Healthy Wealthy & Smart

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Elaine Lonnemann on the show to discuss the impacts of being diagnosed with degenerative disc disease. Elaine Lonnemann has served the public clinically as a Physical Therapist for over 30 years practicing in a variety of settings in Tennessee, Florida, Kentucky and Indiana. Her early clinical interests in treating patients with low back pain evolved into a clinical academic career with a focus on best practice in orthopaedics, teaching and leadership. She lives in Southern Indiana and is the mother of four boys with her partner and husband Paul Lonnemann who is also a Physical Therapist. In this episode, we discuss: -The American Academy of Orthopedic Manual Physical Therapists position on the opioid crisis -Patient health outcomes following the diagnosis of degenerative disc disease -The use of Clinical Practice Guidelines for low back pain in physical therapy practice -Pain science education and the treatment of low back pain -And so much more! Resources: Email: elonnemann@usa.edu Elaine Lonnemann Twitter AAOMPT Website AAOMPT Position Statements Battie et al. 2019: Degenerative Disc Disease: What is in a Name? JOSPT CPG: Low back pain For more information on Elaine: Dr. Elaine Lonnemann received a BS degree in PT from the University of Louisville in 1989, a MSPT from the University of St. Augustine (1996) and DPT (2004). She is the program director of the transitional Doctor of Physical Therapy program for the University of St. Augustine. She has served in several positions for the University of St. Augustine for Health Sciences since joining in 1998 including teaching in the online and continuing professional education divisions. Her responsibilities include oversight of the transitional DPT program as well as the orthopaedic and manual physical therapy residency and fellowship. She is a board-certified clinical specialist in Orthopedics, Certified Manual Physical Therapist and a Fellow of the American Academy of Orthopedic Manual Physical Therapists (AAOMPT). Her clinical experience have been in private practice, home health, outpatient practice, and as Chief PT of outpatient services in a level II trauma center at a university hospital. Dr. Lonnemann was an associate professor for Bellarmine University in Louisville KY and taught in the first professional program for fifteen years. She has presented nationally and internationally on the topics of spinal thrust manipulation, low back pain guidelines and leadership. She authored textbook chapters in orthopaedic physical therapy and has published in the areas of spine morphology and joint manipulation. She is passionate about leadership, postprofessional physical therapy education, manual physical therapy and integrating pain and movement sciences in the clinical management of clients. She is the current President of AAOMPT and has served two terms as Secretary and Chair of the AAOMPT International Federation of Manual Physical Therapists Educational Standards and International Monitoring Committee, member of the OMPT Description of Advanced Specialty Practice Task Force and committee member and author for the 2018 revision of the Manipulation Education Manual. She received the AAOMPT Mennell Service Award and the 2017 President Joseph and Maureen McGowan Prize for Faculty Development from Bellarmine University which provided the opportunity to study the history of manual therapy at Oxford University. Read the full transcript below: Karen Litzy: 00:01 Hello, Dr. Elaine Lonnemann, welcome to the podcast. I'm happy to have you on. Elaine Lonnemann: 00:06 Thanks. I appreciate being here. Karen Litzy: 00:08 Okay, so today we're going to be talking about degenerative disc disease. But first I would love for you to talk about what it is, why it exists and what do all those letters in AAOMPT stand for? Elaine Lonnemann: 00:27 Absolutely. So AAOMPT stands for the American Academy of orthopedic manual physical therapists and it's an organization, it's an association that started in 1991 basically because some individuals felt like we needed a group that could present scholarly works that could meet, have conferences and also test clinicians based on international manual therapy standards. And so that group, several individuals got together and that's how it started in Michigan actually. So that now we have representing 3000 physical therapists. Karen Litzy: 01:12 That's a lot of therapists. And how long have you been part of the organization? Elaine Lonnemann: 01:19 I've been a member since actually 1994. So quite a lot of time. I was a resident and fellow in training and became a member of really when it was beginning. So I've been involved as a member and more recently as an officer. Karen Litzy: 01:37 Awesome. That's great. So now let's talk about AAOMPT position on DDD or degenerative disc disease, which is something that I think is a very commonly diagnosed. I think it makes people nervous when they hear it because they hear the word disease. So can you talk a little bit about degenerative disc disease and the position AAOMPT has on that? Elaine Lonnemann: 02:03 Yeah, so our position is we just oppose the use of that term. It's commonly used as you said, and it's really used to diagnose an age related condition. And that age-related condition shouldn't be considered a disease. It shouldn't be considered degenerative. So it happens whenever on imaging you see changes in the shape or the size of the disks in the spinal column. So that's how it's identified. And, you know, we know several things that nearly everyone's discs change over time. And the interesting thing about that is that not everyone feels pain even when they have those changes in their discs. So, that's why we oppose it or one of the reasons. Karen Litzy: 02:52 And you know, like we said, it is so highly diagnosed and when people hear that disease, they think of something that like cancer is a disease or Parkinson's is a disease or a syndrome. But I think it's kind of scary terminology and words matter. So what does AAOMPT feel should be a better descriptor? Elaine Lonnemann: 03:19 Well, you know, I don't know that we have a descriptor in terms of a substitute, but I think, you know, patients really have the right to accurate healthcare information. And when, like you said, when they are given that diagnosis, you know, not only disease, disease puts a lot of fear in their mind, but degenerative, I mean they start to lose hope because they degenerative just sounds like, you know, they're gone down a pathway, you know, if it is just described as mechanical back pain or radiating back pain, you know, and our healthcare system really looks at trying to find a tissue or a pathoanatomic cause for low back pain. And the research clearly indicates that and has over time that it's very difficult to find a specific cause for low back pain. So we really need to move away from that model. Elaine Lonnemann: 04:16 And, you know, the other part of that is the patients lose fear, they lose hope. And they also began to believe they can't manage their own pain. So they lose self efficacy. And we know how important that is for our patients. And I think that's the one thing I love about our profession is that we really help patients manage and control their symptoms, their condition, and improve their function. And, whenever they're given that label, it really it can misguide them, you know, because they lose hope. And then they might start choosing, you know, riskier treatment options. Karen Litzy: 04:53 Surgeries, medications, even less invasive procedures, things like that that maybe may not be necessary. But like you said, if you're the patient getting this diagnosis of degenerative disc disease, it can maybe feel like you're at the end of your rope and you don't have much more to go. Elaine Lonnemann: 05:16 That's right. And patients need to know that their situation is real, that the findings that they have, because most people are diagnosed after they've had imaging. And so I think it's really important that we emphasize, yes, those findings are real, but this isn't a disease and this can be managed. And you know, the other thing is that oftentimes those imaging findings stay, but their pain goes away after they're treated. So, you know, that helps to give them some hope. I recently had a student who was 26 years old who came up to me and said, you know, I'm really concerned. I went to see a healthcare provider and because I was having some back pain and they diagnosed me with degenerative disc disease, what am I going to do? And then she just went in, almost fell apart because she said, you know, I love to run. Elaine Lonnemann: 06:06 I don't, you know, I don't know what I should do. Can I continue to exercise? And I'm thinking about getting an epidural injections because I don't want this to progress. And so I had to kind of step back for a minute and say, okay, it just explained to me why you went, you know, tell me about your pain cause you're not going to, she told me, I'm not even in pain now. She said she had had pain for a week and then went in. Because her sister had structural scoliosis, so she was fearful even though that was at 16, she was fearful that she might have a condition that would be a problem. And now she's fearful because she's been labeled as having degenerative disc disease. So, you know, it really took a while to counsel her and you know, to again, affirm these findings are real, there are changes in our discs but these are normal changes that occur with aging and they shouldn't be considered degenerative. The studies indicate that, you know, there's oftentimes when those findings are present, they don't correlate with the exact clinical presentation of the patient. And that's what we want to get. That's the message we want to get up. Karen Litzy: 07:16 And as physical therapists we can certainly relay that message to our patients. But if the patient hears that from the physician first, it makes it a little bit more difficult. Our job becomes a little bit more difficult because now it makes it seem like we're giving two different diagnoses. Maybe it starts with us as individuals, but how can we as the physical therapist who is maybe seeing this patient after they were given that diagnosis from the doctor communicate to the physicians or you know, cause this is a medical system wide use of terminology and it really needs to change from top to bottom. And I feel like sometimes yeah we're that point of entry but oftentimes where people are coming to see us after they get that diagnosis. So how do we as a profession advocate for this change to the greater health care system? Elaine Lonnemann: 08:22 Well I think we definitely need to partner with our medical colleagues with APTA and we are already partners but definitely get the word out that you know, this type of diagnosis really does misinformed patients. There is research and AAOMPT has developed a white paper that explains the research related to how this misinformation can potentially guide their treatment or lead them to choose, like you said, riskier treatment options. And you know, one of those, obviously the opioid epidemic is something that we have to think about. And not to say that it's going to lead them directly into that path, but it does. There has been some research that indicates that, you know, the healthcare costs are driven because we aren't following the practice clinical practice guidelines for back pain. So I think the biggest message that needs to come out is we need to follow those clinical practice guidelines. Elaine Lonnemann: 09:22 And I just heard Tony Toledo, do you have his keynote presentation at the interprofessional collaborative spine conference? And there were physical therapists and physicians and chiropractors all together in a room and you know, it was a great opportunity to meet, you know, as partners with them and you know, what can we do for the greater good of our patients? And I think the biggest, yeah, and he actually presented some of the challenges and what can we do from here forward really to improve this situation. And you know, he was talking to all of this. It wasn't just physical therapists, but one of the things that he did address was the continuity of care. And he said it's really important that patients don't wait, that we get them in early and not that every patient would and I don't want to, I don't, I want to make sure this is clear. Elaine Lonnemann: 10:12 Not every patient who has low back pain needs to be seen by a healthcare provider, whether it be a physical therapist or other conservative type of clinician. Sometimes that pain will go away, but if it's very intense and if it doesn't go away, then they should seek care and it should be early. So talking about the continuity of care, you know, in terms of who sees the patient first and whoever does it should follow the clinical practice guidelines that recognize, you know, with some time with some activity, with some coaching, a reassurance and a comprehensive medical exam that really does rule out a systemic cause or something more sinister because that's the other thing. Patients are fearful. My 26 year old student was fearful that this was something sinister. So I think that is a really important message to get out that comprehensive physical exam can really help to rule out some of the medical disorders that, you know, are uncommon in low back pain, but that our patients are concerned about. Elaine Lonnemann: 11:21 So, continuity of care was one thing he mentioned. Oh, and the other thing he mentioned is variation in care. Of course, you know, it's a big problem because you know, whatever healthcare provider you see with low back pain, there's a ton of variation in how the providers performing interventions. So, you know, he highlighted that and I couldn't agree more but one of the things that he mentioned and you know, of course president of the Academy of orthopedic manual therapy, you know, so one would think I'm going to mention manual therapy, but really it's because that is part of the clinic, one of the recommendations of the clinical practice guidelines, is manual therapy for back pain. And again, not every patient needs it, but he mentioned, you know, manipulation, mobilization, those are forms of manual therapy along with exercise. And so I think that following the clinical practice guidelines, trying to reduce our variation in care and also recognizing that, you know, as physical therapists, we need to refer on or we need to know when not to treat and when we do need to treat consistently and follow those guidelines. Elaine Lonnemann: 12:36 So that's probably a long answer to your question, but as far as the message that needs to get out, I really just think highlighting those things are important. Karen Litzy: 12:45 No, and I don't think that was a long answer at all. I think that was a very good comprehensive answer. And you know, we're talking about clinical practice guidelines. Where can people find these clinical practice guidelines? I know the orthopedic section of the APTA has clinical practice guidelines on their website. Are there other places where people can search for these guidelines? Because oftentimes we talk about clinical practice guidelines, but people are like, I don't have any idea where to find them. I don't know where to look. Elaine Lonnemann: 13:21 Well, so that's a good, good point. In terms of looking at websites, you know, I think the orthopedic Academy, their clinical practice guidelines follow the majority of practice guidelines that are out there. The American family practice group also has clinical guidelines. Ciao, published a group of guidelines and they're all fairly consistent. In turn there are some variations and you know, sometimes people ask what, well, why are there, you know, so many variations. And part of it's because the different groups, there might be some bias in those. Just if you break them down and look at the commonalities, you know, again, at least for back pain, I think those are the things that you have to look at. So I know APTA has some links. And now that you mentioned it, we will put links on our website as well to the clinical practice guidelines that are out there. And we'll have a a link to this white paper as well that the Alicia Emerson led that charge along with Gail dial and, and Dan Roan and other Jason's silver. Now other a PTA members amped members that, um, we're working in this area. Karen Litzy: 14:38 Yeah. Because I think it's, there is a breakdown from, so you graduate with your PT degree, you start working and if you don't keep, you don't know where to look. You're, you're kind of just sort of floating along using maybe what you learned in school, which is great because hopefully you won't kill anybody or do major harm to somebody. But I think when it comes to diving deeper into treatment paradigms, these clinical practice guidelines, people have to be proactive about that. And so knowing where to look and knowing where to find them is great. Um, and I also want to touch back on the variation of care. And when you're talking about variation of care, are you talking between physical therapists themselves or between a PT versus a doctor versus a chiropractor? Uh, manual therapist versus non-manual therapist? I mean I think there is a lot of variation to care and that can also be quite confusing to the patient. So I don't know in that keynote if he sort of touched on what he meant by variation of care. Elaine Lonnemann: 15:50 Yeah. He met within physical therapists and or within profession and, and really looking at, you know, and all the individuals in the room, many of us are providing very similar [inaudible] at least are able to provide similar treatment options. And so his, his point was that, you know, we really should be looking at more consistent care model following the practice guidelines and not, um, varying to other types of, of treatment approaches that may not have the evidence and, and so variation and care, but also that evidence, um, the care that is supported by the evidence Karen Litzy: 16:28 of course. And you know, that brings me to, this is going slightly off topic, but, well, no, not really. It's still on topic. It, it reminds me of a, a post that I saw in a Facebook group, a physical therapist, and it was a newer ish grad, maybe out a year or two. And he said something to the effect, I'm paraphrasing. Um, when we advertise to the public about what we do as physical therapists, you know, everyone tends to say, you know, we're evidence-based profession. You said, shouldn't the consumer already know that? And how important is it? Like, don't you just have to do what the patient wants? Because all we're worried about is our job is to make a person feel better. So what does it really matter what you use to get them there? Meaning does it matter if you use something that's evidence-based or not? Elaine Lonnemann: 17:28 Well, and I think, you know, part of that is patient education and having a relationship with your patient so that they do trust you. So you have, you know, I think they have to be able to trust you and you have to develop that therapeutic Alliance with them too. Help them understand that, you know, these are treatment options and it should be patient centered. You know, we want to be patient centered and we want to help them understand that, that these are the best approaches and it's not a one size fits all. I mean there are some outliers, but the extreme variation that has been shown is the problem. It's not the occasional patient who, well yeah, sure. Maybe that PA it's more patient centered to do a different approach, but there's extreme variation. Elaine Lonnemann: 18:16 And I think even if we just reduce that by 50%, I think it would have a huge impact on care and the research that's coming out of university of Pittsburgh that I'm not involved with this, so I'm just, I'm just reading and trying to do the same thing, everyone else's. But there's some big research that's coming out to talk about that will speak to, you know, following the guidelines when there is variation of care or if there is a variation of care. Okay. Yeah. What's different? Karen Litzy: 18:51 Yeah. And I know there was a study that came out a couple of weeks ago that showed that, you know, with different diagnoses, less than half of physical therapists actually follow best evidence to treat. Elaine Lonnemann: 19:08 Yup. And the thing that you mentioned before too is how do we avoid that? I think as you mentioned, a PTA or being a member of the American physical therapy association really helps. It's made to streamline my direction of understanding so I can go to PT in motion. I can look at, you know, there's a lot of great white papers that they have position statements, you know, on the opioid epidemic. There's just a ton of great resources there. And it was another thing that I would emphasize for clinicians. Karen Litzy: 19:43 Yeah. Because you know, in the end, you want to treat people using best evidence, you know, and I think it was Jason Silvernail in a comment said something. Again, I'm paraphrasing, but something to the effect of why would I waste my time doing something that I know doesn't have evidence behind it, when I could be spending that time, precious time with our patients. Sometimes you get an hour, sometimes a half an hour, sometimes 15 minutes, right? So why would you waste that precious time on something that you know, doesn't have the evidence behind it when instead you can be doing something that has been shown to help and that goes back to, and then you'll hear the argument against that was like, well, the patient really wanted it. So that's how I'm developing my therapeutic Alliance. Elaine Lonnemann: 20:39 Yeah. But I would still argue against that. Karen Litzy: 20:43 And that's where like you said, patient education comes in, you want to explain to the patient, Hey listen, I understand that you like treatment X, Y, Z, but right now we know that treatment ABC is more appropriate for you given where you're at. And explain to them why. And I've done that plenty of times and patients are like, okay, so right. Elaine Lonnemann: 21:04 And then there's an opportunity to negotiate, you know, let's just try this. If it doesn't work, you know, this seems to be more effective than, and it is more efficient. And like Jason said, why, why would you waste your time and their time? You know? And that's what I tell the patient, I respect your time and this is what we understand and this is what we know at this point and is best care. So, you know, if you're willing to go along with me on this, you know, I think we can try it out. And if it doesn't work, you can fire me. You can find another physical therapist or, you know, I'll find you someone that it works, you know, or the treatment, you know. So yeah, I think you have to be really, Karen Litzy: 21:45 And I think, like we said in the beginning and going back to degenerative disc disease, words matter, right? And how you explain things matter. Elaine Lonnemann: 21:55 Yes. Well and Michelle just published a systematic review in spine, she looked at the term degenerative disc disease and the name of the article is what's in a name. And, also found that there's so much variation in what, you know, healthcare providers are calling degenerative disc disease and you know, in summary found that it's just, it's inconclusive and there's not evidence to support this as a disease and there's so much variation in it that they also recommend not using it as a term. Karen Litzy: 22:37 And so from what we talked about from a sort of 30,000 foot view as to what associations can do to kind of help clean up terminology, this kind of medical terminology and that may, like you said, partnering with our physician colleagues partnering with maybe our chiropractic colleagues to kind of change the narrative. But what can, for all the listeners out there, let's say you're an individual therapist, what can you do to kind of help change the narrative around that term degenerative disc disease? So your patient comes into you, they're fraught with worry, what can you do? Elaine Lonnemann: 23:19 Okay. You know, I think the biggest thing is to get our patients as our advocates. And so taking the time to educate them about it and say, yes, you know, this is real. Your changes are real. This isn't a disease. And to help them to understand that and then give them the tools, you know, say, Hey, you know, when you go back to your physician or your other provider, whoever referred, or maybe they didn't refer, you know, get the word out to these medical providers, get the word out too, you know, senators, legislators and because they're speaking to them as well and support, you know, this aspect of, you know, whether it's conservative care, you know, and also having pamphlets or educational materials, you know, that really do talk about, you know, if you are referred to a physical therapist first, that there's, I believe it's an 89 point something percent less likelihood for that patient to be prescribed opiates in the following year. Elaine Lonnemann: 24:23 And that's a huge statistic, you know, and everybody's concerned about the opioid epidemic right now. So, you know, following practice guidelines and physical therapists should be considered, you know, first primary contact providers, then we can do a comprehensive medical exam, we can screen, we know when not to treat, we know when to refer on. And following those guidelines I think is the other part of what I educate my patients about. So I would say, you know, these are the guidelines and having this material. So if you're interested in sharing this with other people and you know, there are certain patients that are more vocal than others and whenever I hit those patients, I really get them and hit them hard and say, you know, help share this information. If you found this valuable, please advocate for not only yourself but for the next person that comes down the road. So they don't have to worry that there are 26 year old now and they have, you know, this label. Karen Litzy: 25:28 Yeah. He had this quote unquote disease. That is not all right. So is there anything else that from your perspective or for AAOMPT's perspective that we missed that you're like, you know, I really want, whether it be other physical therapists or healthcare providers, even the general public to know. Elaine Lonnemann: 25:52 You know, I think it's important that I'm clear on this. I'm not saying that imaging isn't useful. Because you know, I've talked to us a little bit on the downside of it, you know, but in the absence of trauma or any other systemic medical