It's okay. There's no need to like, feel guilty if you're in the same boat, cause I'm right there with you. But yeah, I will be writing more on that blog. I have actually a couple of different topics on the blog. One is just kind of rehab of soccer related injuries. And then I talk about some of the social issues related to soccer, things like racism and soccer and inclusion and diversity and things like that. And then also I have this little fun part. That's kind of just for me as a little self-indulgent, but life lessons that I've learned through soccer. And so that's on there as well. I also have some eBooks on my website. You can get to just by going and Nicole Serta, physio.com and it's under the eBooks tab. So on an ACL injuries, ankle injuries maybe hamstring injuries too. There's a couple on there now. Awesome. yeah, that's it. Excellent. Well, Nicole, Speaker 1 (32:42): Thank you so much. This was great. I great addition to our month on ACL injury and rehab. So I thank you very, very much. Thank you Speaker 2 (32:52): For having me on carrying this. When I graduated PT school, this is the first PT podcast I started listening to. So it's awesome to be on it. It's come full circle. It truly has. Yes. Speaker 1 (33:04): Well thank you and everyone. Thank you so much for listening. Have a great week and stay healthy, wealthy and smart.

In this episode, Owner of Sisu Performance and Physical Therapy, Dr. Ellie Somers, talks about bone stress injuries, specifically in female runners. Today, Ellie tells us about differentiating between the male and female runner, and she elaborates on a subjective and objective exam of a bone stress injury. We learn about the most vulnerable sites for a bone stress injury, the misconception about the severity of the diagnosis, and the strategies Ellie uses to get women on to strength and flexibility training programs. Ellie talks about the concerns that many people have after a BSI, and she gives her younger self some valuable advice, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “Female runners have a lot of particular and special needs and considerations when talking about evaluation from a physical therapist perspective, as well as from a communication standpoint, that need to be considered.” “When you’re getting someone into your clinic, you don’t want to make assumptions about their circumstance.” Things to consider in a subjective exam for a bone stress injury: Is the patient grasping why they got into this situation? A bone stress injury isn’t necessary about the shape of their body or foot, it’s a result of limitations of their dietary intake. Their menstrual cycle. This can be an uncomfortable conversation for many clinicians, but it is a required question for a subjective exam. “If a runner is coming to you explaining that they think they sustained a BSI because of their pronated foot or because they were wearing the wrong shoes, we’ve missed a huge piece of why bone stress injuries actually happen.” The most vulnerable sites for a BSI: The femoral neck, the first and second metatarsal, and the anterior tibia, among others. The objective exam: Palpation, single-leg balance, and walking. More explosive movements. These include the single-leg hops and taking steps up or down. “You can still be stressing bone and it’s going to heal. When we don’t stress bone enough, it could theoretically take longer and put that bone in a more vulnerable position.” “Women athletes are more prone to lower bone density than male athletes are.” “Runners kind of have this misconception that running itself actually strengthens bone. In reality, it doesn’t really strengthen bone as much as we’d like to think.” “History of bone stress injury is the number one risk factor for new bone stress injury.” “There’s no rush. You have your entire life ahead of you to work and refine. As long as you’re working on something, you’re working towards it.”   Suggested Keywords Running Injuries, Rehabilitation, Therapy, Physiotherapy, PT, Training, Injuries, Sport, Wellness, Health, Recovery, Female Runners, BSI, Bone Stress Injury, RTS   More about Dr. Ellie Somers Dr. Ellie Somers is a physical therapist, run coach, weightlifting coach and the owner of Sisu (pronounced see-su) Performance and Physical Therapy in Seattle, WA. She also serves as the team physical therapist for the women’s United States Australian Rules Football Team. As a private practice owner and coach, Ellie specializes in work with women athletes, specifically runners and field athletes.     To learn more, follow Ellie at: Email:              ellie@sisuwolf.com Facebook:       Sisu Performance PT Instagram:       @thesisuwolf Twitter:            @drelliesomers YouTube:        Sisu Sports Performance and Physical Therapy Website:          https://sisuwolf.com/resources/e-books/return-to-run (FREE gift!)   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:  Speaker 1 (00:01): Hey, Ellie, welcome to the podcast. I'm happy to have you on. Thanks for having me, Karen. So this month we're talking all about running injuries. Just so people coming onto the podcast is the first time you're listening this year, sort of changing up the format each month is a different we're focusing on a different topic. So last month was all about ACL injuries. This month, we're going to concentrate on running injuries, which is why Dr. Lee summers is here. And today we're going to be talking about the female runner. So Ellie, my first question is, are female runners, just little petite male runners, and it should be treated as such. Speaker 2 (00:38): Well, obviously the answer to that question is drum roll, please. No, yeah, yeah. I think female runners have a lot of particular and special needs and considerations when talking about evaluation from a physical therapist perspective, as well as from a communication standpoint that need to be considered. Speaker 1 (01:02): And what kind of, can you kind of differentiate that male runner from the female runner? What are kind of some of the big differences that if you are a physical therapist, a run coach, even a personal trainer, a strength and conditioning coach, what are some things that we need to be aware of in the female runner? Speaker 2 (01:20): You know, the way that I think about this, I actually think about it from a bio-psycho-social perspective. So what women are exposed to in our environments, in our engagement with other human beings, with social dynamics and things of that nature is very different than what men are typically exposed to. I also think of it as you know, generally speaking in terms of adaptability, women and men have the same traits and characteristics, but certainly things that need to be taken into consideration for women include our biology and physiology more specifically our menstrual cycle and hormone cycle. So I tend to think of it as a very holistic thing. And what are the things that female runners might be exposed to that set the stage for certain types of injuries or pain experiences that maybe male athletes aren't or are less likely to be Speaker 1 (02:22): Right. Got it. And so now let's take a common injury that you may see in a female runner, and let's talk about what you would how you would go about your subjective exam, and then we'll get into objective exam and some possible treatment options, but let's take a bone stress injury, pretty common in female runners. So first talk about, well, actually, let's talk about why is that common in female runners? Speaker 2 (02:54): That is a great question. Lots of there's probably a lot of nuance to answering that question. I think theories abound and I'm thinking of those series. I think that the primary thing that we get exposed to as female athletes is how do I want to phrase this considerations about our body and in the run community? I think it's a lot more pervasive for women athletes. So not only are women on the whole exposed to messages about their body, that they need to be smaller, that they need to be thinner in the run community itself. Women are then also exposed to this concept that you'd need to be in order to get faster. You need to be thinner. And that sets the stage for eating disorders and diet restriction and limitation that can lead to bone stress injury. Speaker 1 (03:55): Got it. Okay. So obviously very sensitive subjects. So the subjective exam becomes all the more important. So walk us through maybe how some questions that you would ask and kind of how you would asking keeping that sensitivity of this may be a person that's experiencing maybe some eating disorders or experiencing some body image body image issues. So walk us through your subjective exam. Speaker 2 (04:27): Yeah. So I think it depends on what they're coming to you for and what you know already. So depending on your clinical setting, you might already know they're coming to see me for a bone stress injury. And this person may have already seen a physician and had the imaging done at which point you may not need to dive into a lot of detail there, but I think what you want to try and capture is is this person grasping why they got into this situation. And I think as a clinical provider, that's working to reduce risk, prevent air quotes around prevent these types of injuries. You need to understand that this person knows that bone stress injury isn't necessarily a result of the shape of their body or the shape of their foot. It's the result of really limitations on their dietary intake. So when you're getting somebody into your clinic, you don't want to make assumptions about their circumstance, but I think it, it behooves you to start to ask questions around, you know, do they understand why they got this injury? Speaker 2 (05:40): And if their answer to you is while I was over-training, you might want to start to dig deeper and figure out if you can fill any gaps and holes there to help them understand that fueling strategies are a big contributor to these injuries. So subjectively there's that piece to cover. Then I think you also have to think about how do I want to say this their menstrual cycle basically. And I think for a lot of clinicians, these topics can be very uncomfortable, hard to, to talk about, hard to ask questions of, but when you're doing a subjective exam, this is a required question to be asking, what is your menstrual cycle? Like, are you having regular and normal periods? When did you start your period? At what age, if you're not comfortable asking these questions in a face-to-face manner, or you don't think it's appropriate for you, then they definitely need to be included on your intake forms. And you need to be reviewing your intake forms before you see that person in your clinic. So those would be, I think the two primary things that you need to sort of start to get a picture of, because if a runner is coming to you, explaining that they think they sustained a BSI bone stress injury because of their pronated foot or because they were wearing the wrong shoes, we've missed a huge piece of why bone stress injuries actually happen. Speaker 1 (07:17): And I really do like including that on your intake paperwork, because then even if, whether you're uncomfortable asking that question or not, or you are comfortable either way, I mean, either way, quite frankly, you should be comfortable asking that question. I don't care who you are. You're a physical therapist, you're a healthcare provider. That's a question you should be very comfortable asking because it is part of their medical record. And part of, of like can be part of the reasoning behind these bone stress injuries. But it also gives you if it's on your intake form, it also gives you more information so that when you are in your subjective exam, you can perhaps hone into that and you can even say, Hey, listen, on my on the intake form, I noticed that you're not having like regular periods. Can you tell me a little bit more about that and that's it. Speaker 2 (08:16): Yeah, exactly. Yeah. And I think all it will show you is, is this person having energy demand issues? You know, we know that if you've lost your period or you're having irregular periods, it can be a very clear objective indication that your energy in is not matching your energy out. And it's what we would call somebody suffering from low energy availability or in the, the more maybe more like broad terminology would be relative energy deficiency in sport. And this can cause a host of different and problems. And the last thing you want to do as a clinician or provider is I think miss that, especially in a female runner, because it just sets them up for recurring bone stress injuries, or recurring injuries. And that cycle will just repeat itself. Speaker 1 (09:11): Yeah. Now, okay. So you've asked those questions. Are you asking questions on how much are you running? How often are you running? Have you picked up your mileage and things like that? Is that something that you're asking as well? Speaker 2 (09:25): 100%, because a lot of the times people who are training for a new distance of an event, right? So if I have a person who's like I was training for my first marathon, they might have sustained a bone stress injury as a result of some of that increase in strength in training while also maybe not matching that with their fueling. So it helps you get a picture of what this person is training for and why they're training for it and how much training they have. And then you can move forward from there with a more practical plan as a physical therapist on how we're going to strategize a graded return to activity. Speaker 1 (10:07): Got it. Okay. Any, what else are you asking? What else do you need to know from this patient, Speaker 2 (10:19): Everything else that you would need to know in a physical therapy exam? I think you know, I think for a lot of folks, these injuries are scary and they've disrupted their lives to a great degree. A lot of these runners will have to stop running for months of time. So all of the same questions you would ask, but then I would also add onto that. You want to know, sometimes you want to know, does this person have a registered dietician as part of their care team? Are they working with an endocrinologist? Have they had any blood work done to determine if they were suffering from relative energy deficiency in sport? Do they have a team of people that can help support their progression back to play? Now? I want to be clear. I don't think every single person who has a bone stress injuries requires a team of people. I think it's an ideal. And if I've got somebody who's come in, who's got a bone stress injury, and doesn't have a team of people I'm planting seeds to get them, that team. So that they're set up for success. Speaker 1 (11:34): Yeah, that makes sense. Yeah. And gosh, I just had a question and it was like in my head and just went it'll it'll come back. It'll anyway, it'll come back to me. I'll edit this part out. It'll come back to me. Cause it was a good one. It's there it's there. I just there's days. It's just it's. I was like, Oh, I got to ask this question anyway. If I think of it later, I'll ask it later and we'll just splice it in. No one will know the difference. Oh yes. Got it. It's back. Okay. So is there a difference when someone is coming to you via direct access, just versus someone has already been to a physician, they have been diagnosed with a bone stress injury. Let's say they had some imaging done. It has shown up where, what is the difference there? Is there a difference in your examination of this person? Speaker 2 (12:28): Yes, absolutely. Because, and I work primarily in a direct access capacity. So by when people come to me, they haven't typically seen anybody else. And now it's my responsibility to be able to pick up on these things and tell someone, you know, I need you to go see your physician. We need to rule out bone stress injury before we move forward. So from a purely exam standpoint, when somebody is coming to me, who is a runner who potentially has pain at a site that could be risk for bone stress injury, I need to have the evaluation skills to be able to, to rule that in or rule that out to some degree so that we can move them in the right. Speaker 1 (13:15): Got it. And what are those sites? What are the most vulnerable sites for a bone stress injury? Speaker 2 (13:21): Well, the femoral neck is one of the most vulnerable, I would say anyone who's coming in, who's a female athlete. Who's complaining of anterior hip pain. That's maybe a little bit vague and is presenting with some of those additional sort of risk factors changes in their menstrual cycle, low energy availability training, abrupt training changes. I'm starting to stew a little bit and get a little bit concerned. So that's going to be a high-risk stress fracture site, some other high risk stress fracture sites include the first and second metatarsal. And I want to say the anterior tibia as well. It's likely that I'm forgetting one, but yeah, some of those regions are considered high risk. High risk essentially means that the likelihood for healing is a little bit harder, I guess you could say. Speaker 1 (14:18): Okay. All right. Thank you. All right. Now let's move on to your objective exam. So what kind of things are you looking for? Are you going to say to this person, let's get you on the treadmill and see what you're doing with your run? Okay. Speaker 2 (14:34): That's the great part of the subjective exam because the subjective exam is going to lead me into thinking whether or not I need to test for bone stress injury before we pursue running. Right. And there are a couple of things that are going to lead you that some of which I've already talked about, but site-specific pain is definitely one of them, localized pain. Sometimes people will point directly to their pain and be like, it's right here. They can have pain in, I know femoral, neck stress fractures. They can have pain with offloading. So sometimes they'll say, you know, like stepping off of a step, I suddenly have pain in my hip. So there are things that you'll just pick up on and then you do not want to get on the treadmill at that point, if you're suspecting bone stress injury, you need to do the tests to sort of rule it out before you get to the treadmill. Some of those tests that I would do, I think first would probably be about palpation. So depending on the area, you know, the femoral neck is Speaker 1 (15:42): D that's tricky. That's a tricky one to help paint, Speaker 2 (15:46): Be able to get there with your hands, but certainly a medial tibial region or an anterior tibial region. You can palpate that with your hands. And we're looking for pretty pinpoint tenderness. From there we might get them up and then first have them walk. What's their walking look like, is there any offloading happening then I might have them do a little single leg balance. How does that feel? A lot of the times people may not have very distinct acute pain with some of these low level impact activities, right? So if they're presenting with no pain, now this sort of, I'm going to describe it as like this first level, no pain with walking, no pain with single leg balance. Now I want to get them doing a little bit of an explosive move, maybe a step up or step down and determine are they having pain with some more functional tasks? And I think the single leg hop test is a pretty, like just straight up and down. Three hops is a pretty decent maneuver for almost any lower extremity potential stress fracture site. You know, I don't know the statistics on reliability and validity, but it's one that I use very regularly with somebody I'm suspecting that. And then from there you can kind of make a determination about how you want to proceed. Typically, speaking of the folks that I work with, they're going to have pain in one of those moves. Speaker 1 (17:20): Yeah. And, and at that point, does it then come down to, if you're seeing them via direct access, explaining to them, Hey, listen, this is my hypothesis. Let's get you to a physician at that point. Yes. Speaker 2 (17:34): Yeah, yeah. Okay. Yeah. Usually I'm revealing at that point, I'm concerned for bone stress injury. I want to get you, you know, examined for that. So, and they can, you know, go to their physician that they know and that they trust. But I think it's important depending on the region that we get the right imaging. Certainly if I hip femoral, neck stress fractures suspected, I really want to push that person to try and push for an MRI. So you know, it kind of depends on your relationship with the person and where they're at on a lot of different levels, but, but that's what we're going to be going for. Speaker 1 (18:15): Okay. And so let's say this is someone who has already gone to the physician. They've had the MRI, this is diagnosed. So you've done your evaluation now, what do you do? I guess the question is, is, are they come, are they non-weightbearing at this point? What are, what are some things that we can do as physical therapists for these patients when they're coming in? They've already been diagnosed? Speaker 2 (18:37): Yeah. Well, so many of these athletes don't get referred to physical therapy in the first place, which I think is a problem. But yeah, if you are getting these people, we really do want to be loading those tissues. And bone responds really positively to stress as long as the environment is you know, a strong, healthy, robust environment as well. So depending on their level, we're going to be progressively loading those tissues all the way up into the point where they're cleared for a return to run. So, you know, squats step up step downs. If they're not cleared to weight bear, you know, we're definitely doing stuff on the table, that's just pull it using the muscles around that tissue. And even just by using the muscles around that tissue and the injury, you're stimulating bone adaptations that are positive. Speaker 1 (19:37): And so I guess the, the thing that might come into a patient or a therapist is, well, if I'm non-weightbearing, I don't really want to do anything with this side. Cause what if I make it worse? Right. So is it, is this injury, let's say we're talking about a femoral neck BSI, is this injury so fragile that if you're doing things in a non-weight bearing capacity, can that make it worse? Speaker 2 (20:05): Not typically. You know, I, I, I tend to think that people who have had BSI or are so much more resilient than they get credit for, I have had and seen, and I don't commend this necessarily. So many runners who have run through BSI and there is, there is some toxicity there to unpack that we don't need to do today, of course. But all that tells me is that you can still be stressing bone and it's going to heal. And I think what we know is that when we don't stress bone enough, it could theoretically take longer and put that bone in a more position. So in my opinion, all of these athletes with BSI need to go to a physical therapist so that they can load those tissues up. Yeah, Speaker 1 (20:56): No, that makes, that makes perfect sense. And I just wanted to kind of make that distinction because I'm sure if someone is told, Oh, you have a bone stress injury, you know, scary, scary, right. Very scary. And that's where I think the team comes in. Like you said, assembling this team around that, around that runner is so powerful, Speaker 2 (21:20): Right? I mean, gosh, I think those soft skills are invaluable when working with women who have had BSI, because so many of these runners it's like totally ruined their perception of who they are and their worth and their value. And so you have to be really good at being a kind and generous and thoughtful and considerate to that person's experience because it's still very much in a way I'm going to use the word trauma to them. And I think not everyone is going to be ready to work with a mental health therapist or work with a registered sport dietician. But I think as their support person, your job as a physical therapist is to really listen to what's going on and gain some of that trust so that you can softly nudge them in those directions and work them towards a more robust, healthy lifestyle. Speaker 1 (22:23): Yeah. Because you don't want this single bone stress injury to set off a cascade of other events. That could be really detrimental to them. Not only as an athlete, but just as a person. Speaker 2 (22:36): Right? Yeah. I mean, women athletes are more prone to lower bone density than male athletes are. I'm just women in general. Let's just use women in general and runners, you know, runners kind of have this misconception that running itself actually strengthens bone in reality. It doesn't really strengthen bone as much as we'd like to think. And all that means as women is we need to be thinking about other ways to strengthen our bones. If that's something we care about. Speaker 1 (23:08): Right. And that's where a good strength training program comes in for runners because I have spoken and I have treated plenty of runners and runners like to run when you tell them, Hey, you, we should get you on a robust strengthening program. It's like, what a no. So, yeah. So now let's say you're, we're still in the treatment process. So we're, we're past the, this vulnerable part of the bone stress injury. They're able to weight bear, they're able to do more. What strategies do you use to get these women on to strength, training, flexibility programs? Speaker 2 (23:49): Honestly I show them, I think that's like a big component of how I work with the people that come to see me is showing them what they need to be doing. And first of all, that it's fun and that it can be fun that it's not intimidating and that we can keep it really simple and easy. And it doesn't have to be a huge long laundry list of exercises to keep them healthy. And FEMA women especially are so subject to carrying, you know, a list of 20 to 30 exercises that they're doing to, you know, through the guise of staying, I'm going to use air quotes, healthy and keeping tissues healthy, and it's just way more than it's necessary. So I think part of why women, like working with me is I have been able to really speak their language, pare things down significantly. So that it's simple. It's, you know, 25 to 30 minutes, one, one to three times a week is really all runners need to, to keep that bar trending in the positive direction. Speaker 1 (24:56): Yeah. And I think that's an important distinction to make because oftentimes we think we have to work out five days a week and it has to be this like really complicated. I have to do a chest day. I have to do a leg day. I have to do a hamstring day. I have to do a quad day. I have to. And with all of that said, you're like, Oh, screw it. This is too complicated. I'm just going to run. Yeah, no, Speaker 2 (25:20): I do not blame them whatsoever for giving up on programs in part, because they're just so complicated. And for runners, we just need to keep it simple, keep it clean, keep it short and sweet and to the point and get on, get on our way. Speaker 1 (25:37): Yeah. Excellent. Excellent advice. Now, is there anything that we missed as far as that treatment aspect with these women with bone stress injuries, and obviously we're not going into like individual programming for an individual person because it's so varied. I'm sure. But I guess, are there X speaking of exercises, are there exercises that you do like to include with most of your runners? Speaker 2 (26:06): Yes. So they're getting lower extremity strengthening exercises. So, you know, a squat and a deadlift of some sort, all of my runners will give that we're also going to be incorporating and especially for bone stress, injury, plyometric, explosive exercise. So, you know, squat jumps, counter movement jumps, broad jumps, Pogo jumps. We don't have to do those in like a hit style. If that makes sense. We don't need to be like every minute on the minute you're doing this many jumps or whatever for runners, what we need to be doing is doing it to load the bones for one and two, doing it to create and foster tendon stiffness. And so I think there's a little bit of a misnomer amongst women athletes, especially that in doing plyometrics, they have to be really, really intense. And I'm of the opinion that we want your running to be really, really intense. We don't also need your strength training and your physical therapy to be to the nth degree, intense just needs to be targeted. Speaker 1 (27:21): Yeah. That makes a lot of sense. So you don't need to like kill yourself on your workout day and then go out and run the next day with like jelly legs. Right. Speaker 2 (27:30): Exactly. Exactly. Speaker 1 (27:32): Yeah. It doesn't make sense. It doesn't make sense from a running standpoint. It may make sense in, in another population. Yes. But you have to be specific with your population. And this is where the skill of a good physical therapist comes in to be able to tailor that program, to that specific runner and what their needs are, especially coming off of a bone stress injury. Right. Exactly. And is there a fear in the runner after a bone stress injury, and you say to them, let's start doing some jump squats. Like what lady are you kidding me? Yeah. Speaker 2 (28:08): Yeah. I think people are pretty forward with some of their concerns and their worries. And depending on the capacity that you're seeing them, you see it in their body language. Right. But that's why physical therapy is so advantageous because that's where we Excel is helping people understand why something is valuable and then why it's safe. So I think it's about addressing those fears, head on getting at the heart of what they're concerned about and meeting them exactly where they're at. You know, maybe if they're not ready for that, we just try something else. In the meantime, until they're building up confidence, there's not a single person that I've worked with who has had a bone stress injury that doesn't have some of those fears pop up. It is a very real piece of a return to sport on any level. So, Speaker 1 (28:59): Yeah. Agreed. Excellent. Now, is there, is there anything that we missed, anything that we glossed over that you feel like you want to explain to the listeners a little bit more, or do you think we've covered, you know, sort of the high level basics on how you would look at one of these patients with a bone stress injury? Speaker 2 (29:20): Yeah, I think we covered most of it. You know, I think in, you know, reflecting back, it's really just understanding that we don't want to make assumptions about somebody's circumstance. You don't want to assume that somebody with bone stress injury has an eating disorder. I've worked with a number of people who have bone stress injuries, who do not have what I would consider disordered eating to the level that it's clinical. They just didn't understand how much fueling might be required for their activity. So I think in your subjective and in your relationship building with these people, it's important to keep that in mind that we don't need to medicalize everyone that walks in our door with a bone stress injury, but certainly we want to prepare them better for the future. I should also add that history of bone stress injury having had one in the past is the number one risk factor for a new bone stress injury. So in your history, in your subjective exam, that's another great question to ask. Have you ever had a bone stress injury before? If the answer is yes, you're already starting to postulate that that could be a possibility. Speaker 1 (30:33): Got it. Excellent. Excellent. Well, this was great, Ellie. I think that you gave the listeners a really, really robust understanding of looking at bone stress injuries from the point of view of a physical therapist. So thank you very much. This was great. Thank you. Yeah, I appreciate being here. Of course. And then where can people find you? Speaker 2 (30:57): Yes. So you can find me on my website, www.cc wolf.com. It's brand new. I'm just going to say brand new France shine. You can also find me on Instagram handle of@theccwolf.com. And if you want to reach out to me personally, I love getting emails from folks it's Ellie, E L L I E at [inaudible] dot com. Speaker 1 (31:23): Awesome. Well, thank you so much. I have one final question for you and it's one that I ask everyone. And that's knowing where you are now in your career and your life. What advice would you give to your younger self? Let's say right out of PT school. Speaker 2 (31:39): There's no rush. There's no rush. I think, you know, as a young PT, it was like, I want to be the best now. And you have your entire life ahead of you to work and refine and you know, as long as you're working on something, you're working towards it. So there's no Speaker 1 (31:58): Excellent advice. I love that. So everyone, no rush, no rush to all those student physical therapists out there. Well, Ellie, thank you so much. This was great. I really appreciate your time. Thanks Karen and everyone. Thanks so much for listening. Have a great week and stay healthy, wealthy and smart.  