concern, imaging studies aren't necessary for, you know, low back pain, a comprehensive medical exam is. So I think that's something that I would like to emphasize, but there are times when imaging is necessary and I don't want to come across as saying that, you know, we're downplaying it all the time because sometimes it certainly is necessary. But I think that, you know, the biggest thing that people don't understand is that these are common age related changes in the spine. They don't correlate with symptoms. You know, that's hard for the patients to understand and providers because we are so focused on finding, you know, some type of pain generating tissue as the cause, you know, so sometimes I'll share stories too with patients and say, you know, because they've now got this disease, they've got imaging, they've got findings and you have to kind of talk them off the ledge to a certain extent. Elaine Lonnemann: 27:14 And I say, you know, if I had a group of 20 year olds, 120 year olds in a group, and then I have a group of 80 year olds, 180 year olds on, on the other side of the room and none of them have back pain. Now they may, probably 90% of us have back pain at some point in our life. But at this point in this room, none of them have back pain. But then if I sent them all into the MRI or imaging room, then 37% of those 20 year olds would come back with degenerative changes in there. There's fine or changes by positive findings and if you then look at the 80 year old group who then goes in and has the MRI, that number goes up to 96% so that kind of gives them a little bit of a balance. So I guess that's the other thing I would share, you know, just that these findings on imaging don't necessarily have to lead individuals to go down a path for riskier treatment options. Karen Litzy: 28:15 I think that's a great statistic. And thanks for sharing that because now that's something that if there are any therapists listening, they can kind of use those statistics to say, Hey, listen this is common as you get older. And I think, you know, the downfall that I can see from having this conversation with the patient is then the patient's saying, do you think it's all in my head? Elaine Lonnemann: 28:40 Right. And that's what I emphasize. Yeah. Karen Litzy: 28:42 Oh, real. Yeah. That's why I'm glad that you said like, listen, your pain is here. It's real. You're experiencing this. This is not made up. But let's see if we can, like you said, follow these guidelines get you to move, do exercise, feel more comfortable in your body in order to help reduce your symptoms, reduce the pain. Cause I know, I mean when in my early days of explaining things like that to patients, I've had someone say so it's all in my head and I was like, Oh, that is not what I meant. I definitely screwed that up. And with experience you learn, right? You learn how to do that better. You learn how to relate to the patient. And the best thing to do, like you said, is to use stories and to use statistics and to use metaphors and things like that so that people can kind of understand where you're coming from. But yeah, that's the only downfall that I could think of. That devil's advocate here. Right? Elaine Lonnemann: 29:41 Absolutely. Yeah. And I think as physical therapists we have to kind of get outside of ourselves. Yes, we know that pain is, you know, it may begin in the brain and the synapses and all of that, but do we really have to say that specifically to the patient? Can't we just say, you know, it's a normal, natural physiological response. You've had it, what you have is real and it's impacted by a lot of things. That's a complex issue. But what you have is real. And I have never argued, that was probably some of the best advice I learned in my fellowship training when the patient has pain. And this was way back when before a lot of the pain science research has come out. But when the patient says they have pain is their pain, that is what they have, you don't argue with them about that. You know, regardless of what type of physiological response you're seeing, what they have is real. And so, yeah, I do hear what you're saying about the downside of it. Yeah. They do have physiological changes, but pain is a complex matter. Karen Litzy: 30:43 Well, thank you for all of that info. And I think that this will definitely give therapists something to think about. It'll give therapists a great way to move forward with treatment. People now know how to access the clinical practice guidelines. And that leads me to the last question for you and that is knowing where you are now in your practice and in your life, what advice would you give to yourself as a new grad, fresh out of physical therapy school? Elaine Lonnemann: 31:16 I would probably recommend to take more time to reflect on my patients. Not necessarily bringing them home, but to take a little more time to reflect on the things that they said personally related to their care. And also reflect on outcomes to a greater degree. Karen Litzy: 31:44 Great advice. I always say that I would like to go back to my patients in my early days and just, you're like, I'm sorry. Karen Litzy: 31:57 I mean, you know, I was doing the best I could with the information at the time. But you know, of course as you gain more knowledge, you gain more experience. You look back on things and you're like, Oh man, I could've done that better. But that is part of that reflection process. So you look back on patients and you reflect and you think, Hmm, you know, maybe I could've done X, Y and Z. So then the next patient comes along and you do better. So I think that's great advice. I love it. And yeah, where can people find more information about AAOMPT and more information about you if they have questions or anything like that? Elaine Lonnemann: 32:30 Oh, absolutely. So, the AAOMPT website is https://aaompt.org/ and you can certainly email me. I'm happy to answer any questions or talk to you more about, the Academy of orthopedic manual physical therapy, APTA, where to find guidelines, research on low back pain. It's just something I'm very passionate about and always enjoy talking about and working with patients with as well. Karen Litzy: Awesome. Well thank you so much and thank you for coming on sharing all this info. I appreciate it. Everyone else, thank you so much for tuning in. Have a great couple of days and stay healthy, wealthy, and smart. 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On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Eva Norman on the show to discuss her cash based physical therapy business. Eva Norman, PT, DPT, CEEAA is the President and founder of Live Your Life Physical Therapy, LLC, 100% of cash-based business since 2013. It is the first mobile medical wellness practice in the country run by an inter-professional team of physical therapists, occupational therapists, speech language pathologists, personal trainers, acupuncturists, massage therapists, health coaches and dietitians dedicated to optimizing health by transforming lifestyles through innovative wellness, fitness, rehabilitative and preventative services. The company's success can be attributed to standardizing an approach to develop a life-long client, transforming lifestyles through care collaboration, and mentoring and investing in their employees. In this episode, we discuss: -The shocking story behind how Eva was introduced to physical therapy as a teen -How to attract and maintain patient flow with a mobile cash practice -The benefits of virtual assistants for the operational side of business -The importance of maintaining a connection with your network -And so much more! Resources: Live Your Life PT Website Live Your Life PT Twitter Live Your Life PT Facebook Live Your Life PT Instagram Eva Norman LinkedIn APTA Private Practice Section For more information on Eva: Eva Norman, PT, DPT, CEEAA has been practicing physical therapy for nearly 20 years. She received her B.S., M.S. and Doctor of Physical Therapy degree from Thomas Jefferson University in Philadelphia, PA. Through the years, Dr. Norman has practiced in different practice settings with patients of all ages with various diagnoses. Early on in her career she developed a strong interest in geriatric rehabilitation. To expand her skill set over the years she has taken numerous continuing education courses and also worked in the areas of neurology, orthopedics and cardiopulmonary rehabilitation. In 2013, she became a Certified Exercise Expert for the Aging Adult. Dr. Norman, an active member of the American Physical Therapy Association since 1994, has served in numerous roles. She is currently serving as the MN Physical Therapy Association's (MNPTA) Federal Affairs Liaison, MNPTA Delegate, and PT Political Action Committee Trustee Chair. She is a member of the private practice, home health, geriatric, health policy and neurology sections. In January 2013, Eva founded Live Your Life Physical Therapy, LLC in response to her passionate desire to offer to her clients, patients, and the public, services both in home and the community that could help them to experience health, wellness, and a more active lifestyle throughout their life spans, through the creative applications of preventative and rehabilitative physical therapy, occupational therapy, speech therapy, personal training, acupuncture, massage, health coaching & dietary services. Read the full transcript below: Karen Litzy: 00:01 Hi Eva, welcome to the podcast. I'm so excited to talk to you today. As a lot of people may not be familiar with your story quite yet, but those of my listeners who are know that we have a lot to talk about and we could've gone in a million different directions here from advocacy to APTA membership to the PT pac. I mean on and on and on. But what I really want to know, I'm being selfish here, would I really want to talk about is your business, so live your life, physical therapy. It's a really interesting business model, I think. I think and I hope that a lot of physical therapists will trend into your business model at some point. But before we get to that, can you tell us the story behind it? What is the why behind the company? Eva Norman: 00:57 Yeah, it's quite a long story, Karen. But yeah, that definitely will help you understand why the model is the way it is. So when I was 13 years old, I was involved in a hit and run accident. And actually this was actually the weekend before I was going to go trial. I was headed to nationals or I was trialing for the Olympics and swimming. And so it was pretty life changing. My coach said, don't just go do something fun. And so, ya know, I just don't really have the best balance and obviously hindsight's always 20, 20, I don't know what crops go roller skating with my girlfriend, but I did. And so I was literally going across this crosswalk and the 72 year old man who wasn't wearing his glasses that day and drinking, unfortunately instead of hitting the brakes at the accelerator right at the left side of my body, I'm pretty much fractured all my major bones in my left leg that I honestly referred to myself as road kill, to be honest, for a long time. Eva Norman: 01:56 And it was very, very traumatic. I was rushed to the hospital where I was told that we needed to amputate within 72 hours. Cause that's all of my ability that we had the femoral artery. There was just, I mean, just a really weak thready pulse. And I come from a family of healthcare professionals. My father's a physician and my mom's a surgical nurse and my team took me home. They told the doctor that they would respectfully disagreed with his conclusion, obviously the diagnostics that had been made and they were going to take me home and have me heal there. So, which is pretty, I know, right. And I just remember being hooked up to morphine and thinking like in shock, of course I'm still in shock, but I trusted my father, but I just remember thinking, okay, how's this going to go? Eva Norman: 02:47 And I remember the doctor saying, you realize you're leaving the hospital AMA. And my father's like, I perfectly understand that and I work here. So yes. And so they took me home, they converted our living room into a hospital. And, I was going to the hospital for outpatients though. So the one thing my father did ask, the surgeon is to order outpatient physical therapy because at the time, sadly, there wasn't home care for kids. And even today, as we all know, there's very limited. And so I went to outpatients. You're not even going to believe this, but I had anywhere from two to three times a week at non-weightbearing for nearly four months. This was years and years ago. And so, my parents essentially the range of motion through stretching do it, just retrograde massage, acupuncture, and honestly, incredible nutrition. Eva Norman: 03:49 So during this time, actually I got very depressed. As a matter of fact, I tried to commit suicide during this time. And so it was really dark hours, I'd have to say during my life. And I got really depressed when my father came home to tell us that our insurance had exhausted. And so you can imagine having two to three times a week of therapy for that long period of time. No wonder we reached our annual cut so quickly. And so, my dad asked the hospital if they could see me privately and they said, no, we don't do private pay. And, then my dad was like, well, do you know any other providers in the area that could do this? And they're like, no, we don't know anybody. Eva Norman: 04:34 So of course my dad literally opens up the yellow pages. Remember back in the day we had yellow pages and just calling anyone and everybody and couldn't find anybody. I mean he researched high and low. They couldn't find anyone outside of where we were from. We're actually from a little town called holiday for Pennsylvania and couldn't find anybody. And so he took the director of the rehab program there at the hospital to breakfast one day. And he asked her if she would consider coming. And the reason is because, you know, people have often asked me like, who is your physical therapist? To be honest, I don't remember. I still don't, it's very foggy. And I've actually looked into this that it was multiple people, but the person I did remember was Jean. So she was the director of the program. I'm not going to share her last name. Eva Norman: 05:22 Jean, if you're listening to this, hopefully someday you'll listen to this cause God knows you've heard my story before. But she is very modest and she's okay with me calling her Jean. But anyhow, I would love to share her name. I was interviewed and she said now just by first name and I'm like, okay, I want to share that because a lot of people want to know who she is. And so the person that I remember is her, cause I connected with her, she was in PR. She was honestly, my cheerleader walked in always the high fives would always give me hugs and I left. And so my dad took her to breakfast and begged her truly to come over and she said to my dad, you know, you realize I haven't touched a patient for two years. Eva Norman: 06:04 Like, why would you ask me? I'm like, the last person you would see your daughter, you know, and my dad's like, but she loves you. She's connected with you. And she thinks that physical therapy, you're the person she remembers. And so she just come over, you know, I don't know, just talk to her. I'm just worried. And, of course my dad shared with her about the fact that I was so depressed and so I think that's really what motivated to come over. And I don't really know that she knew what she was getting herself into, but that day was honestly very transformative. And I use that word there because it truly was, she gave me hope that day. I might get emotional here cause it is very emotional for me. But she came in and it's just this holistic approach that she had. Eva Norman: 06:49 The first thing she saw me, she said it was just this picture of depression. And she came over and gave me a hug and I honestly didn't want to let go. And, she's like, you know, she said to me, she goes, when was the last time you saw your friends? I'm like, it's been months and you know, it's been four months. My mom has me on isolation here. Essentially you're donning gloved right now because my mom's still afraid of infection. And she goes, no, I'm just, yeah. And she turned and looked at my mom's, of course, my parents are sitting there in the room and she said, you know, she needs social interaction. She needs people in her life and you know, is there any way, I mean, her friends could come over and gown and glove like I am. Eva Norman: 07:27 And it was at that moment, I think the light bulb went off in my mom's head. Like, what have I done? You know? And so my mom, my mom is like, you know, of course she's like, you know what, I'm going to call your best friend's parents today. We'll have them over for dinner. And of course, my mom's solution, everything was always food. So I had this big dinner that she, of course, Christmas staying for. And then the next thing you know, Jean asks me, she's like, your dad tells me you're not doing your schoolwork. And you know, it's all about like, you know, she's like, you love to read. Your dad says you don't even want to read anymore. And I said, Jean it's the concussion. Cause that's something I forgot to mention earlier that I had sustained a concussion. Eva Norman: 08:04 I'm having a hard time focusing. I'm still seeing double, you know, I'm just having a hard time concentrating and she goes, but you have the TV on. I said, I can listen. I just can't read. I just am having a really hard time with that. And she goes, well have you been doing your exercises? I think she assumed that the PT that I worked with gave you exercises and like no one's ever addressed it. No one's ever assessed it. I don't think anybody even knows that add one, except for the doctor that told me I had one. She goes, Oh my gosh. Then you could just tell by the look of her face. She was just livid. Like, gosh, how are we not addressed that? And she turns to my dad's, she goes books on tape. Remember back in the day we handle, yes. You know, that will be a great solution. Eva Norman: 08:45 You know, she's like, go. And of course my dad's like, Oh, library down the street, I will get every book imaginable. Great idea. So moving forward. Then the next thing she says, she's like, she's like, now I understand why I haven't been to church and do you actually went to our church? And she's like, I understand your mother doesn't want you leaving this house, literally these four walls. And because she's so afraid that you're going to, you know, obviously end up with an infection. And she said, but you know, I know sister's been calling here a lot and we've been praying for you. Like, I haven't wanted her to come over. And, you know, and it was just an, and I just remember at that moment, I mean, my parents had asked the same question and I finally admitted, I said, you know, I just feel like a failure. Eva Norman: 09:25 You know, they had just, you know, four months ago, they had this pep rally for me cause I was heading to nationals or I was going to try nationals again. And you know, I was just so happy about that. And I just honestly felt like I failed my town and my failed my school and who had, okay, there's so much time into me, like coming in, rooting me on everywhere, honestly. And, and so and she goes, no one cares about that. All right, let me be happy that your alive. And an amazing family. And she obviously was telling me everything, but you know, obviously I should be thinking, but I mean, that's really what it was, honestly eating away at me. And so, and I said, you know what, and she made me realize that that's just, that's not important. Eva Norman: 10:07 Right? And she goes, well, would you welcome communion? I mean, is that something important? And I honestly broke down at that moment because, you know, I really thought God had abandoned me. Just for her, just to even offer that. And so I welcomed it and she's like, well, you know, sister and I were going to have dinner tonight, so how about she come over tonight as well? So like I said, that day was just amazing for me. And so just knowing that sister would come over with really miss a lot. And so as you can tell, I mean, just even just with these few little things I have shared, I mean, it was just such a holistic approach. She hasn't even touched me yet, but yet cared about, social, my emotional wellbeing. And so then this next piece she was like, okay, today for therapy we're going to take a shower. Eva Norman: 10:54 Cause clearly we need one. And so she's asking me about like, where do you shower? I said, well, my mom washes my hair in the sink and then, you know, I sponge bathe in the bathroom, so where's your shower? And I go, well there's one in the basement. Went upstairs, but I can't do steps. And as she goes, why can't you do steps? And I said, well, my leg is just very unstable. And so, it obviously is very painful still. And, and she said, well, why couldn't you go up on your bottom? And I said, well, I don't know how to do that. Can I do that? I remember my dad, like I just remember he was interjecting was like, wait a minute, does this say for her? And she's not allowed to anyway. She's like, absolutely. And of course rolling her eyes again. Eva Norman: 11:32 How is it, my staff is not addressed this right? So don't we see that a lot in home care? Clinics don't even ask you like how many steps you have or where your bathroom is and so forth. So Jean shows me how to get up there. She has, my mom had her wrapped my leg, literally had my first shower on the second floor, I mean, in four months. Oh my God. And then I get into my bed for the first time in four months. And so now I'm just crying uncontrollably. I'm just so happy. And it truly, I honestly have hope for the first time. And,I remember her really close to me on the bed and she literally grabs me and like my two arms pretty firmly. And she looks at me like really close and she's like, yeah, Eva do you trust me? Eva Norman: 12:16 I go, Jean, I love you. Like, and I'm sorry and I'm going to get emotional right now. I'm like, of course I trust you. And she said like, why don't we have you back? She's like, well, we're not done yet. We haven't done exercise yet today. But she's like, I will be back. She's like, I want you to know is that you will walk some day. Do you believe me when I say that? Yes, I do. And this was, I mean, of course I've been told by, I mean we had had numerous specialists now, you know, had okay examined me and it was like conclusive apparently according to them. It wasn't scary. Oh, it was. And so that day was the start of a whole new life for me. And, I mean literally eight months later. Eva Norman: 13:03 Tell them this is the day I was walking with no deficits like in or anything, it really was amazing. He was coming anywhere from two to three times a week. But who did she bring along the way? She brought an OT. She brought a speech therapy because of my concussion, I also ended up with you have ADHD as a result. And I also worked with a dietician to work on my nutrition. I had massage because I had a lot of pain on my leg. Chris, I had mentioned it's an acupuncture earlier. So good luck even today at live your life. I was just thinking that is all said and done. My mom made. So I made two promises, went to my mom. Okay. My mom promised God that if I lived that we would give back. And so from that day, like literally my mom had me volunteering at every PT location, whether it was adult day program, LPP, clinic, you name it. Eva Norman: 14:06 I was there when I applied to PT school. I had 3,600 hours of volunteer hours. And that was all with my mom. And, then of course today you could see why it means so much to me to give back to them that I love so much and I'm obviously long story how I got into government affairs, but I think that honesty is the best way that I feel like I have to give back. And then, with regards to the promise that I made my father, my father made me promise it some day I would have a business where I could help others in similar situations. So it's very personal to me and obviously it's kinda been like this healthcare ministry in a sense to me. I'm very spiritual but it's just also just become this. Yeah, just something that I'm just so passionate about. Eva Norman: 14:50 And so I started out, so the company started with just physical therapy initially. It's because I would do what I knew best and what I felt comfortable with. And just so you know, by the way, Jean is still my life helped me get into PT school, had my first clinical with her. And the time I graduated, she has seven like thriving clinics all over Pennsylvania. I mean she's doing as she's teaching the last that she sold her businesses now teaching on a penny towards retirement but still doing amazing. And so now I feel like I'm somewhat following in her footsteps and so like it took a while though cause people always ask, they're like this is somebody that you obviously had this promise to make and cause I was afraid of failure to be honest. Eva Norman: 15:48 And it sadly took this horrible job to finally take the plunge to be honest. That's usually how it works though, right? And so, I'll never forget the day that then I left that job, which honestly was great day, but my husband said, you know, good for you because this is literally how the company started. And so we go to Buka is you know how they have like the table nets that are just, you know, okay you could with crayons, right. All over and so forth. And we wrote my business plan downstairs just on crayons and stuff. He wrote like generic little business plan but then coming up with the name. Right. So how did we come up with live your life? So I mean we had another sheet, all these words that were meaningful to us, right as a couple. Eva Norman: 16:35 We had thought of that cause we don't, we talked about the business for so long and Dan was so supportive of this and so, and I remember like, I mean they're literally words live like these words are everywhere, you know, in physical therapy. And I mean there's was just like live, well I remember there's all these different like verses, you know that I envisioned it so forth. And I'm not even kidding you, but I have to share this. Cause people always ask like, how did you finally come up with that? So we're sitting there and you know, there's music always jam and right. And sure enough, Rihanna comes on the side, live your life. And I'm like, and I literally called Paul walk at that moment, he was like business lawyer. I'm like file it right now. Eva Norman: 17:16 Like file it right now. We're not changing our buys like