Episode Summary In this episode physical therapist, biomechanist, and researcher,Dr. Amy Arundale talks about how to decrease the risk of ACL injury.  Amelia (Amy) Arundale, PT, PhD, DPT, SCS is a physical therapist and researcher.  Amy is transitioning to a new role as a physical therapist at Red Bull’s Athlete Performance Center in Thalgua, Austria. Today, Amy tells us about injury-prevention programs, communicating with different stakeholders, and helping empower athletes through education. We also get to hear about her recent publication on Basketball, Sports medicine, and rehabilitation. How does motor-learning, creative thinking, and problem-solving relate to ACL injuries? Amy tells us about implementation and compliance with injury-prevention programs, internal versus external cues as they relate to injury prevention, and the gaps in the research, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “We’ve got great information. We know these programs can work, but for them to work, you have to do them.” “You may be a physio, and you may have this injury-prevention knowledge, but you don’t have to be there for this to happen. It’s just as effective for you to run this program as it is for a coach or a parent to run it.” “It’s exciting to see where this next generation is going to be because I think we’re going to have some athletes that are more empowered to know more about their body.” “We need to be better at reporting our biases, looking at our subject populations, and funding and encouraging studies outside of ‘the global North.’” Giving yourself the space and kindness to recognise that you don’t know everything and make it a point to learn more is good therapy.   More about Amy:  Amelia (Amy) Arundale, PT, PhD, DPT, SCS is a physical therapist and researcher. Originally from Fairbanks, Alaska, she received her Bachelor’s Degree with honors from Haverford College. Gaining both soccer playing and coaching experience throughout college, she spent a year as the William Penn Fellow and Head of Women’s Football (soccer) at the Chigwell School, in London. Amy completed her DPT at Duke University and throughout gained experience working at multiple soccer clubs in the US and Norway. Amy applied this experience working at Balance Physical Therapy providing physical therapy for the Capitol Area Soccer Club (now North Carolina F.C. Youth) and the U23 Carolina Railhawks. In 2013, Amy moved to Newark, Delaware to pursue a PhD under Dr. Lynn Snyder-Mackler. Amy’s dissertation examined primary and secondary ACL injury prevention as well as career length and return to performance in soccer players. After a short post-doc in Linköping, Sweden in 2017, Amy joined the Brooklyn Nets as a physical therapist and biomechanist as well as The Icahn School of Medicine at Mount Sinai Health System as a visiting scientist. Currently, Amy is transitioning to a new role as a physical therapist at Red Bull’s Athlete Performance Center in Thalgua, Austria. Outside of work, Amy plays Australian Rules Football for both the New York Magpies and US National Team.  Amy has also been involved in the APTA and AASPT, including serving as Director of the APTA’s Student Assembly, a member of the APTA’s Leadership Development Committee, chair of the AASPT’s Membership Committee, and currently as a member of the AASPT Diversity and Inclusion Committee.   Suggested Keywords ACL, Injuries, Recovery, Injury-Prevention, Learning, Sports, Physiotherapy, Research, PT, Rehabilitation, Health, Therapy,   Recommended reading https://bjsm.bmj.com/content/54/21/1245     To learn more, follow Amy at: Instagram:       @squeakyedgar LinkedIn:         Amelia (Amy) Arudale Twitter:            @soccerPT11   Subscribe to Healthy, Wealthy & Smart: Website:  https://podcast.healthywealthysmart.com Apple Podcasts:      https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud: https://soundcloud.com/healthywealthysmart Stitcher: https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio: https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here:    Speaker 1 (00:07): Welcome to the healthy, wealthy, and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information. You need to live your best life. Healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, Dr. Karen Litzy. Speaker 2 (00:38): Hey everybody. Welcome back to the podcast. I am your host. Karen Lindsay, and today's episode is brought to you by net health net health therapy for private practices, a cloud-based all in one EMR solution for managing your practice. That's right. One piece of software that handles all of your scheduling documentation, billing and reporting needs. Plus a lot more in one super easy to use package. Right now, Neta health is offering a special deal for healthy, wealthy, and smart listeners. Complete a demo with the net health team and get $100 towards lunch for your staff. Visit net health.com/ [inaudible] to get started and get access to free resources for PTs like eBooks on demand, webinars, and business tools. Once again, that's net health.com/l I T Z Y my last name very, very easy now onto today's episode. So what we're doing with the podcast this month, and really every month going forward is we're going to have several guests that are all going to talk about one topic in various forums. Speaker 2 (01:40): This month, our topic is ACL injury and rehabilitation. And my first guest is not only an incredible physical therapist, a great researcher, but also a great friend of mine. That is Dr. Amelia, Aaron Dale, or Amy Arundale. So Amy is a physical therapist and researcher originally from Fairbanks, Alaska. She received her bachelor's degree with honors, from Haverford college, gaining both soccer, playing and coaching experience throughout college. She spent a year as the William Penn fellow and head of women's football at the Chigwell school in London. Amy completed her DPT at Duke university and throughout gained experience working at multiple soccer clubs in the U S and Norway. Amy applied this experience working at balanced physical therapy, providing physical therapy for the capital area soccer club. Now North Carolina FC youth, and the U 23 Carolina rail Hawks. In 2013, Amy moved to Newark Delaware to pursue a PhD under Dr. Speaker 2 (02:40): Lynn Snyder, Mackler Amy's dissertation examined primary and secondary ACL injury prevention, as well as career link and returned to performance in soccer players. After a short postdoc in Linkoping Sweden in 2017, Amy joined the Brooklyn nets as a physical therapist, the biomechanics as, as the Icahn school of medicine at Mount Sinai health system, as a visiting scientist, currently, Amy is transitioning to a new role as a physical therapist at red bull's athletic performance center in Austria, outside of work, Amy plays Australian rules football for both the New York magpies and us national team. She has also been involved in the AP TA in the AA S P T, which is the American Academy of sports physical therapy, including serving as director of AP TA student assembly, a member of the AP TA's leadership development committee, chair of the AASP membership committee, and currently as a member of the AASP T diversity and inclusion committee. Speaker 2 (03:37): So what do we talk about today? All about ACL's right. So we talk about injury prevention and risk mitigation programs, how they work, what the pros and cons are how collaboration is so necessary amongst all stakeholders and why exciting new research that includes motor learning principles, creative thinking, and problem solving, and are there gaps in the literature and what can we, as clinicians and as researchers do about those gaps in the research. Now, the other thing Amy has so generously done for our listeners is she is going to give away one copy of basketball, sports medicine in science. This is a book that she was involved in as an editor, and it is over 1000 pages. The book is massive, it's huge. And she's going to give a copy away to one lucky listener. So how do you win that copy? All you have to do is go to my Instagram page. My handle is at Karen Lindsey, and you will find out how to win a copy of basketball, sports, medicine, and science. Again, that's go to my Instagram page at Karen Lindsey, and we will give this book away to one lucky listener at the end of the month of February. So you have the whole month to sign up for this. So a huge thanks to Amy and everyone enjoyed today's episode. Speaker 3 (05:04): Hey, everybody, welcome back to the podcast. So this month we're going to be examining ACL injuries and ACL rehab. And my first guest this month to help take us through the ACL Mays is Dr. Amy Arundale. So Amy, welcome to the podcast. Thank you so much. We're starting up at the beginning of the year with the A's with it. I didn't even think about that. Yes. But then next month we go right to running and just skip everything else in between. That's fine. Excellent. So Amy, before we get into sort of the meat of the episode, what I would love for you to do is tell the listeners a little bit more about some of your more current research projects, things like that. So I will hand it over to you. Sure. So I'm just finishing Speaker 4 (05:58): Up as a physical therapist and biomechanics at the Brooklyn nets. So I've been working clinically with them and then doing a little bit of kind of in-house research as well. And then on the side have been working on a few different projects. The biggest one right now is starting the revisions for the knee and ACL injury prevention me Andrew prevention, clinical practice guidelines. So those were originally published in [inaudible] in 2018 and clinical practice guidelines get revised every three years. So 2021 we're due for we're due for a revision. So that's my, the biggest project I've got going right now. And a few other things working with the United States Australian rules, football league on some injury surveillance and injury prevention, particularly on the women's side. And I'm getting ready to move to Austria to begin working for red bull and I, which I'm really excited about that. Speaker 3 (07:04): Amazing, amazing. They all sound really like really great projects. And since you brought up injury prevention, let's dive into that first. So there are a lot of injury prevention programs. So can you talk a little bit about those programs in general, and then talk about really, what is what's really key for injury prevention in our athletes when it comes to those programs? Speaker 4 (07:34): Absolutely. So there's a range of different programs that have all been published on and some of them are probably a little better known than others. The FIFA 11 plus, or what's now known as just the 11 plus maybe the, one of the most notable it actually came out of a program that was called the pep program. So the 11 plus was kind of aimed at soccer players, although it has been tested in other athletes and it's considered, it's kind of a dynamic warmup. So it has some dynamic stretching and some running, some strengthening, neuromuscular control, some balance exercises within it. And most of the programs that we see that have been researched are similar kind of dynamic warmups and include a variety of different things that help athletes kind of get warmed up. So some of the other ones that have been published on include the control or knee control program coming out of Sweden at the microburst and the ACL prevention in Norwegian handball has had some great success and great literature. Speaker 4 (08:47): There's the harmony program and then the sports metrics programs a little bit different. It's actually a program that was designed to be kind of a in and of itself. So it's a three times a week, 90 minute per program, primarily plyometric based. So it's a little bit different from the other programs, but has also been successful. So we've got a number of these programs that we've seen to reduce knee and ACL injuries in particular. And most of them actually have been quite successful at reducing just injuries as a whole. But the key components that we see in particular being important for ACL and knee injuries are that these programs have a strength component. So they're building strength, particularly in the hips, the quads, the hamstrings, but also in the core. So it kind of proximal in like terms of like hip and core strengthening, being important plyometric component seems to be important. To some extent a balance component may be important, although that's kind of questionable as to like how important that is. And that's one of the things that we still need more literature on is how do these components interact and influence each other? Because we seem to know what we think is important, but how much and how those different components interact. We still don't know as much about. Speaker 3 (10:25): And when we're talking about these programs, I would imagine some of the most difficult aspects of them, especially if we're looking at a younger population. So your high school, even collegiate athletes is doing them. Yup. So can you talk a little bit about implementation and compliance with these programs and how to instill that into these players and teams? Speaker 4 (10:57): Yeah, I think, you know, we've got, like you said, we've got great information. We know these programs can work, but for them to work, you have to do them. And that implementation piece, you know, whether that be in clinical research you know, we talk about that gap between research and clinical practice. We really see that here in ACL injury prevention. And part of that also is it's not just physios in implementing where we've got a whole range of stakeholders, whether those be the athletes themselves, to coaches who are often running training sessions to parents who really have to kind of be bought in to teams and clubs as a whole. Because if you have a culture that kind of instills the importance of doing a prevention program, then it's going to kind of, it may benefit in kind of trickling down. And that's also a wider culture as well. Speaker 4 (11:58): Social media scene pro teams do it. There's all sorts of layers to this. But what I think implementation really takes is identifying with that athlete or that team what's what are barriers what's important? What do we feel is, is most important? What's not as an important, and then coming up together kind of, kind of with a collaborative strategy to overcome what are those barriers? So we know information and knowledge kind of that buy-in is important. Why the why, why are we doing this in the first place? But then there's also some of the actual practical pieces of your athlete might not want to do an exercise lying down in the grass because that grass might be wet. They're going to be wet for the rest of their training session, wet and cold for the rest of their training session. So I think it has to be a really collaborative effort. Speaker 4 (12:59): And each in each situation that solution may look a little bit different. We've got some really kind of interesting information coming out. For example, the 11 plus has now a couple of studies on breaking it apart. So taking some of the pieces, for example, taking the strengthening pieces and putting them at the end of training sessions. So coaches often complained that, you know, these injury prevention programs take too long and when you've only got the field for an hour, they don't want to give up 20 minutes of their training session to do this program. So now let's take, maybe we can take this strength piece out. I means, all right. So maybe it's 10 minutes warming up at the beginning. That's probably a little easier for a coach to swallow. Then as we're cooling down, maybe we're off the pitch where we get everybody together, we finished those strengthening components. So we're still getting the entire prevention program done with that training session, but it's split up. And so thinking creatively like that are some of the ways that I think we can do a lot better in our implementation, rather than just saying, do this, here you go. Why aren't and then coming back and saying, well, why aren't you doing it? Speaker 3 (14:18): Right, right. Oh, that's, that is really interesting that and what is, does the research show that splitting it up is still as effective? Speaker 4 (14:28): Yeah. From what we know thus far, it does seem to be as effective. I think there's some other projects that are starting to look at, can you actually do that strengthening piece at home now there's other pieces that, you know, compliance at home, remembering doing those exercises the right way that could come into play there. But as of right now, what it seems like splitting it up does seem, seem to be splitting it up. At least within a training session does seem to be as effective. Speaker 3 (14:58): Excellent. And so aside from time and constraints on like you said, wet grass, things like that, what are some other common barriers that you have seen or that the research has shown to be a barrier to doing any of these? The above mentioned prevention programs. Speaker 4 (15:21): Yeah. I think coaching education is a really big one. So whether there's a few studies in Germany that we're just looking at a coach's awareness of the 11 plus and for a program that's kind of sponsored by FIFA, you know, it's promoted as kind of this soccer warmup, you would think that coaches would be kind of aware of it. And it's, it's very quite, it's actually quite surprising how few coaches are, are aware of it. Part of that is it's not in their coaching education. So at least in soccer, as coaches move up, what kind of within the ranks and, and in higher level teams, they've got a complete licenses, just like you have to complete a license to be a physio and complete continuing education in soccer coaches do to getting that program into that coaching education, I think is a really important piece. Speaker 4 (16:18): But then there's also the piece of helping them understand, again, coming back to that, why, you know, yeah, you want your players to be available. You don't want your players injured. And that's not just a, an immediate fact, but helping them understand the long-term implications, especially of something like an ACL injury, this is not an injury. That's just going to mean you don't have this athlete for a year. This is something that's going to affect how they play long-term it's gonna affect their knee long-term it could affect their career. So this has long-term implications. Buy-In also can come from kind of some of the performance effects, the stronger, faster, more talented athlete that's that there are some of those performance effects coming potentially from performing some of these injury prevention programs or injury prevention or injury risk medic mitigation programs that can help buy in. Speaker 4 (17:22): And then if we just look at Google would cut straight to the chase, is coaches want to win oftentimes and money. If you've got more players available, we know more players available equals a more successful team. And even Holly silver is actually in some of her dissertation work looked straight at the more you do the 11 plus the more successful the NCAA division one men's team was. So there's, there's she, she actually was able to draw a connection between doing the FIFA 11 plus and winning that those are the types of things that oftentimes coaches will latch onto and say, yeah, I want to win. Or clubs will say, yeah, we want to win. We want to do that thing that makes us that, that next level that makes us better at the higher levels that keeps us earning money. Speaker 3 (18:18): Okay. Exactly. So from, from what it sounds like is to get these programs implemented is you need a lot of collaboration from everyone, from all the stakeholders, whether it be the coaches, the trainers, the physios, the players, the owners, when we're talking about big league teams and, and with our younger, our younger subset of athletes, parents, coaches, and the kids themselves. And, and I guess communicating the value of these programs depends on who you're talking to, which is why, if you're the physio communicating the program, you really have to have a different set of communication bullet points, if you will, if you will, for each person on the, within that team, because you're going to talk differently to a parent than you are to an owner of a team, or you're going to talk differently to a coach than the player or the parents. So really knowing how to, how to talk to those stakeholders is key. And I think everything you just said will kind of help people understand how to have those different conversations with different people. Speaker 4 (19:26): Yeah. And I think there's all the other piece that some of those conversations is really empowering them. So there's the education piece and helping them understand, but there's also the empowerment piece that you may be a physio and you may have this injury prevention knowledge, but you don't have to be there for this to happen. It's just as effective for you to run this program as it is for a coach or a parent to run it. And we have, there's some good data on that that coaches can run really effective injury prevention programs. And so helping them kind of take on that role and say, yeah, no, I, I feel confident in taking my players through this. I feel confident in knowing why we're doing this there. I think that's the second piece too, is that it kind of empowerment piece, and maybe it's a player, maybe it's a captain that, that needs that education or that kind of empowerment as well. Speaker 4 (20:31): I think the generation of players that's growing up now is going to be very different from the generation of players say that you and I played played with we didn't understand or really have much of this. Whereas I think there's some really, there's some kids growing up now who are growing up with some amazing knowledge. And I think also coming with it, hopefully some better strength, some more and more neuromuscular control than maybe we had coming through puberty as well. So I think it's exciting to kind of see where this next generation is going to be, because I think we're going to have some athletes that are just like that more empowered to know more about their body. Maybe have a little bit more control maybe even coming with also potentially better talent who knows, who knows? Yeah. TBD to be determined. So you mentioned a little bit about motor learning. So let's dive into that a little bit because there is new research that includes motor learning, problem solving creative thinking. So what exactly does that mean in relationship to ACL injury? Speaker 2 (21:51): No, we're going to take a quick break to hear from our sponsor and we will be right back net health therapy for private practice as a cloud-based all in one EMR solution for managing your practice. That's right. One piece of software that handles all of your scheduling documentation, billing and reporting needs. Plus lots more and one super easy to use package right now, net health is offering a special deal for healthy, wealthy, and smart listeners completed demo with the net health team and get a hundred dollars towards lunch for your staff visit net health.com/lindsey to get started and get access to free resources for PTs like eBooks on demand, webinars, and business tools. Once again, that's net health.com/l I T Z Y. Speaker 4 (22:38): Yeah. So I think it's a really exciting area. And I think we're really just kind of tipping a little bit of the iceberg. People are starting to pay attention to some of the work that's coming out. And I think it's, it is really exciting and in the kind of prevention realm what we're seeing is people kind of pointing out that the programs that we have, we know we kind of have some principles of motor learning, but the programs in injury prevention that we have haven't really paid much attention to them. So at a very basic level one of the things that has been talked about from a motor learning perspective for a while now is internal versus external cues. So we know that giving an external cube, giving an output outcome focused, Q2 and athlete is going to help them keep that motion kind of more automatic. They're not going to be thinking about like, I need my hip in line with my knee in line with my toe and foot, my knee. Can't go too far over my shoe laces. I need to sit down. Speaker 3 (23:50): That's a lot to think about. Yeah. You can't Speaker 4 (23:52): Play a sport while you're thinking about all those things. Yeah, Speaker 3 (23:55): Yeah, no, no. Speaker 4 (23:58): So when that, if that cue is external or is outcome-based suddenly that athlete's much, much more, much better able to pay attention to the soccer ball that's flying past them or getting ready to, to bat. Speaker 3 (24:13): And can you let's if you wouldn't mind, just so people have a better idea of what an internal versus an external cue is. Can you give an example of, let's say a situation we'll use soccer as the example and give an internal cue and then give an external cue so that people can differentiate. Speaker 4 (24:34): Yeah. Yeah. So maybe, maybe we'll do say we're doing like a single leg squat, similar to what I, what I just said. So an internal cue might be, I want you to keep your hip, your knee and your foot all in one straight line that external cue might be giving them a we'll say a pole that's lined up in front of them and you might not even tell them what they're, what what's going on. Maybe you've got a pole in front of a mirror, so that's poles running vertically and they're, they're they're we, we just set them up so that their foot's in front of that pole and they're doing that single leg squat. So now you've got a visual line in front of them. You're paying their, their attention is going to be on that visual line. As they're doing that single leg squat, suddenly you see that they see that like, if their hips pretty far adducted or their knees collapsing in, you've got a line you can say, focus on that line. I'm going to focus on that line. Got it. That one, it isn't their body. Other cues, maybe like giving analogies I want you to think of your body as a column or that's, that's not a brilliant one. But you know, things like that. So analogies are helpful for external cues. They're also we'll get in, I'll get into that in a, in a sec, cause they're actually another, Speaker 3 (26:10): Go get into it, get into it. Speaker 4 (26:12): So analogies also bring in another piece of motor learning, which is called implicit learning. Again, kind of having that internal picture of what emotion should like should look or what that motion should feel like is implicit learning. So you've got external and internal, external internal cues, but you've also then got kind of implicit learning. So a great example of implicit learning is when you ask, you know, a really athlete to explain what they do on the court or on the pitch. And a lot of times they can't put words to what they do. And that's, that's kind of a good example of maybe implicit learning is they've got, there's no rules set to that learning. There is no order. It's just, I've got this internal knowledge, internal picture internal kind of motor memory of what, what that is. And I just execute that. Speaker 4 (27:11): I don't think about it. And so with those, all of my attention can stay to the game. I'm not thinking about how I'm moving. I'm just, just, just kind of to the game. So pulling those back to prevention are kind of injury prevention programs have said, here's a video or here's a picture. This is good. This is bad. Or they've given kind of implicit our internal cues. So those internal cues are those, keep your knee, your hip and your foot all in one straight line where we may benefit and where we might be able to bolster. Some of those programs is by adding some of these, these motor learning pieces at the very basic level, adding external cues, maybe adding some analogies or some implicit learning. Another, another way you can facilitate implicit learning is through dual tasking. One of my favorite things reading through some of the literature is in studying implicit learning. A few authors have taken novice novice golfers, and these novice golfers have, have to go and put, and while they're putting they basically yellow letters. Speaker 4 (28:35): So you literally just be out there like trying to learn to put you, you don't. I know how to put, you may not even get any directions, but you're just out there kind of yelling some letters, because if you have to generate letters, you can't be entirely focused on that pudding. So there's that aspect actually, of having two tasks going on at once. That means not all your attention can be on one of those tasks. How does that help? How does that help the movement? Yeah, so, so that's a very good question. What it means is, as you're learning, it it's like harder, but yeah, once you get to that kind of point where you're comfortable, you're able to execute that movement. It's an automatic movement, it's unconscious, it's automatic. And when we put that in the context of sport, that means that movement is happening without the athlete thinking about it and their attention remains, remains elsewhere. Their attention can remain on the game, that's going on the ball, that's flying at them. You know, that random thing that just flew by them that wasn't the ball and wasn't part of the game, but could be that perturbation, that in another situation could be distracting enough and could lead to an injury situation. Potentially. Speaker 3 (29:58): Got it, got it. Yeah. Like I, and you and I have had this conversation before, because I have a young athlete and we're doing, trying to do incorporate some of this stuff. So one of the things we're doing is I'm having her do some unpredictability drills with clock yourself, but we're trying to do them in Spanish. So she has to say things in Spanish as she's doing them. So that she's a little do. So she's accomplishing this kind of dual tasking. And, and I will also say it's fun. It's fun for the patients, fun for the therapist. And they kind of understand while they're why they're doing those things. And then every once in a while, just like throw a ball at her and see what happens. Speaker 4 (30:42): And you put this in the context then of some of those injury prevention programs and coach buy-in. So let's put Bali's in with single leg squats, but, but you know, squats and you jump into a header. There's already a little bit of some of that in some of the programs, but the more we can get that ball, some of those technical skills involved mix them potentially in with some of the movements that we're working on, maybe that might help with some of these, this kind of adding in some of this motor learning piece. Now I say all of this, none of this has been tested yet to change any of these programs we're really doing or to kind of, we need to go back and test them. And so, you know, this is where I say this, but it is kind of hypothetical, but in thinking about it, as well as we're kind of trying to overcome some of those barriers, that 10 minutes, that we're not, maybe we're at 10 to 15 minutes where we're trying to convince a coach to do something. Speaker 4 (31:49): Coaches are going to buy in a lot more. If there's a, if they can build some skills into that or they can see the sport reflected in it, rather than it just being kind of this abstract quote unquote injury prevention program. So can we get some of this dual tasking, can we get some of this kind of real world kind of environment type demands and challenges integrated in with some of those pieces that we're trying to build from a neuromuscular standpoint, can we mix them all together and end up with a maybe potentially more beneficial outcome? Speaker 3 (32:26): Yeah. And, you know, as you're saying all of this, it's kind of opening my mind up into these programs as being these living, breathing programs that aren't set in stone and that have the ability to change and morph over time as research continues to evolve. And I think that's really exciting for these programs as well, because you don't want to have these programs be thought of as stale because then that's going to not help with your buy-in. Speaker 4 (32:55): Yep. Yeah. And that's one of the complaints that you sometimes see about some of these programs is all right, so my team's done him for a season. They've all mastered, you know, all my players have mastered this program. They're bored of it now. And the likelihood that every single one of your players has mastered every single one of those exercises is that we'll put that into question, but we'll put that one on the side, but yeah, if you're doing the exact same program, the exact same exercise, every single training session for multiple years, yeah. Your players are going to get bored of it. And so are these, some of the opportunities where we kind of help with that buy in where we make it a little bit more creative, where we help kind of with some of those implementation pieces to make it more interesting to make it more long-term and to, to really help with people wanting to do them. Speaker 3 (33:50): I think it's great. And now we're, we've spoken a little bit about research here and there. So let's talk about any gaps in the research. So, I mean, are there gaps in the research? I feel like, of course, but are these gaps something that can't be overcome? Speaker 4 (34:09): No. All of the gaps that at least dive I'm aware of, and I'm sure there are more I just finished writing a paper alongside Holly and grant the Mark. So Holly silvers and, and Gretta microburst for the journal of orthopedic research. And, and one of the things that we did was kind of go through the literature and identify some of the gaps. Speaker 3 (34:35): What were, what were they, you don't have to say all of them, just give a couple of a couple of the big ones, Speaker 4 (34:42): But one of the big ones is a lot of our literature is focused on women, which is important, but in total numbers, we still have more ACL's happening in men. So we need more research in men. A lot of our research is in soccer and handball. There's a lot of other high-risk sports at there. So there were focused kind of on team sports but there is some pretty high risk team sports, something like net ball play ball volleyball have very high ACL injury numbers, individual sports things like gymnastics and wrestling. And those are also Tufts sports to come back to they're very high impact or they're very MBA. They've got some crazy positions that you don't see. So individual sports, I think have quite lacked outside of skiing. Skiing's got a lot of attention. One of the biggest ones that I think for me is really important is we don't have good reporting of the subjects and the diversity within the research that we've done. Speaker 4 (35:51): So most of the, the research that's been done has been done in the U S some in Canada and in Scandinavia, or at least in Europe as a whole, there's been a few studies that have been in in Africa. But we even within the studies that we have in the us and Europe and Australia, we don't, none of them have reported any of the, like really the, the, the race or ethnicity of the athletes who were part of them. So those may have implications and Tracy Blake did a amazing BJSM blog that was kind of a call to action for researchers. And it's one that I'd love to echo here that we need to be better at reporting our biases looking at our, our subject populations and funding and encouraging studies outside of kind of we'll call it quote, unquote, the global North. I think that's, that's a big gap that we need to fill and we need to be more aware of. Speaker 3 (37:01): Excellent. And on that note, we are going to wrap things up, but what I would like you to do is number one, is there anything that we didn't cover or anything more that you want to add to any of the subjects we covered? Speaker 4 (37:16): Ooh, I know you always ask this question and I always have never prepared for it. Speaker 3 (37:23): Well, you know, cause I don't want to like skirt over something and then the guests at the end is like, I really wanted to say this. And she just ended the interview. Speaker 4 (37:32): Think of it probably right before I go to bed. Probably. Speaker 3 (37:36): I can't think of anything right now. Okay. Speaker 4 (37:39): Excellent. Excellent. For any readers who haven't read Dr. Tracy Blake's BJSM post definitely go check it out. We'll put the link in. Speaker 3 (37:47): Yeah. Yeah. We'll put the link into the show notes here. So you can read her blog app over at BJSM and I agree. It was it was very well written and it was a really nice call to action and or call to awareness. Yes. Yeah, yeah. Right. Maybe not call to action, but certainly a call to awareness, which is step one in the sequence of actionable moves. Definitely. So yes, she's a gym. So now before we wrap things up I'll ask the same question to you that I asked to everyone and knowing where you are now in your life and in your career, what advice would you give to yourself as a new grad? Let's say like not new grad PhD grad, but new Speaker 4 (38:36): Duke grad, new, new grad coming out of Duke PT school. I'm trying to think of what I said the last time I was on. Speaker 3 (38:46): Well, don't say it again. No, I'm just kidding. Speaker 4 (38:48): Well, yeah, that's what I'm worried about saying the same thing again. I think what I said last time, but what is my like big thing is being more gentle on myself. When I came out of PT school, I started work. I was the first new hire new grad that they'd hired. And so I was working alongside some just phenomenal clinicians, but they had the least experience, one head, like 15 years of experience. And I came out of school, unexpected myself to kind of treat and operate on the, kind of the same experience level that they did. And I it's just not possible. So I've spent a lot of time kind of beating myself up. And so it takes a lot of reminding even now that like, I still have, you know, I've graduated in 2011. So I'm coming up on 11 years of experience and it's still not a lot in a lot of ways. So being gentle on myself that I don't have to come up with, you know, everything on the spot that I don't don't necessarily have the experience to know or have seen everything or every course or development. And so being okay with that and being gentle and allowing myself to be, to, to just be where I'm at is, is I think Speaker 3 (40:08): It's wonderful advice. And just think if you thought you did know everything, I mean, how boring number one and number two, you'd never move on for sure. Speaker 4 (40:18): Yeah. Yeah. Right. So Speaker 3 (40:20): You're stuck. You'd be pretty stuck. So giving yourself the space and the kindness to say, Hey, I don't know everything. So I'm going to make it a point to learn more is just good therapy. It's just being a good PT, being a good physio, you know, otherwise you're just stuck in 2011. I mean Speaker 4 (40:41): Gotcha. Yeah. 11 wasn't bad, but I'm glad I'm not stuck there. Speaker 3 (40:45): Yeah. I mean, what a bore, right. You'd be like so boring as a PT cause you would never advance. Speaker 4 (40:51): Yeah. So your ex Speaker 3 (40:54): Excellent advice. And now where can people find you on social media and elsewhere? Speaker 4 (40:59): So I am on Twitter at, at soccer, PT 11 I'm on Instagram at squeaky Edgar. I will note that's actually more personal but follow me anywhere cause you'll get some great, great adventures. And those are my primaries social media. Speaker 3 (41:20): Excellent. And before we hop off, can you talk quickly about basketball, sports, medicine Speaker 4 (41:26): Science? Oh yeah. I forgot to talk about that in my projects. Speaker 3 (41:30): Yeah. Let's talk about this quickly. Yes. So Speaker 4 (41:34): Was honored to be a part of an editorial group that just completed. I just got a book out. It's an ASCA public, a publication on basketball, sports medicine and rehabilitation. So it's a quite the book. But I say that because it is over over 1100 pages if I remember correctly. So it's, it's a, it's a, it's a chunk of a book. But we are, I've got an extra copy of it. So one of our allowed visitors really be getting a copy. Okay. Speaker 3 (42:15): Well Amy, thank you so much for coming on. I really appreciate your time. Speaker 4 (42:19): Thank you so much for having me. It's always fun. Speaker 3 (42:21): Everyone else. Thank you for listening. Have a great couple, have a great week and stay healthy, wealthy and smart. Speaker 2 (42:28): A big thank you to Dr. Amy Erindale for coming on the podcast today. And of course a big thank you to net health. Again, they have created net health for private, for net health therapy for private practice, which is a cloud-based all in one EMR solution for managing your practice. One piece of software that handles scheduling documentation, billing reporting needs. Plus a lot more. If you want to check it out, there's a special deal for healthy, wealthy and smart listeners. Complete a demo with the net health team and get a hundred dollars toward lunch for your staff. Visit net health.com/glitzy to get started again. That's net health.com/l I T Z. Speaker 3 (43:09): Why thank you for listening and please subscribe to the podcast at podcast dot healthy, wealthy, smart.com. And don't forget to follow us on social media.  