you know, and so we filed literally that day. So it's just such a great name. As we're putting the business plan together, of course this is something I had thought about for quite some time, but the common thread, cause I had been doing home care now at that point. I'm sorry for how many years I been doing at point 10 years. Yeah. At that point. That was almost seven years ago. January 2013. Yeah, I would say essentially open our door I think. But at that point, what I was most frustrated is with the, the noncommunicable diseases, right. From an unhealthy lifestyle. Such like retention, that diabetes, obesity of your RDCs, you know Karen, stroke, cancer, some of the things that truly, I mean that are honestly draining our healthcare system and we're going bankrupt as a result. Eva Norman: 18:21 And I'm like, so much of this can be prevented. And I'm so sick of seeing the vicious cycle again and again, repeat patients over and over and over again. I meant seeing them, you know, or it's the pneumonia with the hip fracture on and on and the multiple falls. So it's just this just crazy. I'm like, gosh, we had to do better. And I've always had such a passion for prevention, hence my background where I kind of brought in right. You know, just that holistic approach and just going well beyond just rehab. And so like every patient just prior to this was always going home with some type of what I would call a wellness program. And so I knew I wanted to go in that niche, but I wasn't sure kind of, you know, who to target. Right. And I should start small initially, but you know, I dunno, can I never go small? Eva Norman: 19:12 What are those things where you just go big or go right, So yeah, let's do the whole spectrum. Since my head said safe and they're like, okay, how about it? Because this all happened to me at 13 we go 13 end of life. Perfect. Let's start there. And it truly is 13 end of life by the way. Still today. So, okay, so that's our target market and then, okay, so who, and what are we going to target? I'm like everything, everything, every noncommunicable diseases, things that we can prevent, those are going to be, those are going to be like their target things. And so of course they started doing research throughout Minnesota to see where, what towns do we target. I mean it was amazing. Eva Norman: 19:53 I found out that like the city of Minnetonka has the most falls than any other city, which is not far from here. And I found that out by looking at the emergency room statistics, you know, so just started targeting like different cities based on, you know, some of that I'd been doing and done that was out there obviously for anyone to find. And so then I'm like, okay. And of course it was just me initially. Right. And I was thankful that I was doing my, it's called a certified exercise expert for the aging adults certification around that same time. And, my lab partner happened to be a PT that wanted to go to cash based business. So it was like my first hire. It was great. And so because I quickly knew right away that I needed to have a backup cause I'm like, I'm never going to be going on vacation, you know? Eva Norman: 20:43 Okay. Right. And how am I going to be able to, you know, continue to grow and he was willing to be that back up who were great by the way. He is now these actually now in Chicago, and doing amazing things with his cash based business but regardless. So we started small, but then I was able to, through those connections and through the certification I was able to identify like all their physical therapists that kind of wanted to start cash based businesses. So targeted them. And then I started teaching at the different universities to connect with other professors, not necessarily wanting to hire students that the professors, because a lot of times they're paying for a part time work. Right. And I thought, yeah, let's target health and wellness professionals. So it was great to kind of, that's how it started and got made. Eva Norman: 21:36 So by the end of year one we had four PTs, one personal trainer and a dietician. And so, and it's not that I didn't want to, you know, third discipline, it's just that we couldn't find the right people. Right. That one perhaps like to be out in the community. But also that one to go you mentioned kind of area, right? Because it was NC state. I mean that was, you know, almost seven years ago. So back well defining terms in the house delegates. Eva Norman: 22:12 For OT and speech was difficult, but sure enough, a connecting. Like I said, it's all been through relationships to be honest. Everyone that I have hired, it's literally a friend. I know someone for your mom that will work well with you and I'll see. It's been great. I was just thinking about that as earlier today. Kind of, you know, just start team. We were just thinking, because I'm planning our Christmas party right now. Like, you know, there's eight individuals that have been with me since the beginning. There's 25 of us now, so seven PTs. We have one OT, one speech therapist, five personal trainers or massage therapists, a health coach, a dietician in for admin staff and myself. So 15 of those individuals are employees and 10 are contractors. Karen Litzy: 23:10 And so if we can just talk, I love the fact that you said you kind of did your research into different towns and tried to see what each one of those towns really needed. So when you are seeing your clients, you had mentioned your cash based, do you take any insurance at all? And so when you're seeing patients more towards the end of their life, you know, a lot of them are Medicare beneficiaries and we had a little chat about this before we went on the air. So, and this is, I'm sure you get this question a lot. How are you seeing those people? Eva Norman: 23:45 Absolutely. Thank you for the question. So end of life would be a lot of patients that are receiving hospice care. So when I can think of end of life, unfortunately a lot of the hospice is in the area only. We'll cover two, maybe three visits at the most of physical therapy so that we have great relationships with all the hospice here in the twin cities. So they'll refer us. Cause a lot of times, you know, people are like, I don't want mom in bed. You know, I don't want her last days to be that. She loves to walk. She loves to, you know, go downstairs and spend time with the grandkids or whatever. Eva Norman: 24:33 So I want you to keep doing that. But I want a professional to help her do that safely. And given her medical, you know, history, you know, her medical complexities, right. Obviously. So, so they hire us. But of course sometimes it's not just physical therapy they may want, sometimes it's just, you know, sometimes they may want a massage because it's just soothing and comforting and so forth. Because they have, a lot of times they have pain and so forth. But sometimes, you know, they'll stop eating and they'll hire even our speech language pathologist to figure out, like, is there something that we could do perhaps to help stimulate the taste buds or give her perhaps mechanical soft diet or something as different type of diet perhaps to help her with eating. Eva Norman: 25:20 And then sometimes even to our dietician will get hired as well to pick up, how can we get enough calories? We have, and I'm really happy to say this, we have had 15 at this point, 15 clients outlive hospice due to our wellness program. Yeah. Remarkable. And so, Oh, how does it work? Right? Like how do people get into our system and how do we figure out. These are the disciplines that you need it. So, absolutely. So they'll call, they'll call, they'll call 'em. You know, we can call a number. So my admin by the way, are all virtual. They're all virtual assistants. Eva Norman: 26:06 So I have one person that literally takes the calls. So there is a series of questions that they get asked and we've actually created an algorithm. So based on how their answers are, you are headed, you know, you're obviously recommended certain different services. Now of course my admin isn't clinical so they don't make ultimate decisions, but they can kind of help start that conversation of where, you know, what they're thinking that perhaps they could benefit from. And so I take that algorithm, the results of that, and then I set up a telehealth free consultation. We do 30 minute free consultation because typically, I mean they have some questions and of course because it's cash, they should. And I open that conversation to like as many family members as they want. You'd be amazed. Like I'm, sometimes I have like the whole family because the family's paying this for mom. Eva Norman: 26:57 Or, you know, the son that's in New York. And then, another cousin that's really involved in Texas or whatever is, you know, is on the phone is on this call. So, that's why we've started to do tele-health, calls. They want to see who I am and obviously want to meet their therapist. And that's like a great opportunity to explain, okay, so according to our algorithm, these are the services that we feel that you would benefit from. So I kind of explain what those services exactly will do for them. And then prior to that conversation, I'm also packaging something for them, you know, depending on what we think would work best for that individual given what I already know about them, I try to package some things so that they know what it's going to cost them. Eva Norman: 27:43 They don't have to, there's no, we don't have any contracts or commitments they have to make, you know, it's obviously up to them. They can start in whenever they'd like and see us as frequently or not as frequently as they'd like. So it's really up to them. We make our recommendations, but ultimately they make the final decision. And we based that after assessments. Cause a lot of times like I'll give them kind of a ballpark of what I think it could be just based on, you know, other experiences with similar cases, you know, it's really going to come down to really determine what would be best. We always think that way. And then at that point is really when we finalize the numbers as far as what that looks like. Eva Norman: 28:28 And they obviously will make some times their decision as far as what they want to do. But oftentimes they do want to meet. Like who would be the dietician, just want to see if that's a good fit for mom or dad, et cetera. But it's interesting how it's usually the sons and daughters that are hiring us. And you know, we do 13 to end of life, but I'd say the majority of our clients are over the age of 65 so the majority, but yet we have the full, we do like, I mean actually my youngest right now I do, I do have a 10 year old gymnast right now that's actually a professional gymnast that is trying for Olympics. So injury-free they're amazing. And our oldest right now is 103 and on hospice, you know, people here in Minnesota live a long time. Amen. I'm going to have a hundred year olds for that matter. We have about 15 clients that are over the age of 90 right now. Karen Litzy: 29:42 So that's amazing. I mean I really liked this business model and I am a huge proponent of physical therapy being the forefront of wellness care because we're educated for it. We understand co-morbidities, we understand surgical procedures, past medical histories and how best to formulate a good plan of wellness for people. And I really, really feel that, you know, what you're doing in Minnesota is certainly something that can be replicated across the country. I mean, I always tell people like, Eva has a home care business in Minnesota. I mean, it's fricking cold there and there's no way. Like if she could do it, like anybody could do it. Everyone always asks, well, I don't know. I live here. Would I be able to do it? I'm like, let me tell you, yes, yes you can. You absolutely can. It just takes a little bit more work, you know, and it's a different mindset, right? Because you're all of a sudden going from in a clinic where people are just coming in one after the other to now you have to make up your schedule. You have to fill that schedule. It's not as, it's not like, I don't know about your practice, but I know with mine, like I got six new patients in the past week. Week and a half. That's a lot. You know, now in a regular clinic that might be like a day, but when you're going out to people's homes and they're paying you cash, that's a lot of new patients. So how do you guys deal with, you know, your new patient flow? Eva Norman: 31:09 Absolutely. Great question. And so, I have to tell you this year, this time of year, so it's fall and spring are our busiest times and I'll tell you kind of why. First of all, right now they're getting ready to head South for the winter. So they're trying to get themselves as strong as possible before the holidays because they want to go to Florida, Arizona or Texas don't make sense. And then in the spring it's those that had been sedentary on the couch all winter long and suddenly they come out in the spring and sure enough things are not working the way they hope to right. Because they haven't been moving. So that's where high season. So right now it's if a 10 grit, good question to ask. Cause we do have a waiting list. It's it honestly. But what happens with the waiting list? Cause I don't think that's good customer service. Eva Norman: 31:58 I ended up out in the fields. And so that's because a lot of times people ask me like, when do you add more PTs? Like when do you decide like you need to hire that next person. So when I get to the point where like three quarters of my week, I'm literally spending in the field, it's time to hire. And even just one week of that is like enough for me to say yes, it's time to hire an as a matter of fact work. We have a full time position right now. And I actually, I'm out now part time, but still I would say, but that's still a lot and I've been consistently that now for a while. So, yeah, we're actually down to final interviews. So I hope to have someone hopefully by next year. But that's kinda how we make that decision. Eva Norman: 32:43 Before, it used to be like three months consistently, but now I've known that if it stays that busy, especially this time of year, it generally stays the same. Oh, and I haven't really had anyone that I've been able to, like I've had to like, you know, go from full time to part time because essentially once we have them, I keep them busy. And that's one thing too. I should probably share what's also help at this model is that it's kind of a level playing field. There's no, I mean I have the bottom up management style. Like everyone has a voice here and so everyone contributes. Everybody has a project and so perhaps developing a wellness program around what they're passionate about. So we have probably about seven projects going on right now and so just the individuals that not everybody has to do it. Eva Norman: 33:33 But right now there's seven individuals that are developing programs around one is looking at cancer. One is looking at diabetes right now. One is looking specifically at dementia. One is looking at dementia, the other one's Parkinson's. And then we are looking at cardiac disease. Develop your like a cardiac rehab program for the community. Like for people they can't get to like the actual, you know, hospital for their cardiac rehab. And I think there's one other ends. Oh, concussions one on concussions. Huge. So those are kind of, I think that was seven. Does that sound like seven. But those are currently actively being utilized and we have multiple disciplines working on one project. So like for example, for like the dementia program, we have a personal trainer, we have an acupuncturist and a physical therapist working on that specific program. Eva Norman: 34:28 And so they meet regularly on their own time, might be doing their own zoom meetings as well and meeting so that's sometimes we'll fill in the gaps when we have ebbs and flows. Cause as we all know in cash base world, it ebbs and flows. So that fills in their gaps. And so they know that they're always going to be full. So when they have downtime, they work on their projects, they'll work on research, they'll meet everybody, also has a mentor that which they're required to meet with regularly. So they might meet with their mentor. And also everybody is required to be a part of the professional association and in their professional association. So that might mean, you know, doing committee work might be on their downtime or you might have been asked to put a presentation together. Eva Norman: 35:12 So they might be working on that. And you know, well up our time in so many different ways so it stays busy. So I share that because a lot of people say, well, what, what happens when there's downtime? So, but you know, all of that helps the business that leads to employee retention, professional growth in the course of the growth of the company. Which has been really one of the, I'd have to, one of the number one reasons why I think it's led to our success and our growth is because, we do empower them to essentially become these young entrepreneurs, right? And so many of them, you know, want to. So, so lot of times we do lose staff because what happens is they learn how to run their business and they go start their business. But I see that as success. Eva Norman: 35:57 They don't compete with us. As a matter of fact, they end up taking their own little niche and they refer and we refer back and forth, which is awesome. So, really it is hard though. That's so much time and energy into them and to see them as always are, don't get me wrong, but you know, it's always great when I go to conferences and I see, you know, my young, you know my employees, my young mentees, you know, they're doing amazing things. So it's always, feels great to see that. So, but yeah, so hopefully so back to you. I mean, I'm sorry that's like, but in a lot of different directions there, but, as far as you know, we have one of actually answering your question a little bit more specific. Eva Norman: 36:43 So we have this waiting list. But like I said, we have a dedicated, it actually monitors our schedules. You know, each professional actually has their own schedule and essentially schedules themselves. But when I say one, like if we see gaps, because they'll put, you know, if they want more patients, obviously you know, they'll put it on their schedules. Like I can take three X week. So she'll monitor that so that she knows of people in as people. And we broke up into four quadrants so for those who don't know cities, we essentially break it up into four quadrants. I'm down a new four 35 w and so we just try to keep people into your graphic areas so they're not driving all over because that's a real pain in the ass right when the snow comes down. Eva Norman: 37:33 Probably a good hour one way. Although you might be traveling that some days, you know, seriously someday. And it has been pretty bad. Like last winter was horrible. It would take you an hour to drive just 10 miles, which is horrible as well. So, she's great about, you know, in keeping me up to date too. So her and I kind of work together as far as making sure that we keep people busy and so forth. So we might need to be reading perhaps referral sources. Oh, some people were starting, you don't, perhaps numbers are lowering in some people's schedules and so forth. But I mean, generally to be honest, they stay so busy. Yeah, I can't say that we've ever had a point where I had to be worried. Eva Norman: 38:24 Like I always feel like there's more than enough that we can do and so on the projects too, our business and they get incentivized to bring in business so we bonus them and so forth. So, you know, people are, we really truly work very collaborative and well together to grow the business. As a matter of fact, one thing I should've mentioned earlier with this interprofessional team that we have established kind of, okay, how do we decide when disciplines come in? Like I need to have packaged something together for someone, you know, PT health coach or I'm sorry, PT, dietician. I think I mentioned speech therapist earlier with an hospice patient. So we meet once a week through zoom and we actually have a care conference while we go through some of these cases where we'll problem solve, you know, when can we bring in the next system? Eva Norman: 39:09 Cause sometimes we don't want to throw everybody all, first of all they're paying cash for that. But also it may not be the best, you know, obviously may not be the best approach. And so we talk through that, you know, as far as who would be best right now, you know, and so forth. Like we just, I have a lady right now that the doctor's recommending like steroid injections for her back, you know, and of course we hear that all the time. And so, okay. So my acupuncturist gets on, she's like, tell her all about me. I'm like, Oh, I already have, you know. And I'm like thinking you might be the next thing because she's ready to like literally go with the steroid injection and possibly an opioid because she is so much pain. But let's have you come in. Eva Norman: 39:46 And so, you know, we look at you, you know, sometimes one discipline may merge quickly just because of something like that coming up. So, you know, but again, we constantly communicate, we're taking notes, we share kind of even, you know, our notes that we take from care conferences. Sometimes I always say we need to eliminate sometimes let it marinate in the brain to see, okay, well Whoa, would work best perhaps or these patients, sometimes we need to really think that through. And depending on what's going on and perhaps finances to it and also the support or lack of support that they may be having. You know, and I think on, I'm very ethical to like, that's the other thing too, like if we feel that they can get a service covered elsewhere, we will share that with them. And we also try to help them figure out ways that they can get this covered. You know, there's a lot of associations out there. I don't know if you guys are aware that, you know, like for example, for a stroke, the national stroke association, both your local and national, they sometimes will have stipends out there for wellness dollars that you can actually apply for. So Parkinson's has done that stroke muscular dystrophy. Eva Norman: 40:53 Most of them are multiples, so we'll have them tap into those resources. If you're a veteran, sometimes the VA has, well, you know, dollars set aside for that. We've found, we actually worked with a purple heart recently that was given 30 wellness visits being purple hearts and purple hearts out there. Take note that you might have a great deal with your wellness. And then all set. I'm just thinking there's also been just even private insurance plans too that sometimes have dollars for memberships and so forth. We've been able to negotiate with them to get them to use those dollars for our services. So, which has been great. So a lot of times just picking the phone and asking that question, is this possible? So, and you know, they're, you know, they're frequently trying to reduce costs, right? They don't want them in the hospitals. So they obviously appreciate what we're trying to do. Karen Litzy: 41:44 That's great advice. I'm really glad that you brought that up. That there are resources out there that we can have our patients, we can help our patients tap into for financial resources. I think that's really important. Good, good, good. Very good. And now you had mentioned earlier that all of your assistants are virtual assistants. Where do you find your virtual assistants? Because I know that's a question that comes up all the time. Eva Norman: 42:12 So, okay. So my virtual assistants are all, let's see, they're either in school or their moms. And they work out of their homes. And so I know that there's been, I've heard that there's virtual assistants that you can get abroad and so forth and things like that. You know, I actually just recently looked into that and she even had an interview ironically today with a woman in the Philippines, which it could be very cost effective. And I was just thinking more for just, there's just a lot of busy work behind the scenes, you know, of course with many different businesses I could save a lot of time and they're very efficient and I was just surprised like how fast they type and put spreadsheets together or actually can update some of our reports and things and wow. Eva Norman: 42:57 This I think good. So, I dunno, it was actually, and she's very cost effective. So thinking about and haven't taken the plunge yet, but just like I said, learned about it recently and interviewed her today, but how do I find them? As I mentioned earlier that really works for us has come to me kind of handpicked from friends or they've reached out, you know, and they reached out because they heard about our company. And I have to tell you, even one of them is a previous clients, you know, that, you know, needed a job and you know, and it honestly was just the right time, you know, it was one of those things where it was, it was truly wonderful. She call it the right time because I couldn't believe that day I shouldn't say I was desperate, but I was at the point where like I wasn't finding what I was looking for and she literally, I could check off all the check boxes with her and I trusted her and I knew her. She was a client of mine and no longer a client of mine. So, and I knew she had a really strong work ethic and the hours would work perfect with her schedule. So, it just worked out. Karen Litzy: 44:04 I think it's great cause I think a lot of physical therapists don't think about using a virtual assistant and it can be an economical way to get stuff done. So I think it's great that, you know, we kind of have that conversation around that virtual assistant and how yes, they can answer your phones or yes they can. Do you know, things like that that you would think that no, it has to be in your clinic, but if you don't have a brick and mortar clinic, then you really have to get creative and that's obviously what you've done at live your life PT. Now, is there anything else that you have found in the building up of this company that you would say to someone, boy, if you have the chance to do this to help your company, I would do it. Does that make sense? Eva Norman: 44:59 Yes. Ah, goodness. Great question. Yeah, so you know, well, I should take you back to, you know, and also just some. Yeah, it definitely. I would say the one thing that I wish I would have done from the beginning that has helped so much since I started the business. So this would be for the new business owners I'm joining and I have to put in a plug here for the private practice section. I joined the private practice session a year into my business and I wish I had joined them prior to that would've been great cause then I, through that network of individuals, I actually ended up with two tremendous mentors that have helped me so much. When I first started out, I didn't really have a whole lot of money for all, you know, contract develop. I mean I had a lawyer and so forth, but I couldn't afford necessarily to have him generating all these contracts for me week after week after week. Eva Norman: 46:01 Cause I would just, you know, I ended up meeting a lot of contracts initially but was really great. Is that I found some tremendous mentors. And I'll name them Sandy Norby, Mark Anderson and Tim shell. I thank you. Thank you. Thank you for listening to this podcast. You guys seriously helped me. Tremendous. I mean save me thousands and thousands of dollars, just sharing what you already had. And just getting me going and just also giving me the confidence and I wish I had had that. I mean, I wish I had met them prior to starting the business, you know, cause then it would've been so hard because I think I was trying to reinvent the wheel and little did I know, like there was all these people that could help me, so I can't stress enough doing that. But then now, once I started the business as far as kind of what I would recommend is, you know, the Rolodex that I have. Eva Norman: 46:59 So one thing that I have to tell you, this phone has 7,000 contacts right now. Yes. I know guys. If you can too. All right. 