In this episode, CEO of Fyzio4U Rehab Staffing Group, Dr. Monique J. Caruth, talks about how she, as a businesswoman, reacted to Covid-19. Dr. Monique J. Caruth, DPT, is the CEO of Fyzio4U Rehab Staffing Group providing home health services in Maryland. She currently serves as the Southern District Chair of Maryland APTA and is the Secretary-elect of the Home Health Section of the APTA. She holds a Masters and PhD in Physical Therapy from Howard University, and she is a proud immigrant from Trinidad & Tobago. Today, we hear what it’s like treating potentially Covid-positive patients, Monique tells us about the screening tool she developed, and we hear about the impact of the pandemic on mental health. Monique elaborates on the importance of Ellie Somers’s list of notable PTs, and she talks about her experiences of losing patients. How did she pivot her business to keep it afloat? How has her perspective as both a clinician and a business owner helped her pivot her business? Monique tells us about obtaining PPE, offering Telehealth visits, and she gives some advice to Home Health PTs, all on today’s episode of The Healthy, Wealthy & Smart Podcast.   Key Takeaways “We started seeing a spike in clients in mid-April when the hospitals didn’t want to discharge patients to the nursing homes; they were discharging them directly home, so the majority of our clientele were Covid-positive patients.” Monique has started compulsively disinfecting all surfaces. Monique’s screening tool: Step 1: Check temperatures every morning before seeing a patient. Step 2: Ask questions about symptoms, traveling, and possible contact with Covid-positive people. Step 3: Ensure PPE is worn. “Gone are the days of spending extra time and doing extra work there.” “One of the biggest things for therapeutic outcome is having a good relationship with your patients. Going into the home, you’re probably the only person that they’re getting to talk to most days. I saw the need to improve on soft skills and being approachable with your patients.” “Some sort of contact needs to be maintained. Even though some patients may have been discharged, they would contact the physician via Telehealth visit and ask to be seen again.” “Everyone deserves to get quality care.” “Some people say, ‘this person probably got Covid because they were being reckless’. You can slip-up, be as cautious as possible, and still get Covid.” “We’re going to see a huge wave of Covid cases coming in the next few months. With elective surgeries stopped, that’s going to be our only client population. To prevent the furloughs from happening again, I would just advise to do the screenings, get the PPE, and go and see the patients.” Why don’t women get recognition in a profession that’s supposed to be female-dominated? “People send out stuff to vote for top influencers in physical therapy. You tend to see the same names year after year, but you never see one that strictly focuses on women in physical therapy. I see many women doing great things in the physical therapy world, but because they don’t have as many followers on Twitter or Instagram, they don’t get the recognition that they deserve.” “The thing that I love about Ellie’s list is she put herself on it.” “In doing stuff you have to be kind to yourself first and love yourself first. Many of us don’t give ourselves enough praise for the stuff that we do.” “You can’t save everybody. When you just graduate as a therapist, you think you can save everyone and change the world – it takes time.”   More About Dr. Caruth Dr. Monique J. Caruth, DPT, is the CEO of Fyzio4U Rehab Staffing Group providing home health services in Maryland. She currently serves as the Southern District Chair of Maryland APTA and is the Secretary-elect of the Home Health Section of the APTA. She holds a Masters and PhD in Physical Therapy from Howard University, and she is a proud immigrant from Trinidad & Tobago.     Suggested Keywords Therapy, Rehabilitation, Covid-19, Health, Healthcare, Wellness, Recovery, APTA, PPE, Change,   To learn more, follow Monique at: Website:          Fyzio4U Facebook:       @DrMoniqueJCaruth                         @fyzio4u Instagram:       @fyzio4u LinkedIn:         Dr Monique J Caruth Twitter:            @fyzio4u   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:               https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the Full Transcript Here  Speaker 1 (00:01): Hey, Monique. Welcome to the podcast. I'm so happy to have you on. Speaker 2 (00:06): Oh, thank you for inviting me. It's a pleasure to be on once again. Speaker 1 (00:10): Yes. Yes. I am very excited. And just so the listeners know, Monique is the newly minted secretary of the home health section of the APA. So congratulations. That's quite the honor. So congrats. Speaker 2 (00:26): Thank you very much. And Speaker 1 (00:28): We were just talking about, you know, what, what it was like being an elected position. I was on nominating committee for the private practice section. I just came off this year. Not nearly as much work as a board member. But my best advice was you'll you'll make great friendships and great relationships. And that's what you'll take forward aside from the fact that it's, you know, a little bit more work on top of the work you're already doing Speaker 2 (00:57): Well, I better get my bearings, right. So I will be on task from the one. Yeah. Speaker 1 (01:04): Yeah. I'm sure you will. And now, today, we're going to talk about how you as a business woman pivoted reacted to COVID. So we're, Monique's in Maryland, I'm in New York city. So for us East coasters, it really well, we know it hit New York city very hard in March in Maryland. When did that wave sort of hit you guys? Was it around the same time? Speaker 2 (01:33): I would say mid March, April because I had returned back to the rest of the first week of March. And then things just started going crazy. They were saying, Oh we have to be aware of COVID. But I was still seeing my clients that I had. Then we started getting calls saying that family members are worried that we'll be bringing COVID into the home. So they wanted to cancel visits. So we were getting a lot of constellations and then electric surgeries was shut down and that meant a huge drop in clients as well. Then we started seeing a spike in clients in mid April when the hospitals didn't want to discharge patients to the nursing homes, they were discharging them directly to home. So the majority of our clientele was COVID positive patients. Speaker 1 (02:36): And now as the therapist going in to see these patients, obviously you need proper protection. You need that PPE. So as we know, as all the headlines said, during the beginning of the pandemic, couldn't get PPE. So what do you do? Speaker 2 (02:54): Well, we were fortunate in Maryland that governor Hogan had PPE equipment ready at state health departments for agencies to collect. So they did ration them out. Also one of the agencies that I contract with MedStar hospital provided PPS to all the contractors and employees that were visiting COVID patients in the home. So we had the goggles face shield gowns mask, everything. There would be a specialized bag with vital sign equipment for that patient specifically that would be kept in that house and then taken back and disinfected at the end of the treatment. So we, we were shored through weekly conferences on what to do do South screenings and screening prior to each visit. So for my contractors, I developed a screening tool to ask questions if clients were having symptoms or if any family members in the home are having symptoms. And if they had exposure to anyone where COVID symptoms in the past 14 days, so we'll know what you will, that person as a person on, on the investigation or somebody who's COVID positive. So we had done the correct equipment when we go into the homes. Speaker 1 (04:18): And what does that, what does that look like? And what does that feel like for you as a therapist, knowing that you're going into a home with a patient who's COVID positive? I mean, I feel like that would make me very nervous and very anxious. So what was that like? Speaker 2 (04:36): To be quite honest, I was scared at first I try to avoid it as much as possible. But I got to a point where I needed to start seeing people or, you know, the business would go under. So you're nervous because nobody really knows how the disease will progress, what would happen. So it's a risk that you're taking. I, I probably developed compulsive disorder, making sure everything was like wiped down and clean. Even getting into the car, you know, this is affecting the stairway, the door handles double checking, making sure that they know the phone was wiped down. You know, as soon as you get in the house, after you strip washing from head to toe, making sure that, you know, you don't have anything that could possibly be brought onto the home. Speaker 1 (05:35): Right. And so when you say going back to that screening tool that you say you developed, what was, what was, what was, what did that entail for you for your contractors? Because I think this is something that a learning moment for other people, they can maybe copy your screening tool or get an idea of what they can do for their own businesses. Well, it's Speaker 2 (05:58): One that they we use to make sure that we don't have any symptoms. So checking the temperature every morning before you actually go to see a patient and asking the question, like certain questions, when, when you're scheduling a visit if they're filing in a coughing or sneezing when was the last time they got exposed or if they've been exposed to someone who traveled in the past 14 days or who's had any symptoms in the past 14 days. And so that was basically if they answered, no, then you be like, okay, fine. All you just need to do is wear the mask and the gloves and make sure that the patient that you're seeing wears the mask as well. Speaker 1 (06:41): Yeah. That's the big thing is making sure everybody's wearing a mask. Have you had any problems with people not wanting to wear a mask in their home when you go into treat them? Speaker 2 (06:51): We've had some, but most have been very compliant with, you know, wearing the mask because they realize that they, they, they do need the service. So like some patients who have like CHF or COPT that will have problems breathing while doing the exercises, I would allow them to, you know, take it off briefly, but I will step back six feet away and make sure that, you know, they get their respiration rate on the control. Then they put it back on. We'll do the exercise. Speaker 1 (07:22): Yeah. That makes sense. And are you taking, obviously taking vitals, pull socks and everything else temperature when you're going into the home? Speaker 2 (07:31): Yes. Yeah. Yeah. Speaker 1 (07:34): Okay. And I love the compulsive cleaning and wiping down of things. I'm still wiping down. If I go food shopping, I wipe everything down before I bring it into my home. And I realize it's crazy. That's crazy making, but I started doing it back in March and it seems to be working. So I continue to do it. And I'm the only one in my apartment, but I still wipe down all the handles. Speaker 2 (08:02): I would say don't lose sight of it though. Speaker 1 (08:07): I am. And I love that. You're like wiping down the car. I rented two car. I rented a car twice since COVID started. And I like almost used a can of Lysol one time. Like I liked out the whole thing and then I let it air out. And this is like in a garage going to pick it up for a rental place. And then I have like, those Sani wipes, like the real hospital disinfectants. And then I wiped everything down with those. And then I got in the car. Speaker 2 (08:36): Well, I saw it's very difficult to find Lysol here right now. So when you do find it, it's like finding gold. I know, Speaker 1 (08:44): I, I found Lysol wipes. They had Lysol wipes at Walgreens and I was like I said, Lysol wipes. And she was, yes. I was like, Oh my gosh. And then last week I found Clorox wipes, but in New York you can only get one. You can't there's no, Speaker 2 (09:04): Yeah. Care's the same thing. Toilet paper, whites, Lysol owning one per customer. So yeah, Speaker 1 (09:09): One per customer. Yeah, yeah, yeah. Oh, that's yeah, I was a thank God. I, I found one can of Lysol, one can at the supermarket and it was like, there is a light shining down on it and it was like glowing, glowing in the middle of the market. I'm like, Oh but I love, I love that all the screening tools that you're using and I think this is a great example for other people who might be going to P into people's homes who may be COVID positive. And I also think it's refreshing for you to say, yeah, I was nervous. Speaker 2 (09:47): I'm not going, gonna lie. You know, you still get nervous because you never know, like someone could be positive. And you're going in there, but you always want to be cautious because you're like, Oh my God, I hope I didn't like allow this to be touched or you forgot to wipe this and stuff too. So Speaker 1 (10:07): How much time are you spending in the home? Because there is that sort of time factor to it as well, exposure time. Right. Speaker 2 (10:16): It depends on the severity of the condition. But anywhere from like 30 minutes to like 45 minutes. Speaker 1 (10:25): Yeah, yeah, yeah. I know gone, gone are the days of, you know, spending that extra time and doing all this extra, extra work there, because if they're COVID positive, then I would assume that the longer you're in an exposed area, even though you're fully covered in PPE, I guess it raises your Speaker 2 (10:48): Well. Yeah. And, and the, in the summer, I would say, you know, depending on the amount of work that you had to do, like if you had to do like bed mobility and transfers with the patient, you'd be sweating under that gong. So you really want to want to be in there like a full hour anyway. But they were advising to spend, you know, minimum 30 minutes and to reduce the risk of you contracting it as well, too. Speaker 1 (11:17): Makes sense. So, all right. Speaker 2 (11:20): Decondition so they really can't tolerate a full hour. Speaker 1 (11:23): Right? Of course, of course. Yeah. That makes, that makes good sense. So now we've talked about obtaining the proper PPE. What other, what other pivots, I guess, is the best way to talk about it? Did you feel you had to do as the business owner? What things maybe, are you doing differently now than before? Speaker 2 (11:49): Well, as I said, I had to start seeing most of the cases to make sure that people were still being seen and like using telehealth. We started doing that. So eventually, well sky came on board to offer telehealth visits. So we were able to document telehealth visits as well. And people are responsive to those which worked out pretty well. So with some cases we'll do a one visit in the home and then do the follow-up visit telehealth. So one visit being in a home one weekend, one telehealth, if it was a twice a week patient. So that would also reduce the risk of exposure. Speaker 1 (12:40): Yeah. Yeah. Excellent. Now let's talk about keeping the business afloat, right? So yes, we're seeing patients. Yes. We're helping people, but we were also running a business. We got people to pay, we got people on payroll, you gotta pay yourself, you got to keep the business afloat to help all of these patients. So what was the most challenging part of this as from the eye of the business owner? Not the clinician. Speaker 2 (13:07): Well, you, you get fearful that you may not have enough patients to see, to cover previous expenses. So that was one of the reasons I did apply for the PPP loan. And as I mentioned to you before I was successful in acquiring that probably like around July and that, you know, cover like eight weeks of payroll, if that but it was strictly dedicated to payroll, nothing else. So everything else I had to do was to cover the bills and stuff, because that was just for payroll. Some of the agencies that we contracted for were having difficulty maintaining reimbursing. So that became a challenge as well, too. So what does that mean? Exactly. so when we contract with agencies, they're supposed to be paying us for this, the rehab services that we provide. Some of them were late with their payments as well, but I still had to pay my contractors on time. Speaker 1 (14:19): Got it. Okay. Got it. Oh, that's a pickle. Speaker 2 (14:22): Yeah, that's the thing. So that meant like sometimes some, you know, weeks of payroll, I would have to probably go over the lesson and making sure that the contractors were paid. Speaker 1 (14:37): And how about having a therapist? Furloughs? Did you have any of that? Did you know, were there any people, like maybe therapists in your area who were furloughed from their jobs and coming to you, like, Hey, do you have anything for me? Can you help? What was that situation? Speaker 2 (14:54): Yes. So I started getting free pretty among the calls about having to pick up to do work because they were followed or laid off. We currently have one contractor was working for ATI full-time that got followed. Now she's doing the home health full-time right now as a contractor we have some that are still doing it PRN, even though they went back to like their full-time jobs. But yes, we had people looking for cases to see, just to supplement the the income. Then we had a reverse situation where some people more comfortable getting the unemployment check than seeing patients at all. So, so that you had different scenarios, but it wasn't that we were in need of therapists during that time because people were willing to work. Speaker 1 (16:00): Yeah. Excellent. Excellent. And from the, I guess from your perspective being owner and clinician, so you're seeing patients you're running a business where there any sort of positive surprises that came out of this time for you, something that, that maybe made you think, Hmm. Maybe I'm going to do things a little differently moving forward? Speaker 2 (16:30): Yes. incorporating more telehealth visits. Definitely one of them and using the screening to there it helps in a lot of situations. So it makes you aware of what you might possibly be going into when you're going into the home. And I am realizing that there is one of the biggest things for therapeutic outcome is having a good relationship with your patients. So since most people aren't locked down, a lot of the patients that we do see they live by themselves, or they may just have one or two people in the home and they may possibly be working. So when going into the home, you're probably the only person that they're getting to talk to most days. So you, I saw the need to improve on soft skills and being approachable with your patients. So that was definitely a, a big thing for me. Speaker 1 (17:46): And how is that manifesting itself now? So now, you know, you figure we're what April, may, June, July, August, September, October, November, December eight, nine months in, so kind of having that realization of like, boy, this is this, I may be the only person this person speaks to today, all week, perhaps. I mean, that's can be a little, that can be a big responsibility. So how do you, how do you deal with that now that you're, you know, 10 months into this pandemic and yeah. How do, how do you feel about that now? Speaker 2 (18:29): Well, I still feel like some sort of contact needs to be maintained. So even though some patients may have been discharged they would contact the physician via a telehealth visit and asked to, you know, can you see it again? But you still maintain contact, make sure that, you know, you dropped a line and say, Hey, just following up to see if you're okay. That sort of stuff. So they, they will remember and they'll keep coming. Speaker 1 (18:58): Yeah, yeah, yeah. Oh yeah. It is such a responsibility, especially for those older patients who are, who are alone most of the time. I mean, it is it's, you know, we hear more and more about the mental health effects that COVID has had on a lot of people. So and I don't think that we're immune to those effects either. I mean, how, how do you deal with the stress of, because there's gotta be an underlying stress with all of this, right. So what do you do, how do you deal with that stress? Speaker 2 (19:38): Well, one was warmer. I would try to at least take the weekends off to go do something or those and like being around people where you can, you know, laugh and, you know, watch movies, you know, goof up, you know, I have to think about work, those things help. Speaker 1 (19:59): Yeah. Just finding those outlets that you can turn it off a little bit. And I love taking the weekends off every once in a while. I have to do that. I have to remember to do that. And I'm so jealous that you're just, you just came off of a nice little vacay as well. Speaker 2 (20:19): Well it was needed. I probably won't be taking one on till probably sometime next year, so yeah. But it was, it was definitely needed. Speaker 1 (20:32): Yeah. I think I'm going to, I think I'm going to do that too. All right. So anything else, any other advice that you may have for those working in home health when it comes to going to see those during these COVID times, whether the patient has, has had, has, or has had COVID what advice would you give to our fellow home health? Pts? Speaker 2 (21:00): Well, I know I've been hearing quite a lot of PT saying that they didn't want to treat COVID patients and they should not be subjected to treating COVID patients, but as we get more awareness of what the diseases and we take the necessary precautions, I think we will be okay. Cause everyone deserves to get quality care. And I know some people will say this person probably got COVID because they were being reckless and stuff. I mean, you can slip up, be as cautious as possible and still step up and get COVID. That doesn't mean you should be denying someone to receive that treatment just to make sure that you're protected when you do go in. Because we're gonna see a huge wave of COVID cases coming in the next few months and with elective surgeries being stopped and everything like that, that's going to be our only client population and to prevent the fools and the layoffs from happening again, I would just advise them, you know, do the screenings, make sure you get your PP and we'll see the patients. It's it's not as bad as, you know, they make it seem. Speaker 1 (22:16): Yeah. Excellent advice. Excellent advice. And now we're going to really switch gears here. Okay. So this is going to be like like a, a three 60 turnaround, but before we went, before we went on the air, Monique and I were talking about just some things that, that you wanted to talk about and recent happenings in the PT world, and you brought up sort of a list of influential PTs that was compiled by our lovely friend Ellie summers. So go ahead and talk to me about why that list was meaningful to you and why you kind of wanted to talk about it. Speaker 2 (23:03): Well, you know, for the past few years I've been noticing like people send us stuff to vote for like top influencers and, and physical therapy and stuff. Do you tend to see the same names like yesteryear? But you've never seen one that just strictly focuses on a woman in physical therapy. And I see a lot of women doing great things in the physical therapy world, but because they do not have as many followers on like Twitter or Instagram, they don't get the recognition that they deserve. For example, Dr. Lisa van who's I think she's doing incredible, incredible work with the Ujima Institute. I actually consider her a mentor of mine. She, she calms me down when I try to get fired. What's it and stuff, Speaker 1 (24:03): Not you. I don't believe it. Speaker 2 (24:06): So I appreciate her for that. So for Ellie to actually construct this list and, you know, I've, I've been observing her, her tweets on her posts for a while, and I see that she questions. Why is it that, you know, women do not get the recognition in a profession that is supposed to be female dominated. So for her to do the side, you know, it was, it was really thoughtful and needed. Speaker 1 (24:40): Yeah. Yeah. And you know, her shirt talk that she gave at the women in PT summit couple of years ago, I think it was the second year we did, it was so powerful. Like everybody was crying like in tears, she's crying, everyone else is crying. And that was the year Sharon Dunn was our keynote speaker. She got everybody crying. It was like everybody was crying the whole time, but crying in like in, in not, not in a sad way, but crying in a way because the stories were so powerful and really hit home and we just wanted to lift her up and support her. But yeah, and you know, the thing that I love the most about Ellie's list is she put herself on it. Yes. How many times have you made a list and put yourself on it? I can answer me. Never, never, never in a million years, have I made a list of like influential people to put myself on it? Never know. So I saw that and I was like, good for you. Good for you. Speaker 2 (25:44): Because you know, sometimes you, you and, and doing and doing stuff, you, you have to be kind to yourself first, love yourself first. And, and her doing that, I, I believe she's demonstrating that that is something that's that needs to be done. A lot of us, we don't give ourselves enough praise for the stuff that we do. Speaker 1 (26:05): Absolutely. Absolutely. It's sort of, it's a nice lead by example moment from her. So I really appreciated that list and, and yes, Dr. Vanhoose is like a queen. She's amazing. And every time, every time I hear her speak or, or I get the chance to talk with her through the Ujima Institute to me, it's amazing how someone can have the calm that she has and the power she has at the same time. Right. I mean, I don't have that. I don't, I even know how to do that, but she just, like, she's just gets it, you know? I don't know if that's a gift. It's a gift. Yeah, totally, totally. Okay. So as we wrap things up here, I'm going to ask you the one question that I ask everyone, and that is knowing where you are now in your life and in your career. What advice would you give to your younger self you're? You're that wide-eyed fresh face PT, just out of PT school. Speaker 2 (27:16): You can't save everybody. You can't save everybody nice. When you, when you just graduate as a therapist, you think you can save everyone a change, a wall. It takes time. Speaker 1 (27:33): Yeah. Oh, excellent answer. I don't think I've heard that one yet, but I think, I think it's true that having, and it's not, that's not a defeatist. That's not a defeatist thinking at all. Yeah. Speaker 2 (27:54): I think this year have thing come to more deaths as a therapist with patients than I have probably in the 12 years that I've been practicing. I'm sorry. Yeah, because you know, you do patients that you get attached to, you know, you have this person passed away and stuff like that. So it's good while it lasts, but to protect yourself mentally and emotionally, you just realize that you can save everybody. Yeah. I think this fund DEMEC is teaching us that too. Speaker 1 (28:35): Yeah. A hundred percent. Thank you for that. And now money, where can people find you website? Social media handles Speaker 2 (28:47): Social media handles are the same on Twitter and Instagram at physio for U F Y, Z I O. Number for you Facebook slash physio for you as well. And www physio for you.org is the website Speaker 1 (29:01): Awesome. Very easy. And just so everyone knows, I'll have links to all of those in the show notes under this episode at podcast dot healthy, wealthy, smart.com. So if you want to learn more about Monique, about her business I suggest you follow her on Instagram and Twitter, cause there's always great conversations and posts going on there initiated by Monique on anything from home health to DEI, to words of wisdom. So definitely give her a follow. So Monique, thank you so much for coming on. Let's see. Last time was a really long time. I can't believe it, it seems like 10 years ago, but I think it was really like three, three years ago. I think it was DSM like three years ago though. It seems like forever ago. So thank you for coming on again. I really appreciate it. Speaker 2 (29:56): You're welcome. And thank you for having me. Okay. Absolutely. And everyone needs to be safe. Okay. Yeah. Speaker 1 (30:01): Yes, you too. And everyone else, thank you so much for listening. Have a great couple of days and stay healthy, wealthy and smart.  

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Shannon Leggett, PT, DPT to talk about how to infuse yoga principles into physical therapy practice. Dr. Legget is a manually-based orthopedic physical therapist with 21 years of experience. I understand the complex nature of pain and the necessity to use a comprehensive, individualized treatment approach. In this episode, we discuss: Shannon's journey to becoming a yoga teacher How to infuse the principles of yoga, not just the moves or poses, into PT practice Cases studies in applying yoga principles in PT  The importance of breathwork  How to be more present through yoga  And much more!    Resources: Shannon's Instagram Shannon's LinkedIn Restorative Yoga  A big thank you to Net Health for sponsoring this episode! Learn more about Net Health Therapy for Private Practice here.    More About Dr. Leggett: I am a manually-based orthopedic physical therapist with 21 years of experience. I understand the complex nature of pain and the necessity to use a comprehensive, individualized treatment approach. I perform a thorough evaluation looking at movement, strength, flexibility and balance, as well as lifestyle. I believe that how we live influences our ability to heal. I combine my extensive background of treating musculoskeletal injuries with my training in mind-body techniques to formulate a holistic plan of care   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:                https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the full transcript here: Speaker 1 (00:07): Welcome to the healthy, wealthy, and smart podcast. Each week we interview the best and brightest in physical therapy, wellness, and entrepreneurship. We give you cutting edge information. You need to live your best life. Healthy, wealthy, and smart. The information in this podcast is for entertainment purposes only and should not be used as personalized medical advice. And now here's your host, Dr. Karen Litzy. Hey everybody. Welcome back to the podcast. I am your host parents in today's episode is brought to you by Speaker 2 (00:41): Net health. So net health now has net health therapy for private practice. This is a cloud-based all-in-one EMR solution for managing your practice. It handles scheduling documentation, billing, reporting needs. Plus lots more in one super easy to use package. And right now net health is offering a special deal for healthy, wealthy, and smart listeners. If you complete a demo with the net health team, you'll get a hundred dollars towards lunch for your staff. Visit net health.com/see to get started, and you'll also get access to free resources for PTs like eBooks on demand, webinars, and business tools. Once again, that's net health.com/l I T Z Y my last name now onto today's episode, we are going to be talking about how you can infuse yoga into your orthopedic physical therapy practice. And this is more than just infusing some yoga moves, but really infusing the background and philosophy of yoga into your physical therapy practice and to help us navigate that I'm really happy to have on the program, Dr. Speaker 2 (01:53): Shannon Leggett, she is an orthopedic, a manual physical therapy with 20 years of experience. She understands the complex nature of pain and the necessity to use a comprehensive individualized treatment approach. She performs thorough evaluations, looking at movements, strength, flexibility, and balance, as well as lifestyle. Shannon believes that how we live influences our ability to heal. So she has been able to successfully combine her extensive background of treating musculoskeletal injuries with their training and mind body techniques to formulate a holistic plan of care. And in this episode, we talk about just that, how to infuse yoga into your regular physical therapy treatments. And like I said, it goes beyond just some yoga poses and stretches, but really infusing the background and the philosophy of yoga in with your patient in with your patient treatments, but also with infusing your whole philosophy of physical therapy and how you work with your patients. So a big thanks to Shannon and everyone Speaker 3 (03:00): Enjoyed today's episode. Hey, Shannon, welcome to the podcast. I'm happy to have you on. Thanks, Ken. I'm really happy to be here. So today we're going to talk about how you have been able to infuse yoga and not just yoga the movements, but yoga, the principles into your physical therapy practice. And just for the listeners, I actually took one of Shannon's yoga classes online and it was wonderful. So thank you for having me joining. Yeah, it was great. So before we get into how you do this within your orthopedic physical therapy practice, I would love for you to let the listeners know how you yourself came into the practice of yoga. Well, it's actually kind of a funny story. I was probably in my mid thirties, which I'm not going to tell you how long ago that was. I'm not dating myself here, but I ended a relationship and I think as so many women do, it's like you either cut or dye your hair or you try something new. Okay. Speaker 3 (04:06): So trying to rock the pixie cut back then, like, I couldn't do anything with my hair. So I, I walked into my first yoga class of the New York health and racquet club on first Avenue on the upper East side. I know it, and there I was. And now that I know yoga, it was an Iyengar class, which is very alignment based very slow, very methodical holding poses. And I remember waking up the next day and being so incredibly sore and like a muscles. I mean, basically I should know what the muscles are, but like, Oh my God, that's what those feel like when you use them for long periods of time and the physical practice that, that sensation, that feeling kind of kept me going back for more. And then as time went on, I started to recognize the mental aspects of the practice that whatever I was walking into the yoga studio with or holding onto was kind of magically disappeared at the end of the class. Speaker 3 (05:13): And I am an anxiety sufferer, which I only have come to understand and realize what that was. And till like in a, within the last 10 years and yoga then became a very strong coping strategy for me. I found being connected to my body and connected to my person and putting an hour of self-care aside for me was absolutely essential. So it's definitely become one of my go-to tools to kind of handle the day in and day out stress of living, working in, in New York city. So I would think, especially now, during the times, yeah, hands down now it is. And I, and I was home for a couple of months, like everybody else. And it was, I was on my mat every single day. And then decided while I was home, I was like, well, why not see who else wants to practice? Speaker 3 (06:14): But yeah, so I, it has always been in the last like 12, 15 years, very much part of my life on a personal standpoint, it has led me to travel. I've met great people, I've taken amazing classes and explored studios in different forms. But it wasn't until probably within the last five or six years that I started to connect some dots professionally, right? Like how, how could this fit into what I do professionally? I, in terms of like a stretching standpoint, a strength building standpoint, yoga is amazing, but what about the body, the mind body connection. And I started to notice trends with a lot of my female patients I've been treating in Midtown for most of my career. And women would be walking into the clinic with your like standard orthopedic injuries, shoulder impingement, low back pain, and their response to an injury that would not necessarily be anything like, okay, just the pain was off the charts and difficult to get under control and not necessarily responding to what you would consider standard practice and you start to talk to them and they have fertility. Speaker 3 (07:38): They've had fertility issues. They've had gastrointestinal issues. They're working full time. They are full time moms too, trying to be the best they can be in both realms and self-care is last. They don't sleep well, they don't eat well. And I realized that the stress component was driving their inability to heal or meaning their ability to, you know, kind of get back to what they enjoyed. And I just was said to myself, well, how can I as a clinician kind of break into that stress cycle, how can I maybe help them Crump, you know, calm down some of their chronic systemic inflammation, how can we help them with negative thought patterns and, and whatnot. And that's not something that we traditionally are taught in physical therapy school and it, and is it my scope of practice and kind of going back and forth. Speaker 3 (08:38): So I started taking some continuing ed classes in the yoga world, and I've done some work with a clinical psychologist in Boston who treats her anxiety and depression patients with, with yoga and bodywork techniques. And, and she's a ton of research as to how mindfulness begins in the body that studies have shown that, that kind of short circuits, that stress response in your brain. So that kind of led me in that direction. And then I walked into my restorative yoga training, which I had never really taken, but it intrigued me. And because I just kind of felt intuitively that it was going to be the, like the last, not the last piece, because there's never a last piece, but a piece of the puzzle that I was missing. And it basically is how we can go from our sympathetic or fight or flight part of our nervous system into our rest and digest our parasympathetic sympathetic nervous system and how much our nervous system can drive, how we feel. Speaker 3 (09:41): And so often we have patients with chronic neck pain, chronic low back pain, like the massage, they feel better for an hour. It comes back and just this idea of chronic tension versus chronic tightness. And what restorative training does is it brings you into yoga shapes, but they're basically supported with props and it's a guided meditation and breath work. And as you move through the shape or state in the shape, you can flip the switch that vagus nerve stimulator, vagus nerve, and move into that rest and digest part of the nervous system. And I mean, in theory, like, okay, great. But four days of training and I always have neck pain, always. And I just attributed to everything we do. And that role was that from holidays and, you know, that's stressful time, but the month of December, yeah. Within four days, my neck pain was gone. Speaker 3 (10:52): It was incredible to me, how much of that pain was actually chronic tension and not necessarily this orthopedic tightness. So it was a kind of an aha moment for me in terms of what patients might carry. And I have used the teaching, the methodology in my treatment sessions, patients don't necessarily understand clients don't necessarily understand that they hold habitual tension. And so much of us, like when we say like, Oh, we have to relax. Like we sit down on the couch and drink a glass of wine and, you know, watch eight hours of Netflix. We're like, we're totally just chilling. But yet, like are holding our belly. Like our shoulders are up here, like clenching our jaw. Like we don't even know because we're relaxing. And part of, part of the restorative yoga is understanding where those patterns are. You get to know your body. Like for me, I'm a draw puncher, I'm a shoulder up late year. And, and, and once you understand that you kinda like kinda, I do like some check-ins during the day, like where are my shoulders? Where's my jaw. And taking a deep breath and kind of like letting that go. Speaker 4 (12:11): Yeah. As, as you say, this I'm unclenching my jaw a little bit. I'm a jock ledger also. So as you say this, I'm like, relax, the jaw, drop the shoulders. I am the same way. Well, it's, it's pretty amazing because it sounds like for you, and this happens, I've heard this over and over again, that it's this sort of personal experience. You have that aha moment. And then you say to yourself, well, I'm a clinician I'm trying to help people. So what can I do to improve my understanding as a clinician to help my patients? So you go, you take restorative yoga training, and then you are able to infuse that into your therapy sessions. And we were joking a bit before we went on the air. And Shannon said, well, it's not like I'm having someone who just had a labral tear, do a shoulder stand. Like that's not what it means to do, like yoga and PT. So when people think of yoga and infusing yoga into PT, I bet a lot of people think, Oh, you must do a lot of downward dogs and a lot of shoulder stands, but can you explain for a little bit more about what, what that means in, in your PT practice? Speaker 3 (13:26): Absolutely. I, if somebody comes in at, like, I was thinking a case, a case study, let's do I have a frozen shoulder? And how much of that again, tension versus tightness, how much of that tightness is being driven by the nervous system? So I'm, I always ask about stress levels. What's going on at home at work. You know, things that people do to, to, to maybe calm down or relax. And I might say, Hey, we're going to have a little bit of an experiment today. Okay. I am gonna prop you. We, I pull off of the blankets and the pillows and I'll put them in a very gentle chest opener because oftentimes you're doing a ton of stretching with a frozen shoulder or a lot of soft tissue work. If there's a level or component to stress or anxiety to that, that cranking is just going to cause your, your nervous system just clamp down and, and, and they're going to, you're going to get the exact opposite of it. Speaker 4 (14:32): Yeah, absolutely. And even like, we know if you're cranking on an arm and the, those first three to six months. No good, no good, no good. Not, not good for the patient, not good for the shoulder, Speaker 3 (14:46): Not at all. So I might spend a couple of sessions with a patient props, kind of guiding their nervous system into letting go. Typically the, you know, shoulders are rounded, pecks are tight, upper traps. So if I can kind of guide them into relaxing, letting go, I typically find a little bit more space. They're a little more trusting of me to like, maybe move them. Maybe I can modulate their pain a little bit. So they will be a little bit more, or a little less fearful of movement themselves because it's a big deal I'm to us are in pain and they don't want to move. They don't want to go in any direction that that is going to maybe reproduce their symptoms. Speaker 4 (15:35): Of course. Yeah. And, and so much goes into that sort of bucket when you're talking about pain. So there's so much that can fill that up. You know, we look at things through a bio-psycho-social lens, you know, you're asking about sleep and stress and all that goes into this, this sort of bucket. And then it gets to the point where the nervous system senses danger. And it's like, okay, that's it. We're gonna it's time. You know, the brain makes that decision. It's dangerous enough pain, right? Yep. Speaker 3 (16:06): We're going to fight, we're going to flight or we're going to freeze and think about a frozen shoulder, how much of that could be nervous system driven. And you know, and also too, just bringing in some of the mindfulness component of yoga, you know, the yoga sutras, which are kind of like the blueprint of yoga, the philosophy of yoga, the first Sutra is yoga is now that is, I mean, that is mindfulness. That is in the moment. That is the definition right there. So I use that idea of mindfulness or the tool of mindfulness to bring in throughout the day. Like I mentioned earlier, like doing a little check-in with yourself, oftentimes with my patients, I'll say, you know what, in the midst of your day, when you're like, Oh my God, if one more person calls me or how am I going to get these emails done? Speaker 3 (16:54): Or like, I have to make the train to get home to the kids. No, one's competing now. I want you to tap in or tune into your body and come back and tell me where you hold your attention. I want to know, are your shoulders up? And your ears are your jaw clincher. So often, do you hold your belly in? You think about our patients with urinary stress incontinence with low back pain. You know, I mean, if you're clenching your belly all day, that's, that is going to be, maybe unclenching will be part of the solution. So that idea of being present of checking in that is a tool I use throughout the day with my patients. That's great. And you know, with so many we're so externally focused, everything is outside. We're always 10 steps ahead. We just become very disconnected with our physical being. And I love bringing patients back into their body to teach them something that they didn't even know. You know? And I, I love when people are like, Oh my, my quadriceps. And they're like holding their hamstrings. Like we have this tool that we've been given this machine that we've been given, but nobody really educates us on how to use it or what it's about or how it moves. And I love bringing that idea of mindfulness and mindful movement into the physical therapy practice. Yeah, Speaker 4 (18:17): I think it's great. And the other thing, as you were talking about putting people into these different restorative poses that can then be transferred over to a home exercise program, Speaker 3 (18:27): Easy. I mean, honestly, like laying down on the floor, throwing your feet over the couch, the restorative doesn't even have to have props. It's basically the idea. Now don't get me wrong. The props are delicious, but the restorative is learning how to let go of that tension. As you breathe, it's letting the ground hold you up. It's letting the couch hold you up. It's letting, it's starting to kind of give into something else. You know, how much of us, like we put a coat of armor on every day, like, especially now to get through the day. And so in order to survive, we, we put on armor. Yeah. It's just in a physical structure. Yeah, yeah, absolutely. On the floor, legs on the couch, close your eyes and just breathe. And honestly, that's yoga. Speaker 4 (19:21): It doesn't have to be too complicated, Speaker 3 (19:23): Not at all. And sometimes when I start to bring things up, people like, Oh my God. Cause they think Instagram, they think poses, they think exactly very like thin, cute people, like by a pool. And it's just, it's mindfulness. It's the breath it's awareness. It doesn't have to be, it doesn't have to be twisty and credit. And I think, I think my practice is in twisting. Speaker 4 (19:48): Yeah. I think that's good to know, because I think a lot of people will look at yoga and they look at the show of it. You know what I mean? The spectacle, the show of, wow. Look at this person being able to, you know, do a handstand or a headstand and look at this and look at the positions. They can go, Oh, I can never do that. So Speaker 3 (20:06): I'm just not going to do it exactly like that. It's not for me. Or people feel ashamed and mean, especially like the, the men, they will not walk into a class because they don't want their I'd be embarrassed. And like, no one is looking at you. No one. And that's the thing I love about a studio. Like I'm an orthopedic physical therapist. I have, I'm not athletic. I love athleticism. I am not athletic. So when I love about the studio is like, I can move. I can breathe. I can exercise. No one's watching. Yeah. It's true. It's like in their own little world and that's speaks to the introvert in me like nobody's business. Speaker 4 (20:49): Yeah. Although sometimes I will say, if I go to a class, I will be looking at other people that being said one of the best yoga classes I ever did, we were blindfolded. All of that's extraordinary because it was a, it was a charity class for a charity called Achilles and Achilles supplies. Pairs runners who are hard of sight. Yeah. To do all different kinds of races from a 5k up to a marathon. And because the people they serve are usually blind. We did the whole class folded and I was thinking, Oh my God, I'm going to fall over because you know, vision is a big part of balance, but it was the best yoga class I'd ever taken because I wasn't comparing myself to everyone else. The instructor was giving really clear instructions and my balance was better because I was actually paying attention to myself versus looking at what everybody else was doing. Speaker 4 (21:46): Absolutely. And you really had to talk about a journey inward. Yeah. Right. And having to be in touch with like what your own body was doing and how you're going to assimilate. Yeah. Yeah. It was really interesting. The only weird part was the woman next to me, kept trying to hold my hand and I had to keep like, I'm like, what are you doing? And then after it, she was like, Oh, I'm sorry. I thought you were my friend. I'm like, I kind of kept taking me out of the vibe a little bit, but that is a loving community. Community is a loving community. Yes. But I really, I really loved the way I felt after that. And it, it, you know, it really got me thinking like, wow, this is something that I should be doing with my patients when we're just working on general movement is kind of have them close their eyes and really feel the movement and get into it. But now let's you, so you talked about some of the the tenants of yoga. One is yoga is now being very mindful. What other aspects of yoga aside from, you know, positioning people, restorative, what other tenants of yoga are you using with your clients or with your patients? Speaker 2 (22:59): And on that note, we're going to take a quick break to hear from our sponsor. And we'll be right back with Shannon's answer net health therapy for private practice as a cloud-based all in one EMR solution for managing your practice. That's right. One piece of software that handles all of your scheduling documentation, billing and reporting needs. Plus lots more and one super easy to use package right now, net health is offering a special deal for healthy, wealthy, and smart listeners completed demo with the net health team and get a hundred dollars towards lunch for your staff. Visit net health.com/see, to get started and get access to free resources for PTs like eBooks on demand, webinars, and business tools. Once again, that's net health.com/l I T Z Y Speaker 3 (23:49): I definitely, yes, I use the restorative, but I also use a little bit more of the, the poses, the strength building poses, the even some small sequences. I, I look at maybe look at the system as a whole, right? The fascial system, everything is connected especially my patients that sit all day. So that front body, everything is tight. Tip lecturers, chest front neck. I will give them maybe sequences of some easy poses that they can do at home to open that whole space. My runners runners don't like to stretch. They just want to run. So I always say, okay, we need to do some flexibility. And some mobility work to keep you running healthy. There's nothing better than yoga as far as I'm concerned. Thank for the buck. Especially looking through like fascial systems, you give someone a downward facing dog. Speaker 3 (24:54): Well, they're opening their shoulders, calves, hamstrings, low back. They're working on their core. So I love, I love the physical poses to help my runners, my sequences, my restorative, my breath work. How could I forget my breath work pranayama? Right? What's one of the eight limb path of yoga is breath work. And I pretty much teach every single patient who walks into my space to breathe. It is one of the most powerful tools that we have to connect to ourselves to calm our nervous system. But again, our low back pain patients, our neck pain patients, how many neck pain patients do we see that are breathing they're with their accessory muscles. So using maybe even to dossena another pose mountain pose, which is basically standing straight it's posture. So everybody learns to Dawson. And then from 2000, and once we get into that, that rib cage of pelvis alignment, we work on our breath and diaphragmatic breath, finding the belly, maybe then connecting to pelvic floor, especially for my women. Speaker 3 (26:15): So I definitely use Tadasana as my, like one point as to finding, finding a good position, finding a good home base and breath and how they can use breath work to help them with their stress response. And part of what I love is sometimes I'll teach my core patients and I don't even tell them what the breathing like. I'll tell them, listen, you know, reading is important for core, and it might with your neck pain and low back pain. So we're just, that's what we're going to start. And what I love is when a couple of visits later, they're like, you know, we feel really calm. I feel calm after I do that. And I'm starting, and I'm starting to use that like during the day. And I secretly love that Speaker 4 (27:02): Really giving tools that they can use throughout the day and that they can also see the difference. And we know that