7,000 and I'm not kidding you. And so I have organized it all beautifully. So I mean, anyone that I need, I literally put a profile together in their context. I labeled them based on her state, they're like their profession and how they can potentially help me. And so that has been huge. So because I mean, I go to so many conferences all over the country. I meet so many people and I'll just do that for PT. I do it for other professions that has been my saving grace. I've been able to find quality staff as a result. I've been introduced to, you know, perhaps, you know, corporations that I wouldn't normally have conversations with thanks to those connections. Eva Norman: 47:51 And so it's almost like, I mean, that's probably been the easiest marketing that I've had. And so, and it's amazing how I'll call up someone five years after the fact that I met them and they'll just remember just based on the little conversation that I wrote, like a little, you know, the little notes that I had. They're like, Oh yeah, I do remember you. You had that cash based business in Minnesota. How's that going? I'm like, Oh my gosh, you do remember me? And so, it's great cause then we'll jump into the conversation and suddenly we're doing business together. So that has helped a lot. And as a matter of fact, sometimes they become even clients themselves. And so, yeah, developing your Rolodex but really organizing it well so that you don't forget those conversations. Use that notes section and write down what that conversation entailed, how you think that person could help you in the future or today, that kind of thing. Eva Norman: 48:41 So that has helped. The honest thing I have to say to, you know, I'll put in a little plug cause as far as the marketing, you probably want to know too, you know, we don't do a whole lot. I'd have to say our website is one of the main things. But the other thing is, I joined BNI about five years ago. I don't know if you've heard of it. It's business network. At the time, I was the only physical therapist I've aligned to the United Minnesota, which I was really surprised cause when I read kind of what you know I was doing for other PTs across the country, I thought, well this is really hard to believe. And now of course there are more of, it's interesting how a lot of private practice section members have joined because I've also shared this with others. Eva Norman: 49:25 And that has also been a great network of individuals kind of outside of my profession, but be able to connect to like other dieticians, other massage therapists and have been able to also, get business that way and just develop those relationships. So I guess what I'm trying to say is don't be afraid to like join like, you know, organizations like that or the rotary club, things like that. Potentially you can develop relationships outside of your usual comfort zone to meet, you know, people out there that can connect you to perhaps people that can afford your business or connect you to those that do. So. Yeah. So I would say that that would be huge. And I wish someone would've told me that like until you know, two years my business that I started. Karen Litzy: 50:09 I mean what great advice and you know, what's the saying like your net worth is your network or your network makes up your net worth or something to that effect. And, that's essentially what, like you said, developing this Rolodex. I love the tips on adding notes into that. I'm going to remember that cause I don't do that and it's a great idea. A friend of mine that I used to play softball with asked me to join his BNI, which I think he's like doing a presentation in a couple of weeks. I'm going to try and catch it, but all amazing advice. And you know, I wanna thank you for being so open and honest about your story. I did not know any of that and that was very, gosh, I can't believe it if I'm being honest what an amazing journey you've had. And especially like, you'd never know it being as every time I see you at a conference, you're out dancing till two in the morning. So how is this possible? Eva Norman: 51:18 Oh, he's asked me like where does that come from? I'm like, well there's a story behind it. So yeah, I mean I deeply love it and I owe my life to it. So I mean I really can say that I owe my life to physical therapy. Karen Litzy: 51:28 Oh, what an amazing story. And the practice is great now. Where can people find more information about you and about the practice? Eva Norman: 51:37 Absolutely. So our website is a great place. Liveyourlifept.com. But we're also on all the various social media facebook, Twitter, Pinterest, Instagram, LinkedIn, YouTube, well, a lot of different forms of social media. Let me think if anything else. No. And, and our website too, we actually have a weekly blog. And if there's anyone out there, by the way, that wants to be a guest blogger, please reach out to us. We're always looking for people to be a guest blogger for us, so we'd love that. Karen Litzy: 52:18 Awesome. And, you know, just for everyone listening, if you go to podcast.healthywealthysmart.com under this episode, we'll have all the links to the website and all the various social media handles and things like that. So, one click, we'll get you to live your life PT, to learn a little bit more about the model and hopefully more PTs can kind of step into this world. And now I feel like I have such a better understanding about what you do and so much more appreciation for what you're doing in Minnesota. I think it's great. So thanks so much, Eva, for coming on. Eva Norman: 52:56 Karen, thanks for having me. Karen Litzy: 52:57 And everyone, thank you so much for listening. Have a great couple of days and stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!

LIVE from the Annual Private Practice Section Meeting in Orlando, Florida, I welcome Lynn Steffes on the show to discuss physical therapy consulting. Lynn Steffes, PT, DPT is President/Consultant of Steffes & Associates a rehabilitation consulting serviced based in Wisconsin. She provides consulting services to rehab providers nation-wide. In this episode, we discuss: -How Lynn's career evolved from treating clinician to consultant -Common consultation inquiries and solutions regarding private practice -Health and wellness advocacy within physical therapy -The importance of building a strong network of experts within your field -And so much more! Resources: BrainyEX Website Steffes and Associates Consulting Group For more information on Lynn: Lynn Steffes, PT, DPT is President/Consultant of Steffes & Associates a rehabilitation consulting serviced based in Wisconsin. She provides consulting services to rehab providers nation-wide. Ms. Steffes' is a 1981 graduate of Northwestern University. She is Network Administrator for a group of 50+ private practice clinics where her primary responsibilities include marketing, payer and provider relations and contract management. She currently serves as the state-wide Reimbursement Specialist for the Wisconsin & Florida Physical Therapy Assns. In addition to her work as consultant, Ms. Steffes works as an adjunct faculty member in the physical therapy program at the University of Wisconsin, LaCrosse Physical Therapy Program, teaching professional referral relations, marketing and peer review. Lynn has addressed private practices, hospital systems, professional associations and therapy networks in forty states regarding Business Aspects of Physical Therapy. Ms. Steffes is active in her profession as a member of the American Physical Therapy Association (APTA) and the Private Practice Section of APTA. She chairs the PPS Task Force for Educational Outreach, is a member of the Impact Editorial Board & the PPS Educational Institute. She is also active in the Wisconsin Chapter of APTA – serving as the Chapter's Reimbursement Specialist, and on the WI Medicaid Committee. Read the full transcript below: Karen Litzy: 00:01 Hey everyone, welcome to the podcast. I am coming to you live from the private practice annual private practice section annual meeting in Orlando, Florida. And I have the distinct honor and privilege to be sitting here with Lynn Steffe's. And I know I have a lot of questions for her and we're going to get to a lot. But first, Lynn, can you just give the listeners a little bit more about where you are now with your business and what you're doing. Lynn Steffes: So thank you so much for having me, Karen. This is really fun and it's especially fun because it's absolutely gorgeous. So we're sitting outside and we have, I know I'm from Milwaukee and we have six inches of snow on the ground, so I am loving this, but, awesome opportunity to communicate with a lot of PT. So I actually, I feel like I kind of do a variety of things, but I have a singular mission and vision for that, which I do. Lynn Steffes: 00:53 And it's all really surrounding, the promotion of physical therapy as an important health care provider and service, not only in rehabilitation and healing of people, but actually in lifestyle medicine, being healthy. You have a dentist, you have a doctor, you have maybe an accountant or a massage therapist while you need a PT. And that's kind of me. So I promote physical therapy to all kinds of people. I teach at the university level, which I love. I speak all over the country. So I've had the privilege of speaking in 43 States, believe it or not. I do a lot of webinars, I do a lot of consulting and I work with practices as small as a guy where his mom does the billing when she feels like it. And I, by the way, don't recommend that. Lynn Steffes: 01:43 And then I also work with systems as large as Mayo clinic. So I have kind of a variety. And obviously when you graduated from physical therapy school, you were treating patients. And I know a lot of listeners here that are physical therapists. They graduate from PT school, they're seeing patients. And oftentimes, I know this is the way I felt when I graduated as well. This is what I'm just going to be doing. I'm going to be treating patients until I retire. I didn't have the foresight, I didn't have the knowledge to say, wait, there are other things I can do. Karen Litzy: So how did you go from treating patients to where you are now and at what point in your career did that shift happen? Lynn Steffes: 02:26 Wow, I wish I had some big strategic plan to share with you that I had like this vision, but I really didn't. When I graduated, I really did pediatric physical therapy. I graduated and worked for a private practice and I worked as a contract therapist in a school district and then moved on to a rehab facility and then opened outpatient pediatric clinics in a couple States. And I kind of, I love being a therapist. I always say, you know, I could still be a physical therapist if anyone would take me, but it's been awhile. But as I was treating, I was seeing all these opportunities for physical therapy and kind of just, getting more and more experience opening businesses. And it was weird because I actually worked in a private practice and I love treating people and I love managing, I loved, but really everything I was doing, but there was just a lot of it. Lynn Steffes: 03:20 And I think I started developing a little bit of an entrepreneurial, just like the sense that maybe I want to do some stuff on my own. I actually left the practice and interviewed with someone to become a pool therapist. And it was a PT I knew. And after I got done talking about everything I'd done, she was like, wow, Lynn. She was like, I can definitely sell you as a pool therapist, but I could, I'd love to sell you as a consultant. And I said, really? And she said, yeah. And I said, is there any reason I can't sell myself as a consultant? And she said, absolutely not. And that was kind of like this big aha moment for me. And I actually thought I would just like do a little bit of consulting until I found someplace I wanted to work and then I'd just take a job. I always assumed I wanted a job. And so I started consulting and it kind of became quickly a multiplier. And then I started thinking, well, I gotta look for a job. And I said to my husband, I gotta start looking for a job. And he said, I'm pretty sure you have a job. And it's consulting. And it's so funny because that was a long time ago, over 20 years ago. And I still love it. Karen Litzy: 04:27 And isn't it amazing that so often it takes that person outside of ourselves, even maybe outside your family or even personal friend group to say, what are you doing? Like you can do this. So what's interesting is you needed that person to give you the push. And now in your work you're giving other people the push. Lynn Steffes: 04:48 You know, I feel, I do, I feel super excited when I meet clinicians. And some of them are very young and some are also people who are kind of getting to a point in their career where they're looking for something else. I feel super excited when they want to do consulting. Number one. I think there's so much work to be done in, I don't feel like a sense of competition. I'm just like thrilled that people are getting into promoting what we do and being a multiplier. I think of a consultant as a multiplier. I think like if a practice comes to me and they wanted to start, for example, you know, a running program, Oh my God, I've already worked with seven practices that have started running programs. Somebody comes to me and they want to revise their compensation plan. I can, you know, it's like I kind of become a repository for everybody's experience. I would say I'm a kid in a candy store and as I travel I like gather up wonderful people and just a lot of cool stuff that people do. Karen Litzy: 05:52 And so what would you say are the people coming to you for your work as a consultant? What are the most common things that you are seeing that people are like, Hey, we really need help with this? Lynn Steffes: 06:04 Well, I feel like everybody needs help with revenue and so anything to do with like marketing promotion, they need help with payer contracting and dealing with third party payers who seem to want to put up roadblocks all the time. And I just have, I have a unique, you know, perspective on that and I've worked with third party payers and I feel like I just am marketing to third party payers. I feel like people come when they look at, you know, how are we going to grow and how are we going to grow in the revenue? And I tap on the shoulder also and go, Hey, yet look at your expenses too. I feel like that's a big thing. I also think compliance, I think we're so burdened and so I try to work with people on what they need to do, but I do it in a different way than a lot of people. I think a lot of people are like into what I call the scary complaints. Like, Oh, you're going to get in trouble. And I do mention that, but I also look at people and I say, you know what, you need to communicate your value in a better way. And if we did that, we'd be in better shape. So that's kind of a variety. Starting cash programs is super fun. Karen Litzy: 07:16 And do you mean cash programs within a traditional therapy clinics? So for people listening, there are a traditional clinics, I guess we can categorize them as such that are, they take your insurance. So if you call up a clinic and you say, I have blue cross blue shield, do they take it? Yes. Great. So when you say you help with cash programs, is that within a traditional clinic or within like an out of network or do you help establish a cash practice? Lynn Steffes: 07:45 Both. So I feel like there are people who do, they're excellent young therapists, consultants who have developed cash based programs and who, that's all they really talk about. And so I definitely work with a lot of hybrid practices. So practices that have one foot on the dock where you know, the third party payment environment is and one foot in cash base and they're developing other programs. Sometimes I'm working with people that are all cash. Sometimes I refer them to people that are focused on all cash. I also think like, I think we've kind of only just begun in the services we're providing that would just third party payer covered is so limited for PT and there's so much we can do if we just are willing to collect money. Karen Litzy: 08:33 And, you know, I think in a traditional therapy setting, I think because physical therapy is always associated with the healthcare system, with the physician, we used to always need a physician referral. So the public's expectation is we take insurance because no one would ever go to a massage therapist, a personal trainer, Pilates or yoga and expect them to be covered by their insurance. Lynn Steffes: 08:56 I completely agree. But I have this thought. First of all, I'm just going to say out loud and I hope it's not offending anyone, but I don't like dentists because I just don't like people messing around in my mouth. But I think dentists have figured it out. They have 100%. I feel like physical therapy as a profession has to grow up to be more like the dental profession. I mean, you know, a hundred years ago, dentists, like basically you saw them when you had to have a tooth knocked out and they were kind of that provider of last resort. They, they really were, a last resort kind of provider. And they have evolved being an amazing healthcare provider. They do prevention, they do treatment, they have specialties, they do cosmetics, they do performance. So there's so many things that are parallel, and I don't know about you, but when I go to the dentist, when I walk in and have something done, they tell me, well, this is what your insurance covers and this is not. Karen Litzy: 09:49 Yeah. And I don't have any dental coverage, but guess what I still do every year I go to the dentist. And PT is, so some of it is the consumer mentality. Like I paid a premium, it should cover PT, I don't doubt that. But a lot of people have dental insurance and they still pay for other things. I think some of it is awesome. Lynn Steffes: 10:11 It's a mindset shift that we have to have. We have to say this is what your plan covers and these are other services that would benefit you that we recommend. So a lot of times that I'm promoting a program, like for example, the annual PT physical or I'm very interested in lifestyle medicine and brain health and the kind of things people go, well, which insurances cover it? And it's like, okay, that shouldn't be your first question. The first question should be, would this bring value to my patients and my community? And if it does, is there something that's paid that's an inappropriate question but not like who's going to cover in it and if it's not covered. Lynn Steffes: 10:44 So some of the mentality shift is our own paradigm. So yeah, and I think there does need to be that shift of this is my expertise, this is what I offer looking around in my community. Would they benefit from XYZ program, a program on brain health, which I know, you have, right? So is this something my community would like because it's not about us. We have to be worried about the end user, which is our client, our patient, however you want to, whatever kind of word you want to put for them. But I do think that from a profession wide standpoint, that that needs to shift. And I think if it can shift, I think you're right, you'd be seeing a lot more hybrid practices where yeah, maybe you take insurance, but you have a brain health, you have a vestibular program, you have a wellness program that can happen. And I think that's where, I mean I totally think there is a 100% place for all cash or all third party. But I think we all kind of went in with more of a hybrid idea. Lynn Steffes: 11:54 We would be able to leverage what insurance pays for our patients. And honestly, a lot of people don't want to do insurance cause they say, well it limits the number of visits. Well guess what? If it limits the number of visits, you still can do cash outside of that. You know what I mean? Like I'm always like, why can't we see that? And so it's interesting that I study like dental marketing and dental operations as a way of just having insight into a different provider even though they're not my favorite healthcare provider. So yeah, I think it's really interesting. Karen Litzy: 12:28 And what advice would you have for someone listening who maybe wants to start shifting their practice? Going from being a treating physician, from being a treating physical therapist or physician or nurse practitioner or even a dentist. So how could they go from a full time treatment to consulting? Like, do you have to take extra classes? Do you need certifications? Do you, you know, all that kind of real practical stuff. Lynn Steffes: 13:00 All right. So really good question. Well, I think first it's a self examination of like what are you good at, passionate about, interested in, and a willingness to share. And, you know, when I first became a consultant I thought I had to know everything and I just realized I just have to like know enough and I have to know, I have to ask you questions so that I can learn what you need and then partner with you to create that to happen. So as a consultant, I did go take additional courses. I took courses through the small business administration through our local college. We have a local women's college that has a business and evening business series. I did some of that. I talked to other consultants and actually I find that, you know, sometimes people come to me and they'll say they want to be a consultant and then I'll have a conversation with them and I'm kind of like, Hmm, okay. Lynn Steffes: 13:48 There's a couple of things you need to do, and you need to listen. I feel like that's hard. I think some people think they just want to tell people what to do, but you kinda gotta listen to what they want and be able to do some diagnostics. I think, getting hands on experience, as much book knowledge and classes as you take in all of that, unless you can relate to somebody's problems and say, yeah, I was kind of bad at that and I learned how to do it. Or, this is where I was and here are the steps. I just feel like that that would be a struggle. So I think getting hands on experience. If you're working in a facility or practice, Hey, volunteer to run a project, get on a committee, take the lead, asked to be involved in interviews, asked to be the marketing person, asked to work with your billing and payment, get involved in the association because I've gotten a ton of contacts and I also, like, I always say it like if I'm the smartest person I talked to all day, that's not good. Lynn Steffes: 14:48 So I know so many people that are so smart, I feel like I can pick up the phone and call them. So they're multipliers for what I'm able to help people with. I think there are steps in a big thing is hands-on, firsthand experience. Another thing is goal lists. Go take some extra classes, do some reading, but work with experienced people and kind of stick your neck out. I've been consulting for over 20 years and people will call me and say, Hey listen, I got this project, do you do this? And I'm like, you know, yeah, I guess I do, but I haven't done it before but it sounds like fun and if I'm in too deep I just call people. Karen Litzy: 15:27 Yeah. That's great. So kind of look for those mentors or friends or like you said, colleagues, people in, I mean we're here at PPS, so it might be people at PPS, it might be your neighbor, it might be, I always say to like, don't overlook your family and your friends because there's a wealth of knowledge there as well. I always tend to look out and I'm like, Oh, what about the person right in front of me who knows how to do X, Y, Z, why am I not asking them? Lynn Steffes: 15:51 Well, it's funny because I was working with a practice that wanted to work with more personal injury attorneys and those kinds of patients. That was something they were interested in doing. And I'm very skilled practitioner in working on spine and cervical issues. I thought, you know, this is a good fit. And he's like, I just don't know how to do it. And so I was like, okay, I know of someone who knows, you know, was an injury attorney who I respected and I just contacted her and I paid her for a couple hours and I interviewed her and spend time with her. Just going through like, what did you want? What's important? All kinds of stuff. What about communications? What is, you know, what would discourage you from using a provider? How do you decide who's a prefered? And it was weird because as soon as the interview was done, it wasn't cheap, but it was so worth it. And she kind of said to me, she goes, you know, I need some good PTs. The more I ask, the more I talked to you, the more I realized like, I know what I need and I don't know if I know who it is. And so it's funny that you know, there are a lot of resources out there. Karen Litzy: 16:55 Yeah. And so from what I'm hearing is one, don't be shy, can't be shy. Don't be shy too. Don't worry if you don't know everything right now because you can learn it in a short amount of time. And this sounds so crazy coming from me as I'm interviewing you, but I love the idea of interviewing people, but I didn't, I don't know why I never even thought of that before to say why don't really know this, but I know this person does. So let's have a formal interview. Not just like a one or two emails, but really take, like you said, take the time, pay for the time if you need to so that you can really understand what that person needs to help your upcoming client like as you can. I guess you can always do the research so we don't just have to stick to things that we think we know we can expand. Lynn Steffes: 17:45 Well, and I think as a PT, I remember as a young PT had a patient once that had a child with osteogenesis imperfecta and I'd never seen it before. I was getting a referral for it and I was like, okay, I don't know what I'm doing. So I just like went on the web and look for a PT that treated that. I found someone out at NIH, national Institute of health. I sent her an email and we set up a call and I went through everything. She sent me her protocols. It was like, and I just realized PTs are such incredibly generous people. A lot of people are generous. PTs are exceptionally generous with that. And that kind of taught me like, Hey, don't be afraid to admit you don't know. I have worked with or had exposure to people have worked with consultants who kind of know what all is. Lynn Steffes: 18:35 And at some level people are like, Oh, we're really excited about them. But it doesn't create long term relationships if you don't say, Hey, that's a good question, let's figure it out. You know? So I don't know. I don't have all the answers, but I sure love the questions. You know, I love that. Love it. That should be like my motto for life. I don't really have any answers, but I love to have lots of answers. But I think what struck me from what you just said, is that we can use our skills as physical therapists. We know how to research, we know how to look up diagnoses and treatments and protocols so we can take those skills and transfer them into consultancy skills. Oh my God. So what I have as a process, when I work with practices, I call differential diagnosis. Lynn Steffes: 19:27 For your practice. And I basically do diagnostics and then I have a hypothesis and then I write a plan. Then I work on implementing the plan and then we stop and measure and we figure out what's working and what isn't. And of course there are plans just like there are a few, if you treat a lot of knees, you have certain plans you use that usually work. And so over time you kind of accumulate solutions. But I still customize. I think some people like the canned solutions and it probably is more cost effective, but I still like working one on one. Karen Litzy: I think this is great. Thank you so much. I'm like learning so much here. It seems like your career keeps evolving. Do you have anything coming up that's kind of different than what you're doing? Lynn Steffes: 20:15 Wow, that's a really good question. First of all, thank you for giving me opportunity to talk about this stuff, but so I have a really big birthday coming next week and I don't need to share the number but it's a pretty big one and a lot of my friends are retiring and I'm always kind of like, what am I going to do next? I'm still, I don't know, I don't know, I just the way I am, but I have been working in the area of brain health for awhile and, and have a signature turnkey brain health program and I have two. I have one thing I want to do with that program and that is to very specifically, instead of just going into the PT market with it, I want to actually start approaching active senior centers and working with their activity people and their exercise and fitness people. Lynn Steffes: 21:07 Because I think the active senior centers have all the tools. They have all the mechanism, they have this captive audience but they don't connect the dots, which is how cognition and wellness fit. So that's something fun I want to do with brainiacs. And then the other thing is I really want to continue to push lifestyle medicine and PT and I want to connect with other like-minded PTs. There was a young PT that I'm kind of that's just starting out. I want to mentor her. She is very interested in lifestyle medicine and exercise and how it relates specifically to anxiety and depression. I feel like we have so many opportunities we haven't even tried to do. And so this year I came out early to go to lifestyle medicine conference, which was next, which was early. Yeah, it was on the front end. So how perfect. But next year I want to be talking at it. Karen Litzy: 21:52 Perfect. We'll get that pitch in there and talk at it. That's awesome. And I have one more question that I ask everyone, but before we get to that, if you can talk a little bit more about just the basics of the foundations of the brainiacs program, just because you'd mentioned it and I just want people to understand what that is. Lynn Steffes: 22:21 Sure. So I have always, you know, as a peds therapist and adult neuro therapists, I've always been into brain neurology and the flexibility and the adaptability and really the plasticity of the human brain. And I've seen back in the day when we didn't think anything could change after childhood, I saw it could. And so I was always kind of like, yeah, we don't know everything. And now we know much more. But unfortunately my parents both passed from Alzheimer's disease. And so when that happens, when you have two parents diagnosed, it kind of scares you. And so I started doing research on brain health and what the literature showed and it's very clear that, you know, prevention, mitigation, and cognitive fitness and health is not just a learning and study and you know, read a book to us to do code. It really is a physiological thing. And exercise probably has the strongest evidence. And so I started a turnkey program and with the basis of it BrainyEx. Lynn Steffes: 23:24 And prescribed exercise at a certain level of walk around. The block is nice, but it doesn't really do the whole job. And so how to prescribe and train someone to, you know, extra as at a proper level. And then I also added health and wellness education that's evidenced based too, it's nutrition, sleep hygiene, stress management, activity management, socialization. And so PTs, we're constantly doing patient education where we're like perfectly suited to do 100% instead of having people come and sit in a class, I'm like, okay, let's work out and teach. And so it's been pretty fun. I have clinics in 13 States doing it now, which I love. Karen Litzy: 24:01 Yeah, that's awesome. We'll have a link to that on the website at podcast.healthywealthysmart.com if people want to find out more information because people aren't getting any younger in this country. And so it's really important and you're right, PT's I think are ideally positioned to be the ones to work with that population. So excellent program. Now, the question that I ask everyone, this is the last question. I probably should have prefaced this to you beforehand, but knowing where you are now in your business and in your life, what advice would you give to yourself as a new grad out of PT school? Lynn Steffes: 24:42 That is such a good question. I honestly, it's weird because I don't think my expectations were high enough as a new grad. I get that. And I think similar to what you said, that everybody graduates from PT school and you kind of think you're going to be a PT and I love being a PT and PT is such an incredible profession, but I never dreamed I would be traveling across the country writing chapters to books, developing my own programs, having an opportunity to speak in front of hundreds of PTs teaching at the university. I never thought of all the possibilities. So I guess as a PT I would say like open your eyes and look not only for what you can do one on one with patients, which is incredibly important, but look for opportunities that multiply our profession. And I think I would've told myself earlier on, like I feel like I started early doing it, but I still think I could have even had the vision earlier and you know, and just ask people for help. I love it when people come to me and say, this is something I want to do. Will you help me? I feel like it's an honor, you know? Karen Litzy: 25:59 Great, great advice. So great advice for all those students in school and just graduating from PT school or really any programs. So thanks so much. Where can people find you? Lynn Steffes: 26:09 So I have a website, www.steffesandassociates.com and I also have a website for my brain health program, www.brainyex.com. You can always find me at all the meetings. Karen Litzy: 26:29 Very true. So Lynn, thank you so much. And just so everyone knows, we'll have links to everything in the show notes for this podcast on the website podcast.healthywealthysmart.com. So Lynn, thank you so much for taking the time out at a PPS and enjoying sitting outside in Orlando before both of us have to go back to our cold places. At least New York doesn't have snow yet. Lynn Steffes: Yeah, we have snow. Hopefully it'll build. Thank you, Karen. You do a great job of, I think sharing a lot of good information and talking to people who are thought leaders and people who have different ideas. And I think that's pretty important. Karen Litzy: Thank you so much. And everyone listening, thanks so much for listening. Have a great couple of days and stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Shelly Prosko on the show to discuss compassion in healthcare. Shelly is a physiotherapist, yoga therapist, educator and pioneer of PhysioYoga with over 20 years of experience integrating yoga into rehabilitation with a focus on helping people suffering from persistent pain, pelvic health conditions and professional burnout. She guest lectures at yoga and physiotherapy programs, presents at medical and yoga therapy conferences globally, provides mentorship to health providers, and offers onsite and online continuing education courses for yoga and health professionals. Shelly is a Pain Care U Yoga Trainer and maintains a clinical practice in Sylvan Lake, Canada. She is co-editor of the book Yoga and Science in Pain Care: Treating the Person in Pain. In this episode, we discuss: -Can compassion be trained? -The six elements of Halifax's model of enactive compassion -Empathic distress, compassion fatigue and burnout among healthcare practitioners -The five facets of comprehensive compassionate pain care -And so much more! Resources: Shelly Prosko Twitter Shelly Prosko Instagram Prosko PhysioYoga Therapy Facebook Shelly Prosko Youtube Shelly Prosko Vimeo Physio Yoga Website Yoga and Science in Pain Care: Treating the Person in Pain For more information on Shelly: Shelly Prosko, PT, C-IAYT, CPI, is a Canadian physiotherapist, yoga therapist, author, speaker and educator dedicated to empowering individuals to create and sustain meaningful lives by teaching and advocating for the integration of yoga into modern healthcare. She is a respected pioneer of PhysioYoga, a combination of physiotherapy and yoga. Shelly guest lectures at medical colleges, teaches at yoga therapy schools and yoga teacher trainings, speaks internationally at yoga therapy and medical conferences, contributes to academic research, provides mentorship to healthcare professionals and offers onsite and online continuing education courses for yoga and healthcare professionals on topics surrounding chronic pain, pelvic health, compassion and professional burnout. Her courses and retreats are highly sought after and have been well received by many physiotherapists, yoga professionals and other healthcare providers. She is a Pain Care Yoga Trainer and has contributed to book chapters and is co-editor and co-author of the textbook Yoga and Science in Pain Care: Treating the Person in Pain by Singing Dragon Publishers. Shelly is a University of Saskatchewan graduate and has extensive training in yoga therapy and numerous specialty areas with over 20 years of experience integrating yoga therapy into rehabilitation and wellness care. She considers herself a lifelong student and emphasizes the immense value gained from clinical experience and learning from her patients, the professionals she teaches and the colleagues with which she collaborates. She maintains a clinical practice in Sylvan Lake, Canada and mentors professionals who are interested in pursuing this integrative path. In addition to her many skills as a healthcare practitioner, Shelly is also an accomplished figure skater and has traveled the world with many professional ice shows. She is passionate about music, dance and spending quality time with family and friends. Shelly believes that meaningful connections, spending time in nature and sharing joy can be powerful contributors to healing and well-being. Please visit www.physioyoga.ca for more info and resources. Read the full transcript below: Karen Litzy: 00:01 Hey Shelly, welcome to the podcast. I am excited to have you on. This is going to be fun today. Shelly Prosko: 00:07 Thank you for having me. Really excited to talk about this. Karen Litzy: 00:11 So I spoke to your coauthor Neil a couple of weeks ago, talking about your book, yoga science and yoga and science and pain care, treating the person in pain. And I'm really excited to dig into sort of your writing within this book because you are writing about compassion. So before we get into the nitty gritty, what is compassion? How do you define it? Shelly Prosko: 00:41 So believe it or not, there actually is not one agreed upon definition. So that's the first thing is some people describe it as a trait. Others say it's more of an emotion. Some people say it's like a motivation or behavior. But the definition that I use in my chapter is the one that is kind of the working definition that the leading compassion researchers use in the Oxford handbook of compassion science. So that's kind of like the compendium, the Bible of all the thought leaders and researchers around compassion. So that definition, the working definition there is basically compassion is first and foremost. You have to be able to recognize that someone is suffering or struggling or in need. And then the second component is then we have to have the motivation to want to do something about it to alleviate or to help. So basically recognizing the suffering with the motivation to relieve and that is not just us and someone else that's also within ourselves. So compassion also includes the self compassion piece and that is I think really important for us to keep in mind. Karen Litzy: 01:56 Yeah, I was going to say, and would you say that having compassion for yourself allows you to be more compassionate towards others? Do you feel like it's a prerequisite for compassion as a healthcare provider? Shelly Prosko: 02:13 That's a really good question. From my perspective, I think it helps. The more self-compassion we have, the more compassionate we can be for others. But the research is kind of right now from what I've been reading, actually, I just listened to a recent podcast a couple of days ago and with a couple of the leading researchers. And there still is no really solid evidence that increasing self-compassion translates to increased compassion for others or that increasing compassion for others translates to increased self-compassion. That said, there is some research that shows cultivating self-compassion does seem to help increase compassion for others. So we have a bit of research that says that. And my own personal view would be yes, I don't know if it's a prerequisite, but I have noticed in my own self without making this like a therapy session, I have noticed that I scored quite low on self-compassion and I have traditionally been quite, you know, self critical and hard on myself. But as I've learned more about this stuff and practicing self compassion, what that is and, and exploring it and experiencing it, I feel like I overall am just understanding more of what compassion is. And I feel like maybe I'm, you know, more compassionate. It could be just age and stuff too and experience, but that'd be my answer to that. Karen Litzy: 03:46 And why is compassion important in the care of people in pain? So how does it benefit me as a healthcare provider to understand compassion? When I'm working with people in pain. Shelly Prosko: 04:02 Yeah. So I just want to be clear that sometimes people equate, you know, just being compassionate, they just equate that to being kind, you know, and it's just should be common sense and just don't be a jerk. You know, a lot of people just say, well just, it's not that hard. But, you know, there it is a little more nuanced than that. And just going back to your question on, you know, what are some of the benefits if we actually look at the, the deeper layers of compassion and which I can get into a little bit there later, but the components that go into offering compassion and also self compassion towards, you know, yourself. Lot of the research shows, I mean, stuff that we're not probably really surprised at. Like it can increase quality of care for our patients, increase patient outcomes, increase patient satisfaction, increase therapeutic Alliance, and increased patient self care. Shelly Prosko: 05:04 So I want to just briefly talk about this cause I think it's really important and we don't think about this part of compassion, but there's this one study that I talk about in the book chapter and it was an entire year long. It was in an integrative rehab hospital and it showed there was a hundred women who are living with chronic pain and it showed that it was only once these women actually experienced what it was like to be loved, cared for, to be seen, to be heard. In other words, to have actually to receive compassionate care. Only then could they take active steps towards their own self care, which I think is really important in pain care because so often we talk about how important it is for our patients to play an active role in their pain care. We're always talking about that. Shelly Prosko: 05:55 The literature says that we're trying to help our patients make healthier choices, et cetera. And now we have some research that says, well, you know what, if we provide this very in depth, nuanced, compassionate care, it looks like people that are patients are then more likely to, you know, better make better choices. And it's neat. Some of the women, what they were saying, things like they felt worthy, they felt loved and yeah, worthy enough to be cared for. And I just think all of that is so fascinating. So those are some of the, you know, the benefits to providing compassionate care, but there's also benefits to us as the healthcare provider. So what some of the research is showing is that it can actually help protect against burnout. Shelly Prosko: 06:51 We can dive into that a little bit later too in some of the myths, you know, around too much compassion. But, you know and also just overall the positive health outcomes are increased in us as the health care provider and even things like reduced anxiety, depression, even stuff like reduced medical costs and errors and malpractice claims. Like this is just what all the research is saying. But then I think the other part of it that I do want to really highlight is the self compassion piece. So there is benefit for the person in pain to practice self compassion is what some of the research is showing us now and there is also benefit for us as the healthcare provider to practice self compassion. And again some of that for us as a healthcare provider is like reducing burnout, reducing excessive empathy, which they're calling, you know, empathic distress or empathy key things like that. Shelly Prosko: 07:49 It helping us improve our emotional resiliency and like we said, potentially even increased concern for others, but in the patient, and this is what I thought was so fascinating as of now, I think there's only about five or six studies out there, but they do show that people in pain that either have higher self compassion or some of the studies actually show people in pain. Doing these self compassion practices actually can show reduced pain severity, reduced anger, reduced psychological distress or things like depression, anxiety and even increased pain acceptance. You know, we know there's some benefits. Especially with the ACT, acceptance commitment therapy research, we're starting to see how that's important and, you know, there's even some links to reduce pain catastrophization and rumination and decreased fear avoidance behaviors. And it's just really fascinating. And I think, just the last bit here on that, on that question is increased self-compassion has been shown to reduce our own self criticism and increase our motivation to actually change our behaviors. Karen Litzy: 09:02 We're just talking today, Nisha mind who's a psychiatrist. And we were just saying, man, how hard it is to change behaviors for human beings. Cause she was talking, she has a dog. And how with a dog, you know, you can change behaviors by motivating them through food. So they have these incentives or incentivize through food. Humans, it's a little bit harder how difficult it is to change behavior in a human being. So now if compassion and practicing self-compassion can help with behavior change, how do we change compassion? I mean, how do we train compassion? Can we train it? Shelly Prosko: 09:47 Yeah. So the literature says yes, it is trainable and we have quite a bit now and there's different programs and different styles. And I think, you know, there's a lot of different models and I think probably just to make it easiest for us here as I'll talk through this one model that I really like. It's Joan Halifax and she's an anthropologist and a meditation teacher and a few other things. But she has a really nice model of inactive compassion. And what she talks about is, you know how I said the definition of compassion was in recognizing the suffering first and then having the motivation to alleviate it. She actually goes beyond this and she says that definition's a little bit limiting because compassion is actually more of a dynamic emergent process. So it's more of a wisdom that emerges within the context of the environment that we're in, which makes sense. Shelly Prosko: 10:53 If you know anything about systems theory or emergent theory and you know, so if we're in a room together with our patient, you've got the patient not person in everything, they're dynamic, you know, evolving system right there in that moment. And then there's us, we're also a dynamic, evolving system that we come together in the context of the environment. And that even changes the dynamic or influences. So compassion can emerge from that interaction, from a series of elements that are actually non compassionate in and of themselves. So we can train and these six elements, and again, this is Halifax's model, but we can train these six elements and it saw like you just train one and then you train the other. It's not linear there, you know, it's like I said, an interdependent integrative process. But I think it's just really fascinating because this is something accessible and tangible. Shelly Prosko: 11:53 And in the book I go obviously into depth and I'll just try to keep this short. But the first element is the attentive domain. So that's just being fully and wholeheartedly a hundred percent present and you can, we can cultivate our focus or concentration ended up and our attention through a whole host of different ways. Whether it's different mindfulness practices or focused concentrative activities. So that's a whole other way to cultivate that. So just by cultivating and practicing the attention is one way to help the process of compassion. And then the second one is the affective domain. So that is being aware of our emotions and we have a lot of research that shows the more aware we are of our emotions, the more aware we can be of others. Shelly Prosko: 12:52 And then we also have research that shows some interoceptive awareness practices, believe it or not because of the way something with the insular cortex, you know, we don't know if it's that more information is being sent to the insular cortex or it's just changing the way the brain is interpreting this. But when we do enter in an interoceptive awareness practices, it seems that that increases our ability to be more in touch with our own emotions, which is super cool. So an Interoceptive awareness practice might be like a body scan. So you're taking yourself, we're guiding a patient through, you know, a two minute, you know, scan of the body and inside and what are inside physiological state is like, it could be even, you know, a breath awareness practice. Shelly Prosko: 13:47 And just knowing how that feels inside the body. And then the third element is intention. So in yoga, that of course, you know, that's my framework, how I frame a lot of things. But in yoga, there's a saying, you know, where your intention goes, the energy follows. So, from a science perspective, when you can actually focus and concentrate on something that you really put, have an attention to it that can affect the outcome. So for example, the intention when you're working with someone might be first and foremost my intention is to care for myself first. Secondly, to then care for the person in front of me. And then you may just want to keep that in mind throughout the whole session. And your intention may be something really specific. Like, I am here to serve, you know, when you sort of keep repeating that to yourself, I'm here to serve, I'm here to serve and my intention setting can be super powerful. Shelly Prosko: 14:54 I don't know if you've done any intention setting before, but you just set an intention. It doesn't even have to be related to our professional career here. Just even personally, you go into a room or a setting where you're feeling like you don't really want to be there, et cetera. Maybe a family Christmas dinner. And if you go in with this intention, okay, I'm just going to focus on, and you could say anything, I just want to be present or I'm just gonna focus on being kind to myself. And you just focused on that one intention. It's like a theme. So that's the third element. So remember, all of these are now together. They start to accumulate into gaining more insight into the person's suffering in front of you, which then can lead us to have a more compassionate response. Shelly Prosko: 15:40 Then the fourth element is insight. And that's basically just the idea that these first three components together and practice can lead to that deeper insight into what that person is, you know, is really going through. And then the other part