once people see the difference in the tools, we give them, they'll use them. Speaker 3 (27:13): Yes. And that's how I listen. Some people I know right off the bat that I can like infuse and introduce yoga and they're going to be all for it. Other people I know that are going to be skeptical. So that's, Speaker 4 (27:25): That's a good point. You bring up because a lot of people like yoga. So how do you, and so do you use then use the breath work to kind of open the Gates a little bit Speaker 3 (27:34): Sometimes, or I'll say, Hey, you know, the yoga has some amazing, you know, stretches that might help you with what's going on. And because they stretch multiple fascial systems, they can be very effective or, you know, not effective, but efficient everybody in the city wants to be efficient. True. So if you give them a couple of things and then they become more curious or I'll work on some mindfulness, or I will educate them, maybe how stress response can be driving their pain how having a hobby or movement can like also be an effective part of their healing process. So I, I kind of sneak it in, in, in different ways. Got it, got it. No, that makes a lot of sense. And also too, for like my, my runners, I have run a bunch of half-marathons. I did in New York city marathon in 2018, yoga is a tremendous compliment to running and read, like, it got me to the finish line. I don't think I'll ever do it again, but you never know. I've never say never, never say, never say never. So that's where, you know, anytime you tell a runner that you could help them be better, faster, stronger of they're onboard. Yeah. Very, very true. Speaker 4 (29:04): Now, what advice would you have to other physical therapists or other clinicians Speaker 3 (29:10): Who maybe Speaker 4 (29:11): Are interested in yoga or interested in infusing yoga into their practice? What are some good starting points Speaker 3 (29:20): For them? I would say, start taking some classes, yourself, understand how it makes you feel, understand the language, the sequencing the poses, you know, I, I think experience is one of the teachers. I learned by doing things in my own body and that makes me a much more effective clinician sometimes. So I would say, start taking some classes, notice the benefit yourself, listen to maybe even how yoga teachers instruct. I learned some of the best cues and best instruction from some of the yoga teachers that I have gone and work with. And starting to maybe infuse it a little bit in your sessions, in your, in your PT sessions and see how the patients respond. And then from there, there are continuing ed classes out there for physical therapists who don't necessarily want to take the 200 hour training that can learn how to use yoga in healthcare. Speaker 3 (30:30): Yeah. I took a, a great one threes, physio, yoga they are amazing. They're, they're great to follow on Instagram, if you want to learn a little bit more. I have, but they have they just did a class that I took, do I want to, no, it was maybe last year again, it's the whole thing of how to infuse yoga and physical therapy. So there there's plenty of stuff out there. There's plenty of PTs out there that are, that are doing this, that have Instagram pages. So just starting to follow, take classes easy. That's what I would do. It is so easy. It's easy. Yeah. I mean, I didn't do my yoga training until, you know, 2016, but I was using the poses and using some tenets like long, long before I was just from my own experience. Speaker 4 (31:22): Yeah. No, I love the advice to kind of take it yourself, see how you see how it feels. Cause listen, you may think you want to infuse it into your treatment and then you may take it yourself and be like, Oh, I don't, I'm not feeling this. And that's okay. You can, you can. Speaker 3 (31:37): Okay. Absolutely. It doesn't resonate with everybody. Speaker 4 (31:40): That's right. That's right. That's right. And that's okay. Awesome. So now before we kind of wrap things up, I think we, we have your one biggest takeaway is to start taking yoga classes yourself. Anything else that you want the listeners to walk away from this conversation? Speaker 3 (32:03): There are many modalities out there to help the healing process. And there are many practitioners that have different ideas to help you get there. And I think that I encourage people to find what works for them. And that sometimes some of the less traditional practices can be extraordinarily helpful. I mean, I think I personally think yoga is an extraordinarily powerful tool from the mind body perspective, we understand how much chronic pain does become a central nervous system, you know, issue that it's not just all biomechanical. So we do have to treat the whole person. We have to treat mind as well as body. And I think that yoga can be a very powerful tool, the combination and to, to, to seek and to try and to find what resonates and find what helps you. And to just, you know, it's not ever linear, it's not ever a straight trajectory. Healing is totally a journey and to not give up and just because you've tried one thing, does it mean nothing? Nothing is going to work, update, curious, stay active stay moving, find something you love to do. It doesn't have to be yoga, but move and movement is meditative. It's mindful. You know, the body, the body responds to movement. Speaker 4 (33:53): Absolutely. And now before we wrap things up, this is a question I ask everyone knowing where you are now in your life and in your career, what advice would you give to your younger self who graduated right out of PT school, a newly minted PT. Speaker 3 (34:11): I wish I had forged my own path earlier. I wish that I had listened to, you know, nothing has ever really fit for me until I brought yoga into my profession. It speaks to me. It makes sense to me. I wish I had, you know, when we did the webinar with sturdy, like let your freak flag fly, you know, be like, don't be like everybody else. I wish I had listened to that earlier, like towards my own path to not try to not try to fit myself into someone else's business model. Yeah. It's okay to want something different. It's okay. To think outside the box. It's okay. Speaker 4 (35:01): And sometimes, Speaker 3 (35:02): You know, what, what you think at first is going to work doesn't and then you find another tool. Totally have a huge toolbox. Yeah. Speaker 4 (35:12): Oh, I know. That was such good advice, you know? Cause I think so often, especially in physical therapy, as we discussed during that webinar, it's like physical therapists tend to be type a, we want to, you know, we want to be the best we wanted. We want to do good. We want to help others. And so we tend to kind of just stay in the lane totally. And are afraid to like, let the freak flag fly if you want is very hard to say, but it's true. It's true. And I thank you for reminding me and reminding the listeners of that now, where can people find you? Yes. Be true to yourself and where can people find you speaking? You can find me on LinkedIn and Instagram and what's your handle on Instagram? That's funny. That is, that is my nickname. My family, my nieces call me Shanny. Speaker 4 (36:03): S H a N N Y O G a P T and my C O very long. Very cute. I get it. I get it. Shen yoga, PTM, YC. Perfect. Perfect. Awesome. So people can find you there and we will have links to all of what Shannon spoke about today, resources and things like that. We'll put them all into the show notes at podcast on healthy, wealthy, smart.com. So one click will take you to everything we discussed today. So Shannon, thank you so much for coming on and talking about how to use yoga in your physical therapy practice. So thank you. Oh, thank you, Karen. It was a pleasure. I love, I love, I got to share the best of like my favorite part of the world. Awesome. Thank you so much. And everyone who's out there listening. Thanks so much for listening. Have a great couple of days and stay healthy, wealthy and smart. Speaker 2 (37:01): Big thank you to Shannon for sharing how she incorporates her passion, which is yoga into her physical therapy practice. And of course thank you to net health for sponsoring today's episode net health therapy for private practice is a cloud-based all-in-one EMR solution for managing your practice. One piece of software that handles all of your scheduling documentation, billing and reporting needs. Plus lots more in one super easy to use package net health is offering a special deal for healthy, wealthy, and smart listeners completed demo with the net health team and get a hundred dollars towards lunch for your staff. Visit net health.com/ let's see to get started and get access to free resources for PTs like eBooks on demand, webinars, and business tools. Once again, that's net health.com/l I T Z Y. Speaker 1 (37:53): Thank you for listening and please subscribe to the podcast at podcast dot healthy, wealthy, smart.com. And don't forget to follow us on social media.

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Joe, Tatta, PT, DPT to talk about using acceptance and mindfulness-based interventions to build resilience and overcome chronic pain. Dr. Joe Tatta is a global leader in integrative pain care and an advocate for the safe and effective treatment of chronic pain. He is the Founder of the Integrative Pain Science Institute, a cutting-edge health company reinventing pain care through evidence-based treatment, research, and professional development.  In this episode, we discuss: 1. Psychological variables associated with chronic pain 2. What is Acceptance and Commitment Therapy (ACT)  3. How is ACT different from traditional cognitive behavioral approaches and pain education? 4. How is ACT different from mindfulness, like the kind we encounter in popular culture? 5. How does ACT help physical therapists’ function better and prevent professional burnout?  6. Dr. Tatta's latest book “Radical Relief: A Guide to Overcome Chronic Pain   Resources: Radical Relief Book  ACT for Chronic Pain Professional Training Course:  Mindfulness-Based Pain Relief Practitioner Certification RELIEF: and online mindfulness community for pain care. Facebook: @drjoetatta Instagram: @drjoetatta Twitter: @drjoetatta A big thank you to Net Health for sponsoring this episode! Learn more about the Redoc Patient Portal here.    More about Dr. Joe Tatta:  Dr. Joe Tatta is a global leader in integrative pain care and an advocate for the safe and effective treatment of chronic pain. He is the Founder of the Integrative Pain Science Institute, a cutting-edge health company reinventing pain care through evidence-based treatment, research, and professional development. For 25 years he has supported people living with pain and helped practitioners deliver more effective pain management. His research and career achievements include scalable practice models centered on lifestyle medicine, health behavior change, and digital therapeutics. He is a Doctor of Physical Therapy, a Board-Certified Nutrition Specialist, and Acceptance and Commitment Therapy trainer. Dr. Tatta is the author of two bestselling books Radical Relief: A Guide to Overcome Chronic Pain and Heal Your Pain Now: The Revolutionary Program to Reset Your Brain and Body for a Pain-Free Life and host of weekly Healing Pain Podcast. Learn more by visiting www.integrativepainscienceinstitute.com.   Subscribe to Healthy, Wealthy & Smart: Website:                      https://podcast.healthywealthysmart.com Apple Podcasts:          https://podcasts.apple.com/us/podcast/healthy-wealthy-smart/id532717264 Spotify:                        https://open.spotify.com/show/6ELmKwE4mSZXBB8TiQvp73 SoundCloud:               https://soundcloud.com/healthywealthysmart Stitcher:                       https://www.stitcher.com/show/healthy-wealthy-smart iHeart Radio:                https://www.iheart.com/podcast/263-healthy-wealthy-smart-27628927   Read the full transcript here: Speaker 1 (00:00:01): Hey, Joe. Welcome back to the podcast. I'm happy to have you on again. Speaker 2 (00:00:06): Hi Karen. Thanks for inviting me. I'm excited to be here. Speaker 1 (00:00:08): Yes. And today we're going to be tough. Well, let's not let's, let's roll it back for a second. So it seems like each time you've come on, we've talked about some different aspects of pain, right? We're both in that chronic pain world, we love treating people with chronic pain and talking about chronic pain or persistent pain. And we've done that quite a bit. We've talked about the psychological variables associated with persistent pain and how psychologically informed physical therapy is so important. So let's talk about which variables we should be most concerned about with regard to effectively treating pain, big question right out of the gate. Speaker 2 (00:00:52): It is, and it's a, it's a great place to start. And that's a question that all of us are asking ourselves and researchers are asking this question more and more and we're trying to figure out, okay, what is like the key variable? Is there one key variable that we should be paying attention to? And it's interesting if you look at the evolution of chronic pain and I think both you and I have been practicing for about 25 years. So we've really have seen things transitioned from this biomedical biomechanical model, right? And the core of that was let me figure out, let's try and figure out or identify what's wrong with the physical body. Right. Pretty easy. Speaker 1 (00:01:34): And then the pain goes away. Speaker 2 (00:01:36): Exactly. And we were all there at one point, then this bio-psycho-social model comes in and we're like, okay, there was there a psychological variables that we should pay attention to. And what's interesting is when I talked to physical therapists about the psychological variables, they bring in a little bit of that older biomedical model in the sense of how can I identify what's wrong. And then if I know what's wrong, then I can fix it. And it makes sense. And that even shows up in some of our mental health colleagues as well when they approach people with pain. So when we look at, you know, there's kind of like five big ones pink catastrophizing, can you see your phobia, fear, avoidance, depression, anxiety, those five persistently show up in the literature as variables that are associated with poor outcomes with regards to chronic pain. So you see them all the time and we have ways we can test for it, right? Pain, catastrophizing scale Tampa kinesiophobia scale, et cetera, et cetera, evolve are well aware of these. And we all use them. What I want people to consider for a moment is these are all what we would call vulnerability processes. So this is what makes someone vulnerable to transitioning, let's say from acute pain to chronic pain and they may be important and they are important, but I would like people to consider for a minute. If you flip the coin over, what's the opposite side of vulnerability. Speaker 2 (00:03:13): And this is really important when we think about chronic pain, because our job as professionals is not necessarily to identify here's, what's wrong. You physically, here's, what's wrong with you psychologically or emotionally. And now I'm going to fix, modify or change those variables. We want to focus on as professionals. The other side of that coin is how can I help someone be more resilient? How do I develop, build or foster a sense of resiliency. So that other side of the coin, which is really what has interested me the most, I'd say in the past 10 years is looking at those positive, psychological factors that are associated with resiliency. There's three of them. We can kind of talk about them a little bit each but there are pain, self-efficacy pain, acceptance, and then values based living. Speaker 1 (00:04:01): Okay. So let's dive into each of those. So let's start with pain. Self-Efficacy what the heck does that mean? Speaker 2 (00:04:09): Yeah. And we hear the word self-efficacy used a lot, and I want to make sure that we tag on the word pain with that because just normal quote unquote self-efficacy you can measure self efficacy, but really as a pain professional, whether you're a physical therapist or another licensed health, professional, or certified actualize professional someone's confidence or their ability and their confidence in themselves to function and figure out what the cause of their pain isn't to overcome. It is basically what we identify as pain self-efficacy. Now you can actually have good self efficacy and have poor pain self-efficacy so it's important as professionals that we look at him as, okay, how can I help someone with pain self-efficacy with regard to their rehabilitation and overcoming pain. Speaker 1 (00:05:04): And so say that one more time for me, I'm going to edit some of this out, but I just want to get that into my own brain. Speaker 2 (00:05:15): No, no problem. So paint, self efficacy is one's confidence regarding their ability to function while they experience a while they have pain. Speaker 1 (00:05:24): Okay. Got it. Got it. All right. That makes sense. And that is coming from someone, the long history of chronic pain. That's not easy. Can I say that? Is it okay to say that that's not easy? Speaker 2 (00:05:41): Absolutely. And it does go back to what I mentioned a little bit earlier, where okay. If I have pain, it's this message this signal, if you will, that something's wrong. And it's perfectly normal that your mind goes to the place of, I want to stop. I want to eliminate, I want to resolve this pain with acute pain. That's fine. With chronic pain. It's something very different. And if someone gets kind of caught up in that Whirlpool, if you will, of constantly spinning and trying to figure out, okay, what is the cause of this? And they go down that biomedical route, that's where people wind up in trouble and where they don't find a solution for their pain and why pain persists. So pain self-advocacy is interesting because it's like, okay, do I have the knowledge? Do I have the tools? I have the ability in myself, right? Speaker 2 (00:06:36): Because if we're not looking at vulnerability for looking at resiliency, really what we're saying is somewhere within, inside you deep inside you actually, you have the ability to contact something that you haven't contacted yet, or maybe you've only contacted a piece of it. But if I can help you with that, if I can help you along that path, if I can help you along that journey, then we can improve your pain, self efficacy. And it's potentially the research is still kind of unclear, but it's potentially the number one factor, the number one resiliency factor with overcoming chronic pain. Speaker 1 (00:07:13): Oh gosh. As you're, you're saying that I, in my head, I'm going back, you know, 10, 15 years to when I was in pain all the time. And yes, I was searching for that fix. And what I found when my pain started to recede, I started to feel better was that I was always looking for that external fix. When in fact I had to look into myself to see how, what I can do to overcome this and, and to kind of move forward and make the best decisions I can at the time, the information that I have and be okay with it and then move forward. And that was the thing that really helped to kind of flip the switch for me. Speaker 2 (00:08:00): That's right. And there's, there's two really important things embedded in what you just said. The first is, as physical therapists were very aware of pain, avoidance painted warnings is almost when I look at pain avoidance now after studying acceptance and commitment therapy, I look at painted. William says, it's too simple. So it's like, if the, you know, if you put your hand over the flame, I pull my hand away. I avoid pain. If there's a rock in your shoe, you want to walk differently or take the rock out. What you're saying in your experience, Karen, which is common in many, people's almost every single person's experience you've had chronic pain. Is that the pain persisted for so long that not only did I avoid pain, but I started to move away from everything that was important in my life. And I moved toward only those potential areas on the, on, toward the potential causes that could alleviate my pain. Speaker 2 (00:09:00): Now in the act that's called experiential avoidance. And again, it's a little bit different than regular pain avoidance because experiential avoidance means the entire experience. The entire capsule of my life what's encased in there is only to seek out the elimination or the control of pain. And when that happens, that's when people go down sometimes sad and sometimes very scary routes of things like surgeries that don't work and one medication or multiple medications, or we see, you know, behaviors lead to passive treatments you know, leaving work and disconnected from personal relationships, all the things that we see that our patients struggle with. So it's what you say is really important. And to try to make those distinctions for therapists, I think are also important as well, because we can skim along the surface of pain, avoidance, so to speak. But I really believe if we want to be effective with pain, we need to go on this deeper level with people looking at that pain, self efficacy, looking at pain acceptance. And then the last one looking at values based living, which is what ha, which is actually the flip side of experiential avoidance. Speaker 1 (00:10:15): And something that you just said that sort of avoidance becomes all encompassing. And, and I will agree. That's exactly what would happen. Like I can remember doing things like going to an acupuncturist and having them put all these needles in my ear. And then I had to walk around the plinth counterclockwise three times. I mean, when you think about that, you're like, what? But I was so desperate. Like I was doing anything and everything for that fix. When I knew even as a physical therapist that walking counterclockwise around uplift three times doesn't really make a difference. But yet here I am doing it and doing that instead of, I don't know, meeting up with friends, right. Relaxing, going to the gym. Like I was avoiding all that other stuff because I was so laser focused on finding this cure, so to speak Speaker 2 (00:11:21): That's right. And as you're talking to me and I'm imagining what it's like for YouTube and in that experience, and you're talking about going to an acupuncturist with which, you know, I tell people, look, if you have one passive treatment that you engage in each week as a, as a means of, stress-relief totally fine by me. I have those as well. So we're not suggesting that people avoid anything that's passive, but as I listened to you, and at first you started, well, I went to the acupuncture was for my pain, but you continue to talk what you actually revealed was most important. The real pain was, yes, it was physical, but the real pain was what, it's, what it's stolen, what it Rob for my life. Right. I think you mentioned relationships. That's kind of like, all right, there's pain avoidance here, but what's the real pain underneath that. Speaker 2 (00:12:16): Cause that's what I'm curious to talk to people about. And that's what I'm curious to learn about patients when they come to me and they say they're suffering and they say, they're struggling. I want to know, okay. What about your life? Do you miss? Who do you miss in your life? What aspects of your life do you miss? Because the truth is Karen. If we look at the, the vast body of research that reaction now have with regards to chronic pain, most things, no matter what it is, if you apply just one, intervention works minimally and the outcomes are not spectacular. So they're minimal and they're not spectacular. But when you start to combine different things together, then you see more moderate improvements in clinical studies and you see a change in someone's quality of life. But ahead of all of that, some of the most important outcomes that we're looking for is to look at, okay, what's meaningful in your life. And how do I help you reconnect with that? And I really believe that the resiliency processes that are out there, they exist in all of our practices and an acceptance that can move therapy kind of has a bunch of different processes that really lend well to this. But if we can engage people with these positive psychological responses and move away from the negative sodas, because people are aware that they realize they're scared, hell of pain, there is trouble. Speaker 1 (00:13:45): Oh yeah, yeah. When I had pain, like I totally understood. Yeah, I have it. I don't want to I'll avoid anything to have it that yes, we totally, 100% get that. Speaker 2 (00:14:00): Right. They realized, they realized, they think about it a lot. They realize they're a little sad or depressed about it or anxious about it. They realized that it consumes their time, but they really want to know is how do I get my life back? There's a whole chunk of my life over here. Yes. When you sit down with somebody who has pain, the first thing they're going to talk about is physical pain and that's Norma. And we should, we should make an attempt to validate that for them. But later on, as you're working on their self-advocacy and as you're working on that third week relationship, which really needs to start like the first 10 minutes of the treatments, it really does. Doesn't it doesn't start like three weeks later. What's the first five minutes. These are the questions that we should be asking ourselves. And these are the questions that we should be asking our patients to help them navigate what's happened to them. Speaker 1 (00:14:48): Okay. So let's, let's talk about that. So you're Speaker 3 (00:14:52): The physical, I'm the physical therapist, right? How do I broach these topics or these questions with the patient without offending them without coming across, as you know, you may have patients say, Oh, that's too personal. Do you know what I mean? So how as physical therapist, and this is where, you know, you had mentioned acceptance and commitment therapy, right? So how has physical therapists, can we incorporate, act into our treatment practice? How can we do this without being offensive, Speaker 2 (00:15:34): The best place to, and I'd like, I like the word offensive because I do believe as even though I'm a big fan of psychologically informed physical therapy, and I've talked about this on podcasts and everything, I've done books, et cetera. We have to realize as physical therapists, there's a cognitive dissonance there, which means when someone comes to see us, they don't expect that we're going to be talking about psychological variables. They don't expect that. And nor should they, we have a long, long, long way to go. Not only in our own profession, but in the entire healthcare system, before we get there. Speaker 2 (00:16:15): When you're talking about interviewing someone or evaluating someone or assessing someone during the evaluation, which is really where you should start to talk about values based living, there are a couple of just simple questions that you can add into your evaluation. So again, this is psychological informed care, right? We're not becoming psychologists. We're just using principles of to inform our care so that our outcomes are better. So for example, one of the most important questions, which I always get positive responses from, and people never feel taken aback by this is if you didn't have pain right now, what would you be doing with your life? Speaker 2 (00:17:00): And it's an open-ended question, right? What kind of weaving in like, you know, principles of motivational interviewing. It allows someone to think, wow, if I didn't have pain, what would I be doing? And you, and I may be able to, to kind of access that very easily or rapidly. However, someone who's had pain for a long time. It's like, there's been a smoke screen in front of their eyes. They're no longer able to see that. Okay. There's another aspect of life for me, somewhere that I can begin to kind of work on. Another really simple one kind of a nice metaphorical one is if I had a magic wand and I can wave the magic wand and make your pain go away, what would you do? What would you do tomorrow? Or who would you visit? Who would you go see and spend your time with? So a couple of just really simple open-ended questions that you include an initial valuation. And I recommend, you know, when people first start training with me, I give them lots of different handouts with regard to values, because you can spend a whole hour on this, but if you're new, just seeding this into your practice just a little bit, day by day or session by session. So to speak, it's a nice way for you to change because there's behavior change. That's involved for us as professionals as we start to use these new interventions. Speaker 1 (00:18:20): Yeah. And I think as the, the healthcare professional, the physical therapist, like you said, there is still that unconscious bias of I got to fix it. Right. So I think I would imagine you can correct me if I'm wrong, but the more patients that we see and the more that we ask these questions, the more that I think we'll be able to kind of delve into this other part of the person sitting in front of us. Because the one thing that comes to mind when you said if you didn't have the pain, what would you be doing? What if someone's like, I don't know. I can't even picture it. You just put, I don't know. I can't picture it and move on to the next question. What, what, what happens next? Speaker 2 (00:19:11): Well, there's a couple of different parts there. Karen. the first part I just want to mention, so physical therapist and other health professionals who work in rehab are excellent at goal setting. And in fact, I think physical therapists and probably OTs are the best at goal setting, probably in the profession, in the, in the healthcare professions. Historically, we've not been very good at talking about meaningful or value based activities. What if I told you as a professional, that it's more important to help clarify someone's cloudy values instead of setting really precise short-term and long-term goals like we've been trained. So what I'm really saying is we have to challenge ourselves and look at our own practice and say, okay, what am I doing? That's effective and what am I not doing? That's effective. Now, the reason why it's called acceptance and commitment therapy is because with regard to pain, acceptance, that's, one's willingness to acknowledge pain as part of their life experience. Speaker 2 (00:20:15): And with that acknowledgement, they avoid the, they avoid the attempts to control or eliminate it. Now pain acceptance is important for people living with pain, pain. Acceptance is also vitally important for practitioners who treat people with pain because of the research is clear that we don't have a really spectacular way right now to eliminate someone's pain. I'm not saying that we can't do that. I believe it does happen, but what I'm proposing. So people who are listening to this episode is that in many ways, we put the cart before the horse, and we've said, I'm going to make your pain go away first. So we have all these ways to make your pain go away. And then you'll return to life. Speaker 2 (00:21:03): When in essence, we have to say, let's talk about how we can start to clarify what was important to you in life. Take little steps toward that. And then with that, your pain will start to go away. They're very different messages and they're also very different ways to approach a patient. So if someone turns to you Karen and says, I have no idea. I've had pain for 10 years. It's affected me so badly. I lost my job. I've lost my personal relationships. Let that person talk about their loss because just like that vulnerability process, right? They're talking about how they're vulnerable. Well, on the opposite side of that, they're really saying, I want to, I want to maintain relationships. I want to get back to work. So allow people some room, actually many times when, when questions like that come up, this is going to sound strange to people. Speaker 2 (00:21:56): But I just sit there in silence. I maintain eye-contact. I maybe move a little bit closer to the person. And I just give them some space to process that and to process the, the idea that someone's asking them, someone's interested in their life beyond just pain relief. And that can be really difficult, especially for physical therapists, because we went to school. And even if you go to like DPT program websites right now, it says like, you will learn how to like resolve someone's pain. And then we get out into the world. We got out into, you know, the profession. I mean, we figure out, Hmm, maybe I'm not as good at this. As I thought, Speaker 1 (00:22:36): This is, this is really hard. Am I missing something? I must have, they didn't teach me this in school. Am I, what do I need to learn to do this? Speaker 2 (00:22:46): That's right. So the question is, you know, what, if the way to help someone contact her values is to just sit with them and allow them some space to start to think about that. Because chances are, if someone's wrapped up in experiential avoidance, they're not thinking about that on a daily basis. They're thinking about, I need to take my medication this morning. I need a hot bath. I need to take my magnesium. I need to take my nap. I need to do some distraction activities. So I don't think about pain. That's what their mind is preoccupied with. Speaker 1 (00:23:26): Yeah. Or yeah, a hundred percent. A hundred percent. Yeah. Everything you're saying, I'm like, yep. I can remember like, Hmm, okay. I have to figure out what pillow I'm going to use. I have to figure out how much I'm going to put my bag. So it's not that heavy. When I walk around, do I have a break during the day? Did I take Advil? Did I? Yeah. So on and so forth, but that is, that's all encompassing during your day. And, and I don't think I had, well, yeah, well, when I sat with David Butler, he's like, well, what, what would you be doing? Right. And I, my answer is, I don't know. I, I never thought about it. Right. You know, and, and, and being able to send, he did exactly what you just said. He's like, well, think about it. Speaker 2 (00:24:17): And I w I want to, you know, reinforce what you're saying is that for some people it's extremely difficult for them to think about it. Yeah. Speaker 1 (00:24:24): Yeah. It's and it's really uncomfortable and it's uncomfortable. So just think of it's in control for the patient. And you're the therapist on the other end, is it uncomfortable for you as the therapist to watch someone be uncomfortable and wiggle in their chair, so to speak? Speaker 2 (00:24:41): Yeah. I love that. And my response to that is empathy for the people we work with involves a little bit of us feeling uncomfortable and sharing that unpleasantness with the person that's in front of you. And in many ways we mirror people actually. So as they're struggling and suffering as a human, who cares about someone we're struggling and suffering too, because ultimately, ultimately every physical therapist I've ever met. And, you know, I've interviewed a lot of therapist. Karen, when I asked him, why did you want to become a physical therapist? And they would say, well, I want to, to help people. And if I always dig, dig in there more, there's always a story of, well, when I was in high school, my, you know, my grandfather had a stroke and he wound up living with us and I saw the PT come in the house, or I was an athlete and I had an ACL repair. And I saw all these people in this PT place and how I could help them. So, you know, there's a, there's an aspect of human resiliency built in with that. I lost my train of thought. Sorry. one thing you can try for people who are having a hard time connecting to their values, their personal values is to ask them, Hey, if I were to share some information with you about how we can alleviate pain, who would you share that with in your life? Speaker 1 (00:26:13): That's nice. So then Speaker 2 (00:26:15): It takes it off of, it takes a little bit of the pressure off the person or off the patient. Speaker 1 (00:26:20): Yeah. Yeah. It takes a little bit off them and puts it onto someone else. Right. Speaker 2 (00:26:25): Right. And in general, we all want to help other people. And especially people with pain, they really do care about other people. And they really have an interest in not seeing other people's struggle the way, the way they've been struggling. So it's a nice way to just kind of shift the conversation a little bit. And if you continue with that, what you'll eventually see kind of like in ourselves when we learn things right. And when we teach things, we actually wind up implementing it into our life in a way that's more effective. Speaker 1 (00:26:52): Yeah. Yeah. That reminds me of Sharon Salzberg, loving kindness, meditations. So when she does those meditations, she sort of starts with, you know, think of someone else and, you know, offer them like a life of ease, a life of love, a life of serenity or kindness. And you kind of repeat that mantra for awhile and then just say, offer it to the world and you offer it to the world. And she's like, okay, now offer it to yourself. So that you've practiced someone else you've practiced the world. And then you can turn it back onto yourself. And it's, I always felt like, Oh, this is nice. Now I don't feel bad. Wishing myself a life of ease or a life of ex you know, love or XYZ. Right. Cause I think sometimes when you, I think a lot of people feel this way. They have a hard time being kind to themselves and allowing themselves to not suffer. Speaker 1 (00:27:50): Even though with chronic pain, you are suffering and you don't want to be suffering yet. It's hard to recognize that in yourself. You'd rather put it onto someone else or wish that for someone else. But it's just so hard to wish it for ourselves because maybe if, if you've had chronic pain and I'm just, I don't know if this is true or not, but you can't, it's hard to see yourself out of it. Right? And so it's hard to even think of yourself, elevating yourself up to something that maybe you'll never get to. So then you'll, won't be disappointed. Speaker 2 (00:28:25): That's right. I, I talk about this in my book, in the, in the sense of self-compassion, which can be difficult, as you said, it's a little bit easier to be compassionate toward other people. And it can be more challenging to be compassionate toward ourselves. Where I see this show up with regard to chronic pain is people have been taught. You have to fight pain. Yes. You have to overcome pain and you see this online people even come in, I'm a pain warrior. Speaker 1 (00:28:50): Yeah. Right. You gotta be tough. Speaker 2 (00:28:52): Right. You have to be tough. You have to fight it out. You have to struggle with it. And my question really with regard to that is, okay, there's definitely some work that we have to do here. There's some effort that we have to put into this and there's some behavior change. We know that as professionals, but if you enter into a battle with pain, what kind of message is that sending your mind? Speaker 1 (00:29:17): You're always on guard. You're always on high alert. And that's kind of the opposite of really what we want when we're working with people with chronic pain. That's right. Speaker 2 (00:29:25): And even, even Karen, because I can see you on video right now, as you do that, you're stiffening your whole body up. Right. And we know that things like spasm, muscle spasm, tightness is an outcome of some of these psychological variables. We're talking about being a warrior. Imagine you see holding a gun or holding like a spear they're stiff and very contracted, right. Really what we do with act. And many of the mindfulness and acceptance based approaches is we start to soften to the idea that maybe I don't have to fight this. And that may be my fighting. This maybe the battle with this is the worst, worst, worst part of this. And if I can just let this go just a little bit and allow it to be that maybe not only will my physical body soften, but also my mind will start to release a little bit with regard to some of the things that I've been struggling with or some of the things that I've been grappling with with regards to pain. Speaker 2 (00:30:21): And we know that when that happens, people work toward more pain acceptance. Not only does the quality of their life improve, but as I mentioned before, or that kind of cart before the horse, that's also when pain relief happens, why does pain relief happen with that? And that's, I think it's an important point to talk about, well, we have a reward system in our brain, right? That produces its own opioids. When you engage in activities that are meaningful and important to you, it kind of, you know, twinges that reward system in your brain over meaning it makes you feel good. Right? So engaging in things that make you feel good or rewarding or engaging in things that are rewarding, make you feel good, they bring you pleasure. Right. They bring you joy. And with that, it alleviates pain. So yes, there are ways for us to help with pain control. And there are ways for us to help people be a little bit more willing to engage in their life, even with a little bit of pain and both work effectively and both work synchronistically together to help people. Speaker 1 (00:31:35): Yeah. I know. I always look back and think, you know, there were days where I couldn't turn my neck from side to side, like I would be crying during the week, but then on Saturdays I pitch a double header and I was a windmill pitcher. No pain felt great, really good because I loved pitching. I love being with my team win or lose. It was awesome. Even if I got like hit with a line drive or something, I just, like, I was hit with a line drive in the shoulder. Didn't bother my neck at all. Didn't even think about it, no problems doing that. Right. And people would always, that's why, when you have someone with, in my case, like chronic neck pain or chronic back pain, and you see them doing something like pitching a double header, a fast pitch softball game, well, there's no way they could have pain because they're doing this. Right. Right. And so it's, it's from what you just said for me, this was really valuable in my life was meaningful. It gave me joy. So I was able to do it with Speaker 3 (00:32:40): Very little, if any pain, but on the outside, people are thinking she's faking it. Right. So what, what, what do you do in that respect? Yeah. Speaker 2 (00:32:51): Well, I just want to what you're saying resonates well with me, it takes me back really to like the first year I was practicing, which is like 25 years ago before I studied anything about acceptance and mindfulness based approaches. And I had a, a young woman who was, she was the same age as me at the time she was 26 and she was walking down one of the beautiful tree line Brown street, brownstone streets of Brooklyn on it's on a Saturday evening and a drunk driver. Kim wants to the curb and pinned her between the car and the steps of the brownstone. And instantly she was an above knee amputee on one side and the below knee amputee on the other side. And she was a patient of mine pretty much the first, entire six months of my career, basically. And the beginning of her rehab was so smooth. Speaker 2 (00:33:44): It was wonderful. And you know, it was a physical therapist. We just feel good because we're helping someone walk again and we're fitting them for prosthetic limbs and we're making them stronger. And that went all really well until two things happen. Once you start to lose some weight because she was in the hospital and eating better and exercising. So the prosthetic didn't fit as well. So it was a constant struggle with the prosthetics every day. And then two, she developed a neuroma on her, on her. One of her legs, there was a period for about two weeks where she was so utterly depressed and unhappy. Cause she was in so much pain and suffering so badly. And all of us, the PT, the OT, the nurses, the psychologists, I mean, everyone went into her room and try to motivate her. You know, we use these like rah, rah, watch your tacky. Speaker 2 (00:34:36): Yeah. Cheer her up kind of thing. So one day I went into her room and I just sat next to her. And I said, I don't, it doesn't seem like you want to walk today because that was my job. Right. As a PTA, she said, no. And I said, okay, well, what do you, what do you want to do? Then? I said, you can't stay here. You can't stay in this bed forever. You know that, you know, eventually you they're going to send you home. And she said, there's only one thing I want to do. She said she was engaged at the time. Actually. She's like, I want someone she's like, I want to get married. And I want someone to wheel me out into the dance floor in my wheelchair. I want to stand up and I want to dance with my dad. Speaker 2 (00:35:23): And that's all she wanted to do. She didn't want to walk. She didn't want to walk 50 feet in a hallway with a Walker times two. Right? Nope. Didn't care about that. She didn't care about the prosthetic legs. Really. She didn't really actually that at that time she didn't even really care if she was in a wheelchair, the rest of her life. That's what she wanted that moment. So you know what we did together. Okay. Put your hands on my shoulders. Stand at the edge of the bed. I put some music on and all we did was weight shift. Now, could I have done something more therapeutic from like a physical therapy perspective? Of course I could. Was there something, was there anything that was more important to her in that moment? No. No. Speaker 1 (00:36:10): Yeah. And now, now given the knowledge that you now have and what we know about pain and what we know about this more value-based activities and mindfulness and act, looking back on that, what does that do for you? What does that make you think of now where you are now looking back on that as such a young therapist? Speaker 2 (00:36:36): Well, it makes me think two things. First I am eternally grateful for the skills and knowledge I have now that I try to share with people as much as I can. And then I also reflect on who didn't I help? Oh, that's a can of worms, right? Yeah. Who slipped through my fingers that I wasn't aware of. And that makes me reflect back on, okay, what are we not teaching licensed professionals, especially physical therapists in school, right? So the amount of time we spend on evaluating the structure, function, the structure and function of a joint is in my opinion, at this point in my career is kind of absurd. Speaker 1 (00:37:23): That's the word? That is. So that's the word that came into my mind too. Speaker 2 (00:37:27): The reason why it's absurd and not no offense against, you know, our colleagues in academia is that this is so much packed into a PT program now. Yeah. So we have to get better at, okay. What do we have to, obviously we have to, we have to understand how to measure strength and range of motion, function, et cetera. But it's perhaps most important that we learn how to motivate and change behavior. Speaker 1 (00:37:56): Yeah, absolutely. Because when you, when you think about pain and certainly chronic pain, but even acute pain, what does acute pain do to us as humans? And then as a result, chronic pain, it changes our behavior. It forces us to change our behavior. If we sprain our ankle, we've got a big puffy ankle. Are we going to walk and run for the next week or so? No, it's going to change our behavior. And in chronic pain, that behavior change becomes more than just a few weeks of a behavior change. It becomes an embedded behavior change into personality and into everything that we do. Speaker 2 (00:38:39): That's right. And the reason why acceptance I commend therapy is so important for physical therapists is because when we look at all the literature on cognitive behavioral therapy, traditional cognitive, behavioral therapy, and even pain science education, and both of those I'm I'm in favor of, and I support, but the outcomes actually may be a little better with act with an act approach specifically for the pain, the population of those living with chronic pain and as physical therapists, knowing that we function in practice settings, where we come face to face with people who are in acute pain. And if we can start to deliver some of this during the acute setting, right, then we can prevent the transition to chronic pain. And I think that's the most important. So if you're in acute orthopedics, if you are working in inpatient rehab, I mean home care, all the various places that we function, physical therapists are in the perfect position to take the brain and the body or the minds and the body put them together and help someone overcome their pain. Speaker 1 (00:39:50): Yeah. And, and it goes back to what you said in the beginning, it's sort of fostering that resiliency in people, and that can happen the day one, you injure yourself. You know, last summer I, I had a partial tear of my calf muscle. And the first thing that came into my mind was, well, the first thing was I felt down when it happened, I was like felt for my Achilles tendon. I'm like, okay, the Achilles tendon is there. I'm good. And isn't that amazing? Like I, anything else to me was like a nothing thing. Right. But the first thing I needed to do was I felt down, I was able to point and flex my foot. My Achilles tendon was intact. I got up, I lived up the field fine. I was like, okay, I'm good. But the next day I was like, Oh my gosh, what if this doesn't go away? Speaker 1 (00:40:41): What if this, because of my own history with chronic pain, it's what if this is chronic? What if it never goes away? But, and I, instead I went the next day, I went to see an orthopedist and he did kind of what you're saying. He was like, listen, this is what's going on. This is what's going happen. And he gave me out like a timeline of expectations and for me, and, and the way that I function, that was a great way to build up my resiliency to know, Hey, first of all, it's not my Achilles tendon. And second of all, this is what's going to happen over the next couple of weeks and over the next couple of weeks, what he said happened. And so I felt okay, I'm good. It's a little sore. It's a little painful. I'm okay. With the backdrop of that chronic pain history was really meaningful to me. Speaker 2 (00:41:30): Yeah. There are variations of informed consent, just informing someone, okay, what here's what's happening. And here's how this is potentially going to play out. Can be really, really important and powerful for someone. It can help ease someone's anxiety. It can help ease their worry and concerned about it. And as I mentioned before, these are the places where, you know, we thrive as PTs actually, especially with regard to pain. I mean, if you look at pain education in licensed health professional training, PTs have the most more than psychologists were than the other mental health professionals, more than OTs. So, you know, we're putting all these pieces together. And in fact, when you look at what are the most important factors to help someone with pain it's pain education, right? So we talked about that some type of cognitive behavioral therapy, acceptance and commitment therapy is a third wave generation, cognitive behavioral therapy. And then something related to lifestyle, probably the most important factor with regard to lifestyle is movement is exercise and physical activity. So when you put pain education together with act together with helping someone or promoting physical activity, that's probably the kind of trifecta. Those are the, that's the secret sauce, if you will, of helping someone with pain. Speaker 1 (00:42:52): Yeah. I, I agree a hundred percent and now let's dive in just quickly. If you can give the listeners kind of like, what's the difference? You, you sort of alluded to it now between acceptance and commitment therapy and cognitive behavioral therapy, and also the difference between act and mindfulness. Speaker 2 (00:43:19): Sure. All really important distinctions. Thanks for the question. So cognitive behavioral therapy is kind of the first therapy that was used with regard to people's thoughts, beliefs, and emotions around pain. Most of that work focuses on identifying or challenging problematic, problematic, or modifying thoughts. And with that, as someone modifies their thoughts, you hope that it modifies and changes their behavior. So restructuring thoughts, we've heard these words before restructuring thoughts, reframing thoughts even the reconceptualization of pain, which is a purely from like a pain education perspective. It's still a more traditional cognitive behavioral therapy model, helping someone identify their thoughts, and if their thoughts are maladaptive, how can we change those thoughts now they're important. And there's a place there for that. What I propose to people when they start to look the literature on changing thoughts, specifically with pain or the route with regard to pain, it can be quite difficult and quite sticky to do that. Speaker 2 (00:44:29): There's some pretty good research that shows that there's a small group that will reconceptualize their pain really early on. There's another smaller, equally small group that will never change. And then most people are kind of somewhere in the middle. So they understand what you're saying. They understand that, okay, the herniated disc in my back, isn't the only factor with regards to my chronic lower back pain. And they understand that, you know, thoughts about your thoughts about pain, negative thoughts about pain are not necessarily good, but they don't reconceptualize. They don't change those thoughts on a hundred percent. The difference with acceptance and commitment therapy and even mindfulness, they're both what they call third generation cognitive behavioral therapies, which instead of targeting these maladaptive thoughts and beliefs, we simply help people observe that they have thoughts about what's happening. And instead of changing that we help people understand or identify, recognize that they can have those thoughts and beliefs, but still continue on with the things that are important to them in their life. So it's a big distinction. It's especially challenging for physical therapist who spent a lot of time studying pain education. And there's a physiotherapist from Ireland that came into my act program and she studied pain education for a long time. And then she studied cognitive functional therapy, both two evidence-based wonderful ways to treat pain, but she found that there were some people, a lot of patients actually, that they understood didactically what you were saying to them, but it didn't change their behavior. Speaker 2 (00:46:10): So what's wonderful about act is that act is a behavior change model. It's really based in behavioral therapy. And there's also something nice about not having to struggle with someone to change their thoughts and beliefs all the time. It takes a little bit of pressure off the person who has pain and it takes a little bit of pressure off of the therapist, Speaker 1 (00:46:30): Right? Because sometimes when you try and change those thoughts and behaviors, and I don't know about you, but I've heard this when I first started you know, really studying more about pain science and, and understanding how, how pain affects people in so many different ways. And when I first would talk to people and I bet, you know what I'm going to say here? What, what would they say to you? So you're saying it's all in my head. That's right. Right. Speaker 2 (00:47:00): And the, you know, when that happens, people feel invalidated and it kind of takes us full circle to the beginning of our conversation is it focuses on their vulnerability. Oh, so you're saying there's something wrong with the way I'm thinking. And the truth is if someone thinks about their pain, a lot, that's 100% normal. Cause that's, that's a pain supposed to do. Pain is supposed to alert you to something that's potentially harmful or something that's dangerous. So just normalizing that everyone's mind my mind, Karen, your mind, someone who has pain, we all think all, most of our thoughts throughout the day, our thoughts about how do I avoid things that could potentially harm me, things that are potentially uncomfortable, helping people just observe that actually can be the step before even the reconceptualization of pain, because how can you, how can you expect someone? How can you help someone to target thoughts and beliefs about pain if they haven't even thought about, okay, what are my thoughts? Speaker 2 (00:48:12): What are my beliefs about pain? What am I thinking right now? The average person has somewhere between 6,000 and 12,000 thoughts per day. And the truth is most of them are negative because it's a survival instinct, right? We brought this through with survival instead. How can I observe these thoughts? How can I observe my emotions? How can I be getting to observe the physical sensations in my body, whether that be anxiety, whether that be physical pain and realize that I can have contact with that, but not let it impact my behavior. So that's really the biggest difference between an act or a mindful, acceptance based approach versus a more traditional cognitive behavioral approach. Speaker 1 (00:48:57): Yeah. Thank you for that. That is very helpful. Cause I'm sure you get that question quite a bit. So it's nice to be able to clear that up. So now let's shift gears slightly ever so slightly and talk about your new book, right? So your new book, radical relief, a guide to overcoming chronic pain. So let's talk about it. Why the title why'd you write it? Go ahead. Speaker 2 (00:49:27): Well, after my first book came out called heal your pain. Now in that book, I had a section called the brain and pain. And at that time, the author only gave me so much space to write about the mind, so to speak. So I had to, I had to include small sections about mindfulness and about act and in general about the mind and how the mind responds to pain. And it kind of forced me to take a very didactic approach to pain. And people would reach out to me all the time. I want to learn more about mindfulness for pain. I want to learn more about this thing. You mentioned act about pain. So both professionals and people were coming to me. So I couldn't put it in that book. And I really firmly believed that deserved its own resource because there are solid mental skills, training and exercises that are in this book, radical relief that wasn't in my, in my first book. Speaker 2 (00:50:24): Second is it's a little bit tongue cheek, so to speak, it's a radical idea to think that two physical therapists want to spend their Thursday evening talking about the mind and mental skills training with regard to pain. So as we said before, like there's a little bit of a cognitive dissonance in there, but we know that physical therapists have a very important part with regard to helping people cope both physically as well as psychologically and emotionally. You know, the third aspect is just in general to give people this notion that it's not a radical idea to use your mind, to use mental skills training, to use mindfulness, to overcome pain. And that can be a part of your treatment. And in fact, as you and I are sitting here counting, I can guarantee you there's someone right now, who's being treated for pain who are not being offered these types of skills and you know, you, and I think it's absurd actually, but this is still happening. So radical relief really is a short book. It's only about a hundred pages. It's a workbook that includes over 50 cognitive and mindfulness type exercises to help people overcome their chronic pain in essence. And it's also written for practitioners to use as a guide in the manual that they can use in clinical practice. Speaker 1 (00:51:45): Yeah. And the one thing that I liked about the book aside from, as we were talking before we went on air, it's very, very pretty all of the illustrations are quite beautiful. But I like the fact that within each chapter there's like exercises and you have to literally write things down, pen, take pen to paper, and you can do it right in the book. Or you can grab the extra sheet of paper or what have you. But I like the fact that you have to write things down because there is something to that, you know, there is something to writing to the physical act of writing something down on paper versus typing it out or just thinking about it. And so that's something that I really appreciated throughout the book. Speaker 2 (00:52:30): Yeah. And I learned that from my first book as my first book was a very education based approach. As we mentioned, pain education is important, but it, it doesn't do a great job of changing behavior when you get involved with act, act as a very experiential therapy. So you're not sitting across from someone like talking to them, you're actually engaging with them in a lot of different ways. So what I really found was, and people can, you know, note this down for themselves. The average person doesn't want to flip through 300 pages of a book to learn about pain. They want something that's relatively short. They want something that's clear. They want something that's useful that they can really pick up, you know, now and start to use. And I think it's the same with practitioners, right? There's only so much theory and philosophy we can think about before we say, okay, what do I do with my patient today? What am I do with patient? I have at nine o'clock tomorrow, who's been suffering with fibromyalgia for 10 years. So that's why I tried to approach this book very differently from, from the first book. Speaker 1 (00:53:35): Yeah. And, and before we went on air, you, you asked me if I had a post-it note to which I said, I have a large sheet of white paper and you said, no, it needs to be a post-it note. And I said, well, I have a mini post-it note, will that do the trick? So please, please tell me why I needed a post-it note and not a large white sheet of paper. And perhaps the listeners, if they have a post-it note, they can go and grab one as well. Speaker 2 (00:54:05): Yeah. So if everyone has a post-it note and a pen or a pencil, please hit pause and grab that and come back. But as you mentioned, Karen, it's a workbook. And you said putting pen to paper changes things, right? Because in some ways it's it's experiential. So I was, as, as I was mentioning before, we don't have a good way to change thoughts and beliefs. So with that, we have to help people relate or respond differently to thoughts and beliefs. Right? All of us have things in life, thoughts and beliefs about ourselves that are somewhat unpleasant and painful, right? Some of them are really, really horrible things about ourselves. And some are, some of them are things like, you know, not so horrible. So if you'll kind of engage in this with me, I'd like you to just reflect on yourself and your own life experience and think about one negative, thought about yourself, not the worst thought possible, but one thought that, you know, maybe on a scale of one to 10 with like one the least impactful and like 10, the worst, maybe you're somewhere like a four or five. And then I want you to write that down on the post-it note. Speaker 3 (00:55:19): Okay. Speaker 2 (00:55:20): So we can't change this thought, right? The thought is there and just rip it off a little post-it pads, Speaker 3 (00:55:31): Still writing. Okay. Speaker 1 (00:55:42): My pen's running out of ink, but I remember what it was. It's, it's half written. It's written. I just, my pen ran out of ink, but okay. We can, we can go on. It is written. Speaker 2 (00:55:52): I'm going to do this with you actually. So it's written there and what I want you to do is pull it off the, pull off the post-it pad. Okay. And I want you to hold it up. I don't know, maybe about a foot or so away from your knees. I want you to look at it. And in your, in your mind, I just want you to repeat the word nice and slowly, and really kind of get lost in that word just for a moment. And then as you get lost in that word, just notice if you feel anything different in your body. Speaker 1 (00:56:37): Yeah. Looking at the yes. Speaker 2 (00:56:39): Right? Okay. So you see how thoughts have an impact on how we feel now, what I want you to do is I want you to take your arm and stretch it out as far as you can go. And I want you to look at that word. And what I want you to do is I want you to flip it upside down. Now, just turn it 180 degrees and now look at it and now see if it has any less of an impact on how you feel. Speaker 1 (00:57:07): I mean, maybe a little, Speaker 2 (00:57:09): A little bit right now. What I want you to do is I want you to maybe prop it up on the computer screen in front of you, and I want you to push back. So maybe you're 10 feet or so. Speaker 1 (00:57:22): Okay. Go. As far as my mic, as my ear, phones will take me Speaker 2 (00:57:28): And then maybe just stand up as you're there and now look at the word and then notice if there's any difference in how you feel or how you relate to that word. Speaker 1 (00:57:43): Yeah. Maybe a little bit, now that I'm standing and people can't see me, but I think I automatically stood up in the power pose. Speaker 2 (00:57:49): I noticed I still noticed put your hands on your hips. Right. So would you say there's less of an impact as you move away from the words so to speak? Yeah. Great. Okay. Come back forward. So what I just did is what they call cognitive distancing. So it was a way to distance yourself, literally as well as figuratively. So now what I want you to do cameras, I want you to take that same post in them. I want you to fold it up into a little square And I want you to put it in your back pocket. Speaker 1 (00:58:24): Okay. I don't have one. So I'll pretend I do. Speaker 2 (00:58:28): Yeah. Just stick it up your sleeve there. Okay. So now you have this unpleasant unwanted thought about yourself. It's not going away cause it's in your back pocket or it's in your front pocket or wherever it is, wherever you placed it. And my question for you is would you be willing to be with that thought and to be with those uncomfortable sensations you feel on your body, if it meant you could be a more effective physical therapist or be a more loving daughter sure. Or a more supportive wife or a girlfriend, or a more effective member of your community or a leader of your profession. Speaker 1 (00:59:14): Yeah. I can do that. Right. Speaker 2 (00:59:16): So it just shows you that we can change how people relate to thoughts. We didn't change the actual thought. Still there. We can change how people relate to them, to it. And we can also show people how, okay, this thought can be present with us and I can still experience it and not feel good about it, but I can still go about my life. And what I do with patients is I have them take these thoughts. Like I have a big herniated disc at L five S one. Okay. Write that on a piece of paper, put it in your back pocket in your briefcase and carry it around with you today and notice how at times that thought wasn't even present and didn't talk to you at all. And other times maybe it was present a little bit, you thought about it, but it didn't stop you. And other times it was like a big barrier. Right. And within those three, they're really important teaching moments that we can help patients with. Speaker 1 (01:00:09): Yeah. Oh, that's great. Great, great. Is that in the book? So Speaker 2 (01:00:14): The book is full of Speaker 1 (01:00:17): Nice. Nice. Yeah, no, I think that's great. And, and for, you know, physical therapists or other healthcare professionals that might be listening, that my hope is that this podcast will plant a seed in them to say, you know, maybe, maybe I'm I need to do a little bit more, you know, and what can I do to do more Speaker 2 (01:00:43): The biggest ask the biggest, one of the great gifts that I have come across in teaching physical therapists about act is yes, it helps your patients, but physical therapists notice a change in themselves from it. Because look, we struggle with not being able to help people. We get burnt out because of it. Absolutely. We have our own personal challenges that cause us pain and suffering. So to speak that we struggle with outside of our clinical work, that this type of work becomes really important to you. And the truth is, as you know, Karen pain will show up in life. Yes, it will show up when you least expect it. And these are effective skills that I really believe all of us need to learn and adopt not only for our patients, but for us to be effective clinicians and effective professionals for us to embody them in ourselves, then we can help people with these types of aspects and these, this type of care. Speaker 1 (01:01:44): Yeah. I don't disagree with that. I think that's great. And you know, I was just going to ask you to sort of put a bow on this conversation, if you will, and what would you like people to take away from it? I think you gave a little bit of it just now, but is there anything you'd want to add on to that? Speaker 2 (01:02:06): What I want people to take away from a mindfulness and acceptance based approach to care is that there's hope in it. And that hope really resides in helping helping, giving you the skills that help someone reconnect with their life. And that resilience that we spoke about in the beginning, the hope is really what people are looking for because they feel helpless. They feel hopeless. And this work is really about, okay, maybe there's some things in your physical body we have to work on. Maybe there are some thoughts and feelings and emotions that are difficult for you. Let's yeah. Let's kind of work on those, but know that you're whole, as you are, as a human being and everything that's required to overcome this already exists in you, I'm just going, gonna help you contact that in a way that's more efficient that moves you along this path in a way that's faster. So the whole part is really important and that's really what people are coming to us for. Speaker 1 (01:03:07): Yeah. Yeah. That's great. And then last question or no, well, last question before we get to, how do we contact you and all that other fun stuff, but, and you know what this question is, I think I've already asked it to you like three times, however many times you've been on the podcast, but let's say knowing where you are now as a therapist and as a person and in your life and your career, what advice would you give to your younger self? Maybe not right out of college, but let's say 10 years ago, before you really started delving into working with information surrounding chronic pain, Speaker 2 (01:03:48): I would say, give yourself space to fail and just allow that stuff, exploration of exploring different things and realizing, Hey, I didn't do that so well, or I wasn't so great today and allow yourself, there's a lot of pressure on us as professionals to be this, you know, master healer, so to speak. And I really think it's damaging to us as professionals. Speaker 1 (01:04:20): And I think that can lead to burnout, all that pressure on you to be the person, the one person in someone else's life. That's going to take away all their pain or take or add this, or take away that boy, that's a lot of pressure. Speaker 2 (01:04:37): That's right. I, I actually, I asked therapists now, who are you to take away someone's pain. Cause really think about what that really means. Speaker 1 (01:04:46): Like the wizard of Oz, Speaker 2 (01:04:48): Right? Like, is there some like magic fairy dust that you have that the rest of us don't have? And again, it doesn't mean that we can't help people with their pain. I mean, we can alleviate some of that pain, but that's not what, that's not what we're there for. We're there to be a witness to someone on their journey to overcome whatever it is that they're struggling with. And the kind of take that into a mindfulness realm, allow yourself to be your own witness as you move through the profession and you navigate and negotiate. Okay. Here's what I'm really good at and why I want to kind of cultivate and things that I don't have to necessarily engage with that. Speaker 1 (01:05:29): Yeah. Well said now, where can people find you? Where can they find the book, social media websites? What do you got for us? Speaker 2 (01:05:39): Easy. People can go to my website. The website is integrative pain, science institute.com or one very long word, integrated pain science institute.com. The book is called radical relief, a guide to overcome chronic pain, which you can find on Amazon in most countries. If you go to either one of those two places, you'll find the book and all the information about me. I also want to plug another book Karen, in which you're involved in. Speaker 1 (01:06:03): Oh yeah, yeah, yeah. That's right. It's a couple of months out still. Yeah, Speaker 2 (01:06:08): I'm working. I'm the chief editor on a book that involves about 45 different physical therapists, some from academia, some from private practice and it's with regard to how physical therapists can use lifestyle interventions and practice that book will come out probably in the fall of 2021. And I want to plug it because it's an awesome book with, you know, as I mentioned, Speaker 1 (01:06:32): Amazed some amazing people involved, Speaker 2 (01:06:34): Amazing people. And Karen is one of those amazing people. Who's doing the chapter where she's offering the chapter on private practice, physical therapy and how to integrate lifestyle interventions into private practice PT. So yes. Check out my book, radical relief now, but look out for that book. Speaker 1 (01:06:50): Yeah. And you, and, and our lovely ginger garner. Yeah. Speaker 2 (01:06:54): Ginger Gara and I are the chief co-editors. Yeah. And then we're fortunate enough to have about 42 other amazing PTs from all over the globe actually. Speaker 1 (01:07:03): Yeah. Yeah. On different topics. Yeah. It's going to be cool. I'm looking, I can't wait to read everybody else's chapters. It's going to be awesome. And then social media, I think your social media is pretty easy. I think it's at Dr. Joe Tata across the board. Am I right? Speaker 2 (01:07:19): I've spent so much time just getting that. Yes. It's at Dr. Joe Tatta across the board. You can find me on Instagram, LinkedIn, Facebook, Twitter, all the main ones. Speaker 1 (01:07:28): Yeah. Awesome. Well, Joe, thank you again so much. It's always, always have a great conversation. When you come on the podcast and you make me think of a lot of things past and present, so thanks so much for coming on. I appreciate it. Thank you so much. And everyone else. Thanks for tuning in. Have a great couple of days and stay healthy, wealthy and smart.