to that insight, I just want to add, cause I think it's so fascinating once we start gaining deeper insight into all this stuff, we do start to understand that there's something called therapeutic humility, which is this idea that, you know, we can't control the outcome. So we do the best that we can. We gain as much information as we can. We be the best people we can be and we help the person as much as we can. And then we detach from outcome and we can pay lip service to that and we can all understand that. But when it comes down to it, I think a lot of us are attached. Shelly Prosko: 16:38 And we're invested in making sure that the outcome is a certain way. So we could talk about that for a long time. But this is huge in part of the compassionate response is this idea to have this insight that we have to have this humility that we're not the almighty savior and we can't control. And then the last two are embodied and engaged. And so the embodied domain is really this idea that we are fully, fully present. So kind of similar to the first one, but this one is more that we are dividing our attention. Meaning we yes, we have to listen fully and be fully present for the person in front of us. But we also have to stay within our body and not detach from what we're experiencing and disassociate. So we have this idea that we can still feel if our breath is tightening or if there's tension in our body and that can give us a lot of information as well. Shelly Prosko: 17:37 That's really important. So that's part of the compassionate process. And then the last one, the engaged domain that's really compassion in action. So that's your compassionate. And I think for here, this one, I think the biggest take home message for me has been, it's obviously informed by everything I just said. And it's different depending on the context. So there's no, well there's no GoTo, this is the strategy or this is my response or this is what I say, you know, when my friend is struggling and where someone's giving you some bad news and there's no really go to response, you can have some ideas of course, and then some things maybe that aren't, we want to stay away from saying, but it's really important to understand that compassion is this wisdom that emerges in that situation and the engaged part might be not saying anything or not doing anything. It could be just holding space. And so I hope that helps you and the listeners sort of get a deeper appreciation for this process and that we can train it and that it takes time and it can be extremely helpful for both the person in pain. Karen Litzy: 19:01 Yeah, I think that's great. And thank you so much for going into a little more detail there on that model. I think it makes it a little more concrete for myself and certainly hopefully for the listeners as well. And now I think something that people may misunderstand or misconstrue is the idea of compassion and empathy as being the same. So my question is there a difference between compassion and empathy? And if so, can you kind of give us the similarities or differences there? Shelly Prosko: 19:39 Yeah. So just like compassion, empathy does not have one agreed upon definition either. So this makes it challenging to talk about this stuff because you know, people have different ideas as to what these things are. So some, you know, of what I've read about empathy, it depends if we're talking about cognitive empathy or emotional empathy, behavioral empathy. So that makes it a bit tricky. But I'm going to stick with the empathy that I find most people resonate with and that is more that the empathy where it's our capacity to be able to share the feelings of another person. So what it's like to be in the other person's shoes, right? To resonate with their experience, even to share that emotional experience. So if we use that definition, then we know we can see that empathy is really more of a competency. Shelly Prosko: 20:43 It can be a motivating force for compassion. But what the literature shows is that empathy is neither sufficient nor required for compassion. And you think about that for a moment. It makes sense because we can have empathy for someone. So we may emote, be able to, you know, really understand and emotionally share that same experience or share that same feeling because we've had a similar experience. The response may not necessarily be a compassionate one and there's lots of different reasons as to why we would or wouldn't. I go into a little bit of that in the book, but just I think, I hope that makes sense to everybody. How you could still have this empathy but maybe not provide of a very compassionate response. The other part of that is you don't necessarily have to even have empathy in order to provide a compassionate response. And I think that's actually quite hopeful. And you know, cause I think even talking to some of my colleagues who some people may feel that they're not as empathetic or they've been told that they don't have, what you don't understand. Shelly Prosko: 22:05 And, you know, the good news is you may not be really empathetic or you may not consider yourself an empath, but you can still have a compassionate response. And I think if you go back to the Halifax model of all of those elements, you know, that help us provide a compassionate response. Empathy can be part of that. Like you say, it can be a motivating factor, but not, no, not the only factor in it. Certainly, it could still be lacking. You could still be compassionate. Karen Litzy: 22:40 That is hopeful for people who may be feel like they're not as empathic as they would like to be. But like you said, that Halifax model is this sort of emergent model by having all of these different inputs go into the system and have, you know, an emergence of compassion from you. So it's not like all of those parts need to be equal. Shelly Prosko: 23:03 Right? And empathy. Like I said, empathy can be good. Of course. You know, just think of a time when you shared someone's experience feeling, you know, or their experience. You've had a similar experience that may help us give us an idea. But we also have to, I think this is interesting too. We also have to look at the fact that sometimes if we have empathy and we can really share that feeling if we're not careful and if we're not in this more clear kind of state. We may actually start to look at our experience and what we went through and put on someone else, like almost feeling that, well, this is how I felt. So they must feel that too. And there's something that Paul bloom, he's a psychologist at Yale, he calls it empathy arrogance or the arrogance of empathy. Shelly Prosko: 23:56 And it's just fascinating. Some of his work and you know, this really made sense to me when he talks about the fact that can we truly, truly have empathy, you know, on that deep level of what it means. Because that means that we want really understand and share 100% with that person is going through. And we can't do that really, if you think about it. And it could be, you know, someone may be that we've had a similar experience, or it could be, think of yourself as a healthcare provider. Look at all the patients we have. I'm coming to see us who are very, very different from us. Different things have happened to them, different socio economic status, people who are maybe vulnerable populations marginalized. And if we're in a position of privilege, how can we truly empathize with some of the issues and the things that they're going through that may affect their esteem? So that's kind of a tangent, but I think why I brought that up. I think it's important is because it's just this idea that we can still be really, really compassionate and we can train for these compassionate responses even if maybe we can't fully empathize. So I think that was the point of me bringing that up. Karen Litzy: 25:22 Yeah. And I think in my mind, it kind of takes a load off of me as the healthcare provider. You know, that you don't have to have experienced what your patient has experienced in order to provide compassionate care in order to have that therapeutic relationship in order to help that patient in some point of their recovery. So I think it takes a little bit of the pressure off of the healthcare provider, which may in turn help us to be better providers. So we don't have that pressure, like you said, that pressure on us for outcomes because perhaps, you know, you don't want to think, well, because I never experienced it that I can't help this person right now, I'm away or I'm not the right person for you, or something like that. So I think it's an important distinction. And now in the book, in your chapter you sort of have this model of comprehensive, compassionate pain care five sort of points to that. So can you speak about that model of compassionate pain care? Shelly Prosko: 26:42 Yeah, so really just looking at all the different orientations of compassion. So Paul Gilbert, this is based on Paul Gilbert's work, he's another compassion researcher in the UK. And he talks about the orientations which is giving compassion and then obviously we also receive it. And then the third orientation is the self-compassion within us. So the five components that I see when you look at the full comprehensive, compassionate pain care. The first one is of course what we've talked about here, the health care provider providing compassion. And then the second component is the health care practitioner and the person in pain, cultivating or practicing self-compassion. Oh, that's within each of us. And then the third one is also close family and friends, cultivating compassion towards self and others, including the person in pain. And then the fourth is that we want to make sure that the values of the healthcare organization, including its leaders are in line with compassionate care. Shelly Prosko: 27:54 So this includes a commitment to providing and supporting an environment where compassion can be cultivated by both the healthcare provider and the person who, and I think that's, you know, just really important to include in a comprehensive model here because it's not just about the healthcare provider and the person. And then the very last point is just the community at large. You know, I think it's important to have overall public awareness and understanding, you know, surrounding the importance and the health benefits and practices of compassion. And then of course, that includes the person in pain. So that's a little lofty and I don't have a task force or a plan or not this, you know, right now I'm focusing on those first two and I'm doing a lot of different things and this is going to be my life's work, Karen. Shelly Prosko: 28:47 Like I really believe in this stuff. And, I think increasing pain literacy and increasing compassion literacy are two things that, you know, I'm in it for the long run and so how that looks on how we increase pain literacy and compassion literacy in, you know, interest in the general public and in healthcare organizations. I mean, that's a huge topic. But, you know, there are some different things that I've been involved and just with, not necessarily with compassion per se, but just increasing pain that I've seen, you know, our health care community and yoga therapy community. So yeah, to me it's got to be comprehensive like that. Karen Litzy: 29:42 That's the way you're gonna make, I think a worldwide impact, certainly on those living in pain when we know, at least here in the United States, and I think this is probably can kind of be generalized to other parts of the world. But here in the United States, the burden of care for just low back pain and neck pain is number, I think three or four behind heart disease, like diabetes. So we're talking about pain as being one of the largest burden of care in the United States. And I would argue probably across the world. I don't know that it's that much different or there's that much difference from other parts of the world. I don't know what it's like in Canada, but I mean it's a lot of money. It's a lot of time. It's a lot of resources. It's a lot of relationships. It's a lot of people in pain contributing to that burden, behind those big numbers of trillions of dollars. They're individual people. And so if adding something like compassionate pain care can help make even the tiniest dent in that, then I think it's, I don't think it's a lofty goal. I think it's just a goal. Shelly Prosko: 30:58 Yeah. I'm glad you say that and you put that into perspective, which I appreciate and yeah, and I think that, you know, just overall this compassion what we've been talking about here, like I think it's the foundation of pain care or is this foundation of health care. You know, you can't really argue with that. And, I don't think anybody would argue with that. But what I think we just don't quite understand is that we may have good intentions and we may think that intuitively, yes we are compassionate people, but the research shows that it can be lacking in certain areas of the world and certain regions, healthcare regions. And also there are fears and blocks and resistances to compassion. Like there are actually reasons why we may not offer a compassionate response. And, you know, some of those reasons are the organizational barriers or different social pressures. Shelly Prosko: 32:05 But some of them may also be certain beliefs that we have that compassion may not be the best response for this person. Maybe we have a deep seated belief that the person needs something different. You know, there's a lot to this, but there are different obstacles. And also just our own health. I didn't really talk about this in here, but you know, we might be overwhelmed by stress in our lives or we may have some unmanaged personal distress and we have research that shows we don't need research to tell us this, I don't think, but we do have research that shows when our own physiological state is not regulated. When we're in a state of flight or stress or a sense of anxiety, things like that. Neuro, biologically we are not set to provide a compassionate response. Karen Litzy: 32:59 Go figure. Yeah, that makes a lot of sense. All right, what would you love for the listeners to take away from this discussion and then we'll get into where people can find you in the book and all that other stuff, but, what would be your big takeaway when it comes to compassion and care? Shelly Prosko: 33:25 I think the biggest takeaway that I would like people to understand is that being compassion is not just about being nice or kind or a good person, so that we could still be all those things, but we actually may still be lacking in that compassionate wisdom. So if you can just think of it more than that and that we could, Oh, maybe get a little bit more skilled at developing this compassionate wisdom. And I guess this is more than one takeaway, but that would be the one. And then just knowing that there are these benefits, both the people in pain and also for us as the practitioner for our own health and yes, for burnout and things like that. Karen Litzy: 34:18 Now where can people find more information about you, what you're doing and where the book is? Shelly Prosko: 34:24 So my website's probably the easiest, kind of the one stop shop. So it's physioyoga.ca like Canada. And you know, if you want to sign up for my newsletter from there, it's on my blog. And then that keeps you up to date. Cause I do online courses, webinars, onsite courses, lots of videos, YouTube, you know, all kinds of different resources and things. So, and then the social media links are all on my website. Karen Litzy: 34:54 Yeah. And we'll have all of that to up on the podcast under this episode at podcasts.Healthywealthysmart.com so people can one click and get right to you. Shelly Prosko: 35:04 Okay. Yeah. And then the book, the co-editors, you've already mentioned Neil Pierson and then Marlisa Sullivan is the other co-editor. And we do have some other authors who are contributing or who have contributed to the book. And you can find that book. I mean it's just Google yoga and science in pain care, treating the person in pain. It's on Amazon, Barnes, Nobles, you know where books are sold. Karen Litzy: 35:25 I can say I have not read all the chapters, but I have read several of them and I 100% recommend this for healthcare practitioners or not even healthcare practitioners. Really anyone. Because I just find that for me, it's helping me to kind of look inward a little bit more what I'm doing and not doing and what I can improve upon. And a lot of good reminders of pain science and, and things that I can thentalk about with my patients. I think in a way that, that they're understanding and integrating yoga and integrating compassion, integrating breathing and things like that into my treatment. So I'm finding it very helpful from a practice point. Shelly Prosko: 36:22 Exactly. That's great. Yeah. That was our hope. You know, our hope was that healthcare providers, regardless if they wanted to go deep into, you know, the yoga therapy and bring yoga into their practice or not, you know, we wanted this to be helpful for, you know, people who, you know, just might be informed by some of these teachings. And of course informed by the science and in mind with what the contemporary science is telling us around patients. Karen Litzy: 37:05 Yeah, exactly. And it's also nice because it's not like, it's not super heavy. It's not like you're like, Ooh, boy, like I need five hours to read two pages. You know what I mean? Cause it's written in simple language, which is very nice versus so you're taking all these studies that are very scientific and able to simplify them and distill it down into something that's very easy to read. And I think that's why it sticks. So well done for you guys on that. You can find the book at any bookseller and we will have links to it on our website. And Shelly, thank you so much for coming on. I mean this is great and hopefully it allows people to at least look into compassion training, at least start incorporating this with clients and with your patients. So thank you so much for coming on. I appreciate it. Shelly Prosko: 38:02 Thank you. Thanks so much for having me. I'm just so, so, so grateful. Karen Litzy: 38:06 Yeah. Pleasure, pleasure. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Nicole Stout on the show to discuss cancer rehabilitation and survivorship care. Dr. Nicole L. Stout is a renowned health care researcher, consultant, educator, and advocate. She is research assistant professor in the School of Medicine, Department of Hematology/Oncology at West Virginia University Cancer Institute. Dr. Stout is an internationally recognized expert and leader in the field of cancer rehabilitation and survivorship care. In this episode, we discuss: -Functional morbidity in cancer survivors and the role of rehabilitation -Evidence for rehabilitation and exercise interventions to support individuals with cancer -Physical therapy clinical, research and education needs to develop survivorship care models -Why every clinician should be familiar with survivorship care -And so much more! Resources: Nicole Stout Twitter Nicole Stout LinkedIn Academy of Oncologic Physical Therapy 2nd International Conference on Physical Therapy in Oncology (ICPTO) American Congress of Rehabilitation Medicine American Cancer Society Nicole Stout Research Gate Email: nicole.stout@hsc.wvu.edu For more information on Nicole: Nicole L. Stout DPT, CLT-LANA, FAPTA Dr. Nicole L. Stout is a renowned health care researcher, consultant, educator, and advocate. She is research assistant professor in the School of Medicine, Department of Hematology/Oncology at West Virginia University Cancer Institute. Dr. Stout is an internationally recognized expert and leader in the field of cancer rehabilitation and survivorship care. She has given over 300 lectures nationally and internationally, authored and co-authored over 60 peer-review and invited publications, several book chapters, and is the co-author of the book 100 Questions and Answers about Lymphedema. Her research publications have been foundational in developing the Prospective Surveillance Model for cancer rehabilitation. Dr. Stout is the recipient of numerous research and publication awards. She has received service awards from the National Institutes of Health Clinical Center, the Navy Surgeon General, and the Oncology Section of the American Physical Therapy Association. She is a Fellow of the American Physical Therapy Association and was recently awarded the 2020 John H. P. Maley Lecture for the American Physical Therapy Association. She holds appointments on the American Congress of Rehabilitation Medicine's Cancer Rehabilitation Research and Outcomes Taskforce, the WHO Technical Workgroup for the development of Cancer Rehabilitation guidelines, the American College of Sports Medicine President's Taskforce on Exercise Oncology, and also chairs the Oncology Specialty Council of the American Board of Physical Therapy Specialties. She is a federal appointee and co-chair of the Veterans Administration Musculoskeletal Rehabilitation Research and Development Service Merit Review Board. Dr. Stout is a past member of the American Physical Therapy Association Board of Directors. Dr. Stout received her Bachelor of Science degree from Slippery Rock University of Pennsylvania in 1994, a Master of Physical Therapy degree from Chatham University in 1998 and a clinical Doctorate in Physical Therapy from Massachusetts General Hospital Institute of Health Professions in 2013. She has a post graduate certificate in Health Policy from the George Washington University School of Public Health. Read the full transcript below: Karen Litzy: 00:01 Hey Dr. Nicole Stout, welcome to the podcast. I am so excited to have you on today. So today we're going to be talking about for all the listeners, cancer, survivorship and morbidity burden among growing populations, probably around the world, certainly in the United States. But Nicole, before we even get to all of those sort of big topics, can you define for the listeners what cancer survivorship is? Nicole Stout: Yeah, thanks Karen. That's a great question to start off with. And it's a little bit of a Pandora's box right now. So we've historically defined cancer survivors as anyone from the point of their cancer diagnosis, really through the remaining lifespan that that individual has. So we consider a survivor from point of diagnosis and you know, it's sort of different or it's kind of different than what the word expresses. Nicole Stout: 01:06 The word survivor, I think in some kind of patient means they're done with treatment, they've survived. And you know, we've seen a bit of pushback in the last few years around people who don't necessarily identify with the word survivor. So if we go back to 2006, there was a very important report that the Institute of medicine released called lost in transition from cancer patient to survivor. And this is where the term came from. Basically that IM report was critical because it said, Hey, medical community, you're doing a great job of treating cancer, that disease, but you're doing a terrible job of helping these people transition back to their life when they're done with treatment. They have a lot of functional morbidities, physical, cognitive, sexual, not managing those things. So this term survivorship was put forward. The idea of managing people to become survivors was put forward. Nicole Stout: 02:05 And what's been very exciting is to see the evolution of emphasis and focus on better managing the human being that goes through the disease treatment in addition to managing the disease. But we've come so far with treatments and in some regard, some people who have advanced cancers for example, will be on cancer treatments for the rest of their life. And you know, I participate in a lot of social media groups and I hear these people say, I'm not a survivor and I'm never going to be one. Eventually I'm going to die from my cancer. I know that. And it's a matter of time. And so they don't identify with the word survivor or survivorship. So, you know, we're sort of moving away from that a bit and we're talking for now without individuals who are living with and beyond cancer. And I like to use that terminology. Even though survivorship is prevalent in the literature and prevalent in, you know, our conversations and in oncology circles is how we describe it. But I think we're trying to be more sensitive to the much, much broader population of individuals who are going through cancer treatments today. Karen Litzy: 03:19 Yeah. And I liked that phrase, living with and beyond cancer, it seems a little more inclusive to me. Is that why you prefer that phrase? Nicole Stout: 03:29 I do. I think that encompasses anyone who ever had a cancer type know who is in treatment, who is a, what we call an ed has completed treatment and has no evidence of disease. And it's also those individuals who may be in palliative care, who are progressing towards end of life, who are still being treated or managed in various ways. So I think it is more encompassing and reflective really of the broad, broad scope of this population. Karen Litzy: 04:04 Yes. Because I think oftentimes, and myself included, people think you either have cancer or you don't. After you've gone through treatment, you don't have it in you're a survivor. So you forget about that population of people, like you said, who have cancers that they'll be in treatment for the rest of their lives. Nicole Stout: 04:26 Yeah. And that that is actually a growing population with more sophisticated treatment technologies and changes that we've seen around the immunological therapies, the hormonal therapy treatments. Many of these targeted agents as we've come to so call them. And we are seeing individuals live much, much longer with disease, with stable disease, we're able to stabilize it. And so therefore what they would have died from in six months or a year, they're now surviving. I have years on continued temporization treatments. And so how would we describe those individuals? And yeah, let me make sure that the supportive care needs of those people are met and identified and met. It is a very broad population. So I think sometimes we say survivorship and it is not nearly as homogenous as, you know, that group of you either have cancer or you don't. You've been treated and you're finished. Now some people, for some folks that is the case. But for many, there's this very gray area that is the remainder of them. Karen Litzy: 05:39 Yeah. And I think saying living with cancer treatment or living through cancer treatment and beyond is just a little more sensitive to the person. Like you said, the person behind the cancer. Because oftentimes when you read articles or even whether it's in a scientific journal or mainstream media and you think about cancer, they are always talking in percentages and numbers but not in the person. And so this kind of brings it down to the personal level. Now you mentioned it a couple of times, as we were talking here about different morbidities related to cancer or cancer treatment. So can you talk a little bit about what people undergoing treatments or maybe have completed their treatments might be experiencing? Nicole Stout: 06:37 Yeah, that's a huge topic. We could spend hours just talking about that. But first of all, just in general, when we say morbidity, we're talking about the complications and the side effects that impact an individual's ability to function. So we're talking about functional morbidity. And the good news, the good news is this. The good news is we have a growing population of individuals who are living with and far beyond their cancer diagnosis. We talk about the population of cancer survivors growing. And you know, we look back to like the 1970s, all types of cancers. We were looking at about somewhere between a 40 and 50% survival rate to five years. So we have, and today we have dramatically driven that number much, much higher when we look across all cancers. That number today is around 70%. But when you drill into some of the more commonly diagnosed cancers like breast and prostate, those survival numbers to five years or even higher, upwards of 90% plus. Nicole Stout: 07:47 So the good news is more people are being treated and getting to that side of your Mark of survival with no evidence of disease. And that tells us a story that they're more likely to live the rest of their lifespan, but they are living with significant functional morbidity. And so the side effects of cancer treatments are things that we absolutely anticipate. We know that when people go through different types of chemotherapies or mental therapies, radiation therapy, you named the therapy, they are going to be side effects that negatively impact their function. The issue is how severe is the impact? How disabling does it become and does it persist? So multisystem impacts from these interventions. Chemotherapy is a multi, it's a systemic approach to managing disease burden. And unfortunately chemo is not selective. It doesn't go into your body and say, Hey, here's a cancer cell and there's a cancer cell and it wipes out rapidly dividing cells. Nicole Stout: 08:54 So is the systemic impact to the body. Your immune system is suppressed, you know, your blood counts drop, you become anemic, you become fatigued. Some chemotherapeutic agents cause cardiac complications and cardiotoxicities some chemotherapeutic agents we know are highly neurotoxic and cause peripheral neuropathies. None of these. And there's a spectrum, right, of the severity of that toxicity that people experience. And so some of those are mild, some of those are more severe. That it is the majority of patients going through treatment will experience at least one or more many experience, more than at least one about 60% experience, at least at one or more functional morbidity. And so when I talk about function, I want to say just sort of as a caveat, I always say I talk about Function with a capital F, meaning that it's not just the physical function. You know, I think in physical therapy we think about movement and mobility and gait and balance and you know, activities. But there's cognitive functioning as well. There's sexual functioning, there's being able to assume your psych. Karen Litzy: 10:10 Yes. Nicole Stout: 10:10 Social and psychological functioning and all of that, assuming your roles and your daily life. So we have to think very broadly, but when we talk about the morbidity burden, it's very real associated with cancer treatments in the short term. So while people are going through treatment, we expect to see it. But here's the trick. When treatments are done and withdrawal, people do recover to a very high degree. They regain their strength and mobility. But many of them suffer with persistent morbidity. And that disables many from going back to work or resuming their prior roles. And again, those can be across systems. And they can be encompassing of the physical, the cognitive, et cetera. Karen Litzy: 10:55 And that gives me a lot to think about as a physical therapist. So if I might be seeing a patient too, let's say they have completed their chemotherapy, radiation, whatever their treatment was a year ago as the physical therapist, it sort of behooves me to ask these questions of them. So even though I may have a patient who's recovering from breast cancer that's coming to see me for knee pain, but these are things that if you are the treating healthcare provider, you have to have in your head and kind of ask these questions of them, of those different systems. Right? Nicole Stout: 11:41 Absolutely. And that's actually a great and very critical point to make for physical therapists. And you know, even more broadly, occupational therapist, speech and language, all of our rehab cohort, you know, you said one year after treatment that the thing about cancer treatments, and I refer to them as the gift that keeps on giving because even though an individual finishes treatments, the treatments are oftentimes not done with them. Radiation therapy is a great example. We see individuals have side effects of radiation therapy in the acute timeframe, of course that we can see for example with chest wall radiation and breast cancer, we can see changes to the lung tissue, the bone and the cardiac function even years beyond the completion of treatment in five years, 10 years. So it behooves us to think about the history of cancer but not just did it have a history of cancer and concerned about recurrence of disease with what I'm seeing in my assessment. Nicole Stout: 12:41 That's one little piece of it. But the bigger question is, is the impairment that I'm seeing in this patient in front of me somehow related to their cancer treatments? Quite possibly, I would say yes. And if it is, are there things that I need to know about cancer and its treatments so that I can optimally manage this patient? And I would say yes to that as well. It's funny because in, I've been a PT for over 20 years now. I've worked in cancer for the majority of that time. Almost 19 of those 20 plus years have been exclusively cancer. And I still today have physical therapists say to me, I don't really see cancer patients in my practice. And my response to them is they see you every day. They see you everyday. Someone who has had a history of breast cancer with radiation therapy to the chest wall on the left side 10 years ago. Nicole Stout: 13:38 And you're seeing them as they are deconditioned, they may have dyspnea, they're now having some cardiac complications that can absolutely be related to radiation cardiotoxicity. You're seeing someone's three years out from prostate cancer treatment who is now having some balance deficits and issues, has had a fall at home for example, do a close assessment of their sensation, because they probably have residual peripheral neuropathy directly related to their neurotoxic chemotherapeutic agents. So we know that many of these side effects persist and can cause what we call these late effects, which are the downstream side effects that patients will experience. And a lot of it is musculoskeletal, neurological as well. You know, there are changes that can happen with regard to sensation, cognition, memory, those types of things also can persist for, can come on more substantially later after the completion of treatment. Nicole Stout: 14:43 So there are functional needs someone's going through treatment, but those needs may be, they may be less, they actually may be more in some folks as they age. Because by the way, there's that pesky thing called aging. I'm done with cancer treatments five years, 10 years later. But you know, you've also aged whole cluster of what are the co-morbidities that we're facing that this individual is facing. You know, what type of lifestyle behaviors are they choosing. So really looking at that from that very encompassing perspective and in the short and the long term, not negating that history of cancer, even though it was, you know, five or seven years ago. Karen Litzy: 15:26 Yeah. And you know, you kind of answered the question I was going to ask and that's as a physical therapist, why should we care? Well, I think you answered that one very well, but let's talk about the evidence for rehabilitation. And exercise interventions for these individuals with cancer. What does the evidence tell us? Nicole Stout: 15:43 Yeah. And so when you asked why should we care, not just to alleviate their morbidity and to give a good quality of life and better function, but there are big, big issues that these folks face that caused downstream medical and healthcare utilization than escalate costs, pain medications, imaging, additional hospitalizations. So we should care from an individual perspective. I want my individual patient to be functioning. We should also care from a system and a societal perspective that we can help to alleviate that burden. So the exercise or the evidence, boy, where do I start? The good news is, as I said, multi-system impact for many of the cancer treatment interventions. And that's everything from surgery through hormonal treatments, including everything in between. But the goodness is there is evidence to demonstrate the benefits of rehabilitation intervention for nearly any patient with any disease type across the continuum of cancer care. Nicole Stout: 16:50 From the point of diagnosis through end of life, there's evidence to support our interventions. And you know, I always say that about cancer oncologist everywhere. Cancer does not discriminate based on body region. It does not discriminate based on system impact. It doesn't discriminate based on race, based on gender. Everybody is at risk for having a cancer diagnosis. Now you know, there are some nuances there that level of risks. So we have to be thinking about that evidence very broadly. And so if we start at the beginning, at the point of diagnosis, there are some populations for whom a prehabilitation exercise intervention is highly recommended. We have seen over the last decade, the idea and concept of prehab is, you know, many times we make a diagnosis for a patient with cancer and it is not emergent to treat them. Now some types, it is some types of leukemias. Nicole Stout: 17:49 We immediately begin treatment like the sun doesn't set, we treat them. But for a number of populations, there's testing, there's workups that are done. There's lab work, there's imaging and that can take several weeks. And so in populations like lung and colorectal, we had started to see these prehabilitation exercise programs put into place and there's a nice body of literature that has grown and has strengthened demonstrating the benefit of therapeutic exercise, aerobic conditioning, moderate intensity supervised over the course of about two to three weeks. What it does is it prepares them to enter, whether it's surgery or chemotherapy. First it prepares them to enter. They are cancer care continuum in a much better physical performance status. Really the exciting thing in lung cancer with the pre habilitation exercise that we've seen some evidence, the lung cancer population in general, many of them are not in good physical performance status when they're diagnosed. Nicole Stout: 18:52 And some of them by virtue of that are not candidates for surgery. They're not candidates for the ideal regimen of chemotherapy because of their performance status. And we're starting to see evidence that that prehabilitation exercise intervention can actually convert someone for being a non surgical candidate to the surgical candidate. And that is, that's where we need to really be looking longer term and saying, does the rehab intervention improve survival in that population? The question is not, you know, something that we haven't answered yet but not far from being plausible. So that's evidence sort of from the point of diagnosis. We also have a large body of evidence around that post usually surgery is the first stop for some, for most folks and that perioperative time period. And it just makes sense. You know, the PT, the rehab consults, for especially our head and neck population, we talk about oropharyngeal, laryngeal parasite as we sort of put those into the head and neck population. Nicole Stout: 19:56 Immediate referral for speech and language pathology should be done in that patient population. Immediate referral for PT or OT console for upper quadrant for cervical mobility, first those things should be standards that should become standards of care. The evidence is building in that regard. And then as patients move through treatment, the chemotherapy, radiation therapy, sometimes chemo, radiotherapy combined, is sometimes the next stop. And around that time period the exercise literature supports intervention during chemotherapy, the conditioning to help to mitigate fatigue, moderate intensity, low intensity exercise for individuals to alleviate distress, anxiety, depression. So exercise prescription is something that we're really starting to see more focused on. The American college of sports medicine just released new guidelines last week, providing some very specific evidence around exercise prescription. So we're getting to the point where we can actually prescribe exercise for targeted impairments that individuals are experiencing during cancer treatments. Nicole Stout: 21:17 There's strong evidence around fatigue management exercise. To moderate and low intensity for fatigue management. There's strong evidence around lymphedema using exercise to help for women who have, especially in the breast cancer population. There's strong evidence also around using weight bearing exercise to mitigate bone density loss that happens with many of the hormonal agents. So I know I'm sort of picking and choosing out of the air here, but in general, what do people experience when they go through cancer treatments? Debilitating fatigue is probably one of the most prevalent impairments across all cancer types. There's also so deconditioning that comes along with that and you know, that's a starting place for exercise interventions and you know, half the battle I feel with the rehabilitation intervention. And I feel like my role sometimes as the PT on the team, half of the battle is engaging the patient repeatedly in a conversation about enabling them because as they go through treatment, they feel terrible. Nicole Stout: 22:30 You're sick. They're fragile, they're medically complex, right? Their blood counts drop, okay, let's maybe low. So there's risks and you know, it's sort of like the docs will say things like, well, you know, I guess you can exercise but don't overdo it. And that's almost worse than saying don't exercise. And so sometimes it's just, you know, our role in rehab is so critical during that time period of treatment to see them in a repeated fashion. And by that I don't mean, you know, two, two times a week for the duration of their cancer treatment. But you know, maybe it's a monthly basis, maybe it's every other month, maybe it's every three months as they're going through treatment for those check-ins. Re-assessing how their function has changed. Giving them guidance and support and enabling them. Karen Litzy: 23:23 Yeah. And it reminds me of some of the work that I do with patients who have chronic pain is that it's not like you said, two times a week for six weeks. It's checking in, it's helping to build their self efficacy so that they can do yeah. And they can do more for themselves. Nicole Stout: 23:47 And within their own bodies and giving them permission to do it. Cause like you just said, well you can work out but not too hard. Well like, yeah, that saying, well that's confusing and sometimes our patients need permission to feel more confident with their bodies. I had a patient say something to me once and I will never forget it and I use it in all of my talks and it's always sort of at the core in my mind. And she said to me, you know, the medical oncologists, they may have saved my life that you gave me my life back and if I'm going to survive cancer, what is it worth if I can't have my life back, at least to some degree to do things that I love to do. That just really hits at the heart of why rehabilitation is so critical for these individuals. Nicole Stout: 24:39 Because yeah, that treatments that we have now, I mean, we're detecting cancers earlier. The treatments are so much more sophisticated. Many people will go on and live their full lifespan and die from something else and however, it's not good enough anymore for us to say. He said, I have cancer. You should be happy to be alive. You know, even if you're suffering with pain or lymphedema or conflict fatigue or neuropathies and, or cognitive dysfunctions and you're frustrated because you can't think straight and you don't have good short term memory. It's not good enough for us to say you should just live with those things and be happy to be alive. Not when we have the evidence like we do around rehabilitation interventions. And I mean, I could go on about the evidence. We could get into specific impairments, pelvic floor, for example, returning people to continent. Nicole Stout: 25:32 Again, that's a place where prehab and then following them through the continuum of care. Makes sense. And you know, we in PT and in rehab has to get out of this episodic care mindset when we're working with patients who have cancer. So that's really where we went and we develop the prospective surveillance model. Way back in the early two thousands when I went to work at the Naval hospital in Charleston, Garvey and Cindy falls there, had developed this protocol for a research study and I went in and this prospective surveillance model said, Hey, we know people going through cancer treatment are gonna experience just awful side effects that are going to negatively impact their function. And if we know that ahead of time, why aren't we using rehab prospectively to help to identify the changes, manage them early when they're less intense and can be managed more conservatively. Nicole Stout: 26:28 So we ran those studies over the course of the next 10 years and published extensively on this concept of prospective surveillance, which is start with rehab at the point of diagnosis, assess function at baseline, know what's normal, follow that patient then at punctuated intervals, throughout treatment, one month after they start treatment, they're going to have had surgery or they're going to have started treatment. They're going to start to decline. See them at that one month period, reassess baseline and identify clinically meaningful change. Everything might look great and then you say, good, I'll see you in three months. And then we follow them on an every three month basis after that for the first year, every six months, then up to two years and you're only out to buy. And what we found was that I do think that we indeed identified impairments early because for most people it's not if they occur, it's when, when is it going to happen? Nicole Stout: 27:23 So we're able to identify them early. We can treat them much more conservatively when the impairment is less severe rather than waiting for severe, debilitating fatigue or a big fat swollen leg, and trying to fix or rehabilitate, right? We have to be much more proactive and we have the tools to be able to do that. We have the clinical measurement tools, we have the problem solving skills as rehab providers. What we have got to change is our perspective on an episode of care. This really is a more consultative role for rehabilitation and I think that's great. I think it's a great place for us to think about moving to as a profession. Consultation in that, like you said, sometimes you just see the patient, we tweak a little bit on their program and you coached them a little bit and talk about some of the behaviors they want to move towards and talk about. You're going to get there and you enable need and then I'll see you in three months. But sooner if anything goes wrong, you know? Karen Litzy: 28:21 And now this brings up to me an interesting question for you. So this, you said back in the early two thousands, this work was done on this, prospective surveillance. So now it is 2019 so you know where I'm going with this, right? So, as rehabilitation professionals, where are we? Are we doing this? Has this been put into mainstream practice? And if not, what do we need to do as the rehabilitation professions? Nicole Stout: 29:00 Yeah. So my heart is really as a researcher and it takes time. It takes time to do good studies. So that protocol kicked off in 2000. We didn't publish really our first remarkable studies until 2008 so it took us that eight years to enroll enough patients, analyze the data, come up with a full data set. You know, we completed our enrollment, we had the full data set. So in 2008 we published the first article from that prospective surveillance trial and then we published many, many more that the first was lymphedema, we published on shoulder morbidity, we published on fatigue and it was sort of this cascade after that, you know, once we had the data collected. So I'll start by saying it takes a long time to do good quality research. So really I sort of start the clock around 2008 and we've all heard the adage it takes 17 years for something to go from, you know, the research being published to actually implementing it in practice. Nicole Stout: 30:08 So I looked around at my research, okay, I'm out waiting 17 years. How did the escalate the timeline to get this into practice? And, I encourage individuals who do publish, to think about how you advocate for your research. And so where are we right now as a profession? Well for the first few years it was challenging to get people around their head around this concept of prospective surveillance. We had some uptake in some larger cancer centers who said, this makes sense, let's implement and put a physical therapist in the cancer center, which I think is an ideal situation. It's hard to do though because again, in hospital systems we're in our cost centers and you know, the rehabilitation department, you have to have her referral to PT. I mean, we've got to find ways to overcome all of those barriers. Nicole Stout: 31:03 So, I would say one moment that was a real catapult for us was in 2010, the American cancer society had identified the evidence around prospective surveillance and they said, do you think that this is ready for sort of an expert review panel? And I said, hell yeah. And so I got to work collaboratively with them and some other colleagues in putting together an expert consensus panel on prospective surveillance. We ended up after a two day symposium look, did the research, worked in groups and teams for about another year and publish 16 articles that came out in a supplement to cancer in 2012. And that I feel like was a bit more of a pivotal moment for us. You know, these research studies were great, but to pull all of that together with a group of experts in a consensus forum and say, this is a model that we need to think about for cancer patients because if we start at the beginning, not just with physical function, but if we start at the beginning with things like assessing someone's cognition, assessing their family status, assessing their financial status, assessing their nutrition status, and we follow them prospectively, all of those things are going to take a negative hit at some point during cancer treatments. Nicole Stout: 32:21 So I think prospective surveillance lends itself to a much larger cancer supportive care model, which is how I have been describing it. And it is my intent to really focus on how we can study that model and look at better avenues for implementation in this new position that I'm in now at West Virginia university. This is my goal, which is amazing. Now how, so, you know, if we look toward the future and hopefully what you will be able to achieve in your colleagues across the medical spectrum, what are there policies that need to change that will impact the future of cancer survivorship or the future of living with cancer and beyond? Yeah, so the good news to that is there are a lot of things we can impact because we've laid this foundation of the evidence. We have laid this foundation of expert consensus and there's been a lot between that 2012 and today, more and more providers in rehabilitation services are becoming aware and engaging in cancer. Nicole Stout: 33:36 You know, it's not something we prevalently teach in our curriculum in PT school. Think about how you learned about cancer. You learned about cancer in the negative. You learned all of the contraindications to your modalities and exercise and cancer was always one of them, right? You would say in your practical, okay, ultrasound, great, don't do it over the eyes. Don't do it on a pregnant uterus and cancer. So we find it in the negative for so many years. We have generations of therapists out there who love cancer and negative that never learned about the interventions to help to impact improve someone's function going through cancer treatment. So we're seeing that change and it's changing in how do we know it's changing? Individuals are engaging in cancer rehabilitation networks. We're seeing far more publications. We've published on this. A couple of years ago we did a billion metric analysis of the cancer rehabilitation literature and we've seen this tremendous upswing in the evidence base and an increase in volume. Nicole Stout: 34:39 We're also seeing more therapists move towards specialty practice and evidence of that is what we have seen culminate in the last year with the first ever deployment of the oncology board specialty certification exam. We had 68 people pass the first exam. So we now have a growing conduct contingency and it will continue to go of therapists who are oncologic clinical specialists, which is fantastic. So we are positioning ourselves, we are moving forward. But when you ask where do we go in the future, I really think of three things. Number one is impacting policy, like you said, second is impacting education. And third really is impacting research. And so I think where do we need to move to in the future? We're starting to see the clinical practitioners really grow. We're starting to see residency programs develop. So from that perspective of the clinical focus, there's evidence, there are pathways that's developing. Nicole Stout: 35:41 We have to start thinking about how do we embed this better into our curriculum. And this was last January in PTJ, the January issue of physical therapy journal. I coauthored a commentary article with Dr Laura Gillcrest, Dr Caringness and Dr Julie silver and Dr Catherine Alfano. We were all putting forward commentary on a recent national Academy of science, engineering and medicine report about longterm survivorship for cancer. And basically that report said rehabilitation should be utilized throughout the continuum of care, cancer care in order to contribute to that are longterm outcomes. And if that not doing so, not including rehabilitation during cancer treatment is almost negligence based on the breadth and depth of the literature that we have. So that was a pretty strong statement in that workshop document. So those are the types of things. Recommendations from the national academies will help us change policies. Nicole Stout: 36:48 And by policies, I mean, you know, it's not just how do we get paid for what we do, but also policies around, standards, policies that our accreditation bodies use to designate cancer centers. In fact we are seeing, I think they were just released today, the commission on cancer, which accredits probably 95%, I think it is, of cancer centers around the country. So they're a big gorilla, their standards for an accredited comprehensive cancer center and include a standard for rehabilitation care services. It used to just be a criteria that you had to have a referral source to rehabilitation. But in 2020, the new standards that will come out from the commission on cancer actually has a rehabilitation care service standard. So it's been elevated. That's going to be critical for us because it will require your cancer committee in your hospital to identify policies and procedures for rehabilitation practices in oncology. Nicole Stout: 37:56 So, you know, this is a place where we've got to start to see uptake in from our rehabilitation directors or administrators in large healthcare systems. The PTA, you know, we were really gonna need to see them start to put forward recommendations. How do we do this to practice? What is the best practice? What are some tools and tool kits that we can rule out. So those things, those policy changes are drivers for us. The education piece, I've spoken to a bit, I think embedding more education into curriculum for the entry level PT. And I think it's critical. You know, we get so bogged down in, well, you know, the capte requirements are, but they are in our curriculum's already too tight and it's a bit of a red herring argument because I see places around the country who have champions for oncology rehab who has put it into the curriculum. Nicole Stout: 38:51 It just takes someone to understand what is the best practice look like for an educational model and how do we implement it. So places like Oakland university in Michigan, Emory in Atlanta is working right now on elective modules. So there are some real novel ways that these are being incorporated into PT curriculum. And the third area that I think of for the future is research. And you know, as I said, wow, we've seen an explosion in research in the last decade. It's phenomenal. A greater volume. A lot of that has focused on intervention. It's been within some very specific populations like breast and prostate. There is a lot of breast and prostate, understandably. But we need to look at going beyond. We really should be thinking about how do we look at populations with regard to our rehab interventions of cohort studies, large population studies, and we've got to start thinking a little bit beyond end points. Nicole Stout: 39:54 Like function, function is important, don't get me wrong, it's the core of what we do. But if we improve function through rehab intervention, does it change the downstream utilization of healthcare services? Does it mitigate costs? Do we see them spend less time in the hospital? Did they have less than, do they adhere to their chemotherapy better? Do they have less severe toxicities? Do they have better overall survival? So they've got to think about some different end points and take a bit of a health services research approach. I think in oncology rehabilitation going forward. That's what I would love to see as the future and really at the core, the change in clinical practice so that we are a proactive consultative risk stratifying, triaging, screening, and proactively assessing profession when it comes to dealing with oncology. Karen Litzy: 40:52 Yeah. And, and you really teed it up for me to ask you this last question here. My question is what advice would you give to your everyday clinician working, whether that be an inpatient or outpatient to allow them to begin to think differently about cancer? Nicole Stout: 41:19 And that's critical because the fact of the matter is we look at places like Johns Hopkins and university of Penn and MD Anderson and those are like the preeminent cancer centers in the country. The truth of the matter is the majority of people get treated for cancer and community hospitals right down the street from where you live and in outpatient, freestanding oncology clinics. So the likelihood that you're going to see them is very high. So it is important for, as I said, the general therapist. It's also important for specialty practice therapists to improve their knowledge base in cancer. So how do you do that? There are some great resources. I'm always going to point to the APTA oncologic Academy for physical therapy. We're now an Academy. We used to be the section, I still call it the section. Nicole Stout: 42:13 But we have an Academy for oncologic physical therapy and there are phenomenal resources there. They do continuing education programs. They provide fact sheets. They often have great evidence base that you can access to understand what are the measurement tools they should be using, what are the questions I should be asking someone. I feel there are also some, you know, continuing education courses focused specifically on the general therapist and I teach one of them. So there's my bias opinion and my disclosure there with great seminars, but I tell people that in the beginning of the course, one of the first things I say is my goal is not to spend two days with you to get you to become an expert in cancer rehab. My goal is to change the way you think about every single patient that you see regardless of the diagnosis, regardless of the setting that you are in. Nicole Stout: 43:05 If they had a history of cancer, what questions do you need to ask? What might you be seeing in your intake that is indicative of side effects of disease treatment, late effects or even metastatic process. The other flip side of that that we haven't talked about and certainly helped me to delve into is that as primary providers, as frontline providers as we are in rehab, right? The direct access. Now, how many of us ask, about screening, cancer screening? How many of us ask questions? How many of us even know what the screening guidelines are for cervical cancer, for breast cancer, for prostate cancer, new screening guidelines for lung cancer. Again, I think that's a great way for physical therapy professionals to brush up in their knowledge base and to start to have these conversations. I'm not going to be the one to order a low dose CT scan for my patient who's at risk for lung cancer, but I might be the person to plant the seed with them and to incite a behavior change if no one else on their medical team has talked to them about it or if they're hesitant about it. Nicole Stout: 44:12 Colorectal cancer screening as well. So all of those, we should take responsibility to have those conversations. And that is 100% of the patients that we see to ask those questions. So I think we need to sort of self-assess and say, how can I do this? Knowing that we had, we have 17 million individuals in the United States right now that we call cancer survivors. We are expecting that number to double, double by 20, 40 just because of the growing population, first of all. And because of the escalating rates of survivors, because we're treating the disease so much better. So there are going to be far more of them with the aging population and far more needs for us to meet. So yeah, therapists should be asking themselves, what are the resources out there? There are a lot of places now hospitals, health systems do cancer rehabilitation programs. Nicole Stout: 45:10 They're doing continuing education courses and they're doing conferences as well. So take a look at some of the, I know Mary free bed, rehabilitation center up in Michigan, Brooks rehabilitation hospital down in Jacksonville, Florida, Marion joy, Northwestern. Many of these rehab hospitals are looking at doing one day, two day symposium open, you know, for folks to attend. So many hospitals as well are doing these cancer rehabilitation one day symposium and NYU is doing one next year, university of Miami. There's also an on pitch this because it's fantastic. And the ICPTO, which is the international conference in oncology, physical therapy, physical therapy oncology. I see PTO, it will be in Copenhagen in may of 2020. That's not a terrible place to go. This is the second that we, the second conference that we've done, the first conference we had over 280 participants from over 25 different countries around, well just physical therapists just in oncology. Nicole Stout: 46:17 It was just amazing. It gave me tingles to be in that room. And so we're hoping to have an even bigger groups. So those are just, you know, again, sort of a snippet of some resources that I can provide. But looking at each of those, I think you can delve deeper into the resources that they have and have them have available within the APTA within the Academy and within some of those other ACRM is another one. The American Congress for rehab medicine has a cancer networking group and that's a beautiful place to go because it is interdisciplinary PT, OT, speech. You have behavioral psychologists, you have interventionalists, you have lifestyle medicine, desire, interest. It's really great. And they have continuous track of cancer rehabilitation content at their conferences. Unfortunately their conferences in early November. So it's coming up quickly, but every year it's in the fall. Next year it will be in Atlanta. So you know, another great place to look for. How do I start to build my knowledge base in this area? Karen Litzy: 47:30 Yeah, this is great. Thank you so much for all of those resources and we will put as many of those up in the show notes at podcast.healthywealthysmart.com. Quick question on some of those resources. When you were talking about the different screening tools, can you find those screening tools under the APTA's oncologic PT? Nicole Stout: 47:50 So if you're talking about the Academy for oncologic physical therapy, the hotly debated title. Yes, there are. So screening tools for identifying functional morbidity. Yes. So the course that was the evidence database to guide effectiveness, the edge test scores for oncology has published over 25 systematic reviews and have looked at measurement tools with by disease type within different measurement domains. So for example, you can find how do I measure functional mobility in colorectal cancer? How do I measure best measure lymph edema in head, neck cancer? So it's broken down by disease type and then domain of measurement. So that's there. It's an annotated bibliography on their website. So they give you a nice little simple compendium. But for the larger screening population screening guidelines, many of those are American cancer society and the us health prevention preventive task force. Those are, you know, large scale guidelines that are developed and put forward for screening for disease. Karen Litzy: 49:02 Yeah, perfect. Perfect. Well that's great. That is a lot of resources for people. So hopefully any rehab professional listening can, if you have no familiarity with any of this information, would you say where's the first place they should go? Nicole Stout: 49:21 Well, the first place, that's a great question. And I can help you put some seminal articles up there too. I think there are one and the open access articles. Julie silver wrote a fantastic article in 2013, about impairment driven as a rehabilitation. I feel like it's foundational. It's a great starting place for someone to get their head around all of the stuff involved with cancer treatment and the functional morbidity. And then I think the PTs for PTC oncology Academy is a great place. But also if you're an OT or speechie, you can join the Academy of oncology, PT, you can be an affiliate member, you can get access to our journal and our resources. Karen Litzy: 50:06 Oh, that's cool. Good to know. That's very good to know. And you know, I think as from what I've got out of this conversation, because I am not embedded in with the oncological Academy but what I am have come to realize through this conversation is that regardless of your setting, you may in your career encounter a patient that has had cancer or is going through cancer treatment and regardless of whether you're in sports, PT, orthopedics, neurological pediatrics, odds are you're going to treat someone at some point with a cancer diagnosis present or past. And to understand the basics of how that might affect overall systems is incredibly important regardless of whether you work at Sloan Kettering full time within specifically cancer population or you are the physical therapist for the New York Knicks, you know, you may encounter this population. Nicole Stout: 51:32 Yeah, that's really a beautiful summary. Karen, I appreciate the way you articulated that because I like to say oncology is everywhere and that's exactly it. It doesn't matter the setting you're in, it doesn't matter what specialty you practice. It doesn't matter geographically where you live. It does not matter, you know, age, gender, et cetera is, it's there, it is everywhere. Multi-system impact across body systems. So I think that's it. And across the lifespan. So I think it's beautifully summed up with that. You just said that, that's how we think about it. Oncologists everywhere. So every patient that you see there is either the risk of them having a cancer diagnosis in the future. So are you talking about the screening guidelines for the chances they'd had a diagnosis in the past and then asking yourself, is that impacting what I'm seeing here in front of me? There's so much we can spend an hour talking about pediatric oncology right now we're talking about red flags, you know, but look around many of the continuing education consortia around the country, med bridge. You know, many of those have a variety of content or are in process of building content for continuing education always look at the references. CSN is a great place to go to get a ton of oncology resources. Karen Litzy: 53:00 Got it. And that is coming up in February over Valentine's day weekend in Denver, Colorado. So if you're a physical therapist or not, maybe you just want to go and hang out with 13,000 other PTs. You can go to Denver and you look at the oncology track for CSM. Nicole Stout: 53:20 Definitely bring your sweetheart, make a ski weekend, I guess with the ecology content. Yep, definitely. Karen Litzy: 53:32 Excellent. All right, so before we wrap it up, I asked the same question to everyone and that's knowing where you are now in your career, in your life. What advice would you give yourself as a new grad out of PT school? So this is the advice you would give to you. Nicole Stout: 53:48 The advice I would give to me, it's funny. People would say, if you look back, what would you change? And I always say not a damn thing. I guess my advice to myself is what I hold close to my heart and what I convey to others is go for it. Don't be hesitant to take on something new or different because the new and different is what is going to expose you to a pathway you never would have imagined. I never would have imagined coming out of school that I would be doing oncology work. I was worried about in PT school. I didn't know that this career pathway could exist. I didn't know a clinical research pathway was something that I could even pursue. And as the opportunity came up, if I would've been hesitant, if I wouldn't have been interested in taking the risks, so go for it. Don't be afraid to take a risk. And sometimes that means moving to a different city, that might mean taking a pay cut. You know, a lot of times if we chase the things we love, we're not necessarily chasing the money along with it. I think if we chase a big paying salary, sometimes miss things above, so go for it and be open to try and taking those different pathways. Karen Litzy: 55:02 Yeah, great advice. And now where can people find you if they have questions or they want to talk about oncology physical therapy? Nicole Stout: 55:12 Oh, you can find me on Twitter, on social media outlet. I really used to try to engage professionally. So it's @NicoleStoutPT. And you know, you can certainly find me there. My Facebook accounts were private. That's where like family and friends stuff. But definitely access and hit me up on Twitter or LinkedIn yet. Another great place. I post a lot of our research articles there. I'm on LinkedIn, so you can certainly connect with me there. Or just email me and always see how many times you can just cold call or cold email. It's some of the most engaging conversations I'll get on the phone with anyone. I will fly anywhere to talk about kids or rehabilitation and you know, some of the best conversations that started with, Hey, I don't want to bother you, but you have some time to talk and I'm happy, you know, to start a conversation via email. So more than happy to engage. Karen Litzy: 56:09 Perfect. And Nicole, thank you so much for a really great talk and I think that you have given the listeners a lot to think about and also a lot to look up into research and hopefully spark someone out there to, this might be the path I would like to take. So thank you so much. Nicole Stout: 56:24 Well, I thank you for the opportunity. I'm just grateful for everything that you've done to put PT on such a stage and I'm really excited to have been a part of that, so thank you. Karen Litzy: Thank you so much. And everyone out there listening, thanks for listening. Have a great couple of days and stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! 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On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Neil Pearson on the show to discuss therapeutic yoga in pain care. Neil Pearson is a physiotherapist, and Clinical Assistant Professor at the University of British Columbia. He is a yoga teacher, a yoga therapist and creator of the Pain Care Yoga training programs for health professionals and yoga therapists. In this episode, we discuss: -The components of yoga practice that benefit people with persistent pain -Yoga therapy as a pain education agent -The Pancha Maya Kosha Model of yoga and the biopsychosocial model of healthcare -Yoga and Science in Pain Care: Treating the Person in Pain -And so much more! Resources: Pain Care U Twitter Pain Care U Facebook Pain Care U Website Yoga and Science in Pain Care: Treating the Person in Pain For more information on Neil: Neil Pearson, PT, MSc(RHBS), BA-BPHE, C-IAYT, ERYT500 Neil Pearson is a physiotherapist, and Clinical Assistant Professor at University of British Columbia. He is a yoga teacher, a yoga therapist and creator of the Pain Care Yoga training programs for health professionals and yoga therapists. Neil is founding chair of the Physiotherapy Pain Science Division in Canada, recipient of the Canadian Pain Society's Excellence in Interprofessional Pain Education award, faculty in yoga therapist training programs and an author. Neil develops innovative resources, collaborates in research and serves as a mentor for health professionals and yoga practitioners seeking to enhance their therapeutic expertise. He is co-editor of 'Yoga and Science in Pain Care: Treating the Person in Pain,' available Aug 2019. Read the full transcript below: Karen Litzy: 00:01 Hey Neil, welcome to the podcast. I'm happy to have you on to talk about yoga and science in pain care, which is a title of your new book. And we will talk about the book throughout the podcast, but I'm excited to learn more about yoga and how yoga can work with people in pain. So welcome back to the podcast. Neil Pearson: 00:24 Thanks so much Karen. I can't remember how long it's been since we've been here but it's wonderful to be back. Karen Litzy: 00:29 Yeah, I think it's been awhile. I don't know either, but I think it's been a long time, but I'm excited today to talk about yoga and how yoga can be an agent for people in pain. So as a lot of the listeners know, I had a long history of chronic neck pain, so this is something that really interests me, but I will kind of pass it along to you. So how does yoga help as a pain education agent? Neil Pearson: 01:00 Okay. So, maybe I'll start at a bit of a different place, but coming to there, so I guess part of my excitement around this, you know, we've got this new textbook out, it's called yoga and science in pain care. And really what it's trying to do is, is teach health care people about yoga and yoga research and how it can help but also some of the research behind that in terms of why it would work. And also it's sort of tried to go the other way as well as to teach yoga people about pain and about the lived experience of pain. So with the textbook, we're trying to hit both sides, right? Because we really see this as being something that needs to be integrated. And I think we sort of hit a really nice time with this because there's such interest in non-pharmacological pain management now. Neil Pearson: 01:54 Everyone's starting to recognize that the long-term management of pain or the care of people in pain has lots to do with what the individual does for themselves. Not completely as self-help kind of work, but more as what the person does for themselves under the guidance of people like us as physical therapists and under the guidance of people like the yoga therapists. So that sort of, the sort of broader where this is coming from. And then if we look at sort of how it can help, we can start by looking at some of the research and I guess probably in terms of pain management and pain care the simple thing to do to start with when we say we have now have formal analysis and systematic reviews that show that yoga therapy has been shown to be effective. Neil Pearson: 02:45 That helping people to have less pain, to improve both perception of ability but also measured function and also improved quality of life. Those three things really are the three keys that people want. When we have ongoing pain, we want to have less pain, better ease of movement, and better quality of life. And the research is showing positive findings there. And it's showing positive findings in quite a varied group. So, there's a lot of research on low back pain. I mean, that's the one that has the most research. So much so that the, you know, the American medical association now has a yoga as one of the suggested treatments for people who have ongoing low back pain. But it also shows benefits for people who have rheumatoid arthritis, osteoarthritis, fibromyalgia, a whiplash associated disorder and a irritable bowel syndrome as well. Neil Pearson: 03:43 So there's this growing body of evidence saying that when people have these conditions that they can find benefit from them. And of course, like any area of research, we'd have to say, you know, it doesn't say that it's gonna work for everyone. It just says that if you take a lot of people and you give it to them, there will be some benefit with using yogas. The therapy people always want to know, well, is the yoga therapy better than physical therapy or is it better than going to the gym? Is it better for other movement practices? And we don't have that research yet. The effects sizes of some of the research when people are going through using yoga therapy for pain management are higher than the effect sizes of movement on their own and comparable to the effect sizes. You see when you do research looking at cognitive behavioral therapy plus movement therapy for people with chronic pain, which makes a lot of sense because yoga therapy really does cover a lot of the aspects of the person. And so your listeners may be thinking yoga for people with pain. That sounds actually pretty ridiculous because whenever I see pictures of people doing yoga, there's no way that that's what people in pain are going to do, Karen Litzy: 05:00 Right? Cause they're always in these positions where even if I don't have pain, I think to myself, how in the heck am I supposed to get into that position? Neil Pearson: 05:10 Well, exactly right. And, and it sort of the other question that often sounds ridiculous to the person who has ongoing pain is like, aren't you listening to me? I told you that movement hurts and you're telling me you want me to move as a way to get better. But movement is the problem. And so it's interesting that the practices of yoga can help people to find new ways to move with more ease. But also, the practice of yoga, we need to recognize really are so vast. We're talking about, if we sort of overviewed yoga, yoga is about learning how to relate to yourself in new ways, how to live in a world in new ways. It is about movement with the postures and it is about doing breathing techniques. And then there are awareness techniques which are akin to mindfulness, but they're a little different. Neil Pearson: 06:10 And then there are also within yoga there are meditation techniques as well. So it really covers a broad, broad spectrum of interventions. And if we go to the literature again around chronic pain and chronic pain care, we see that mindfulness techniques and meditation are showing positive benefits. Movement is showing positive benefits. Gaining knowledge is showing positive benefits, acceptance, commitment therapy, cognitive behavioral therapy. All these things show benefit for people with chronic pain. And there are aspects of those all within yoga sort of as this package. And the idea would be that we could, with the person who has ongoing pain, the yoga therapist would be able to do an assessment to see how the pain has changed the person or influenced sort of all the aspects of their existence. And then try to find how we could use different techniques of yoga to help. Neil Pearson: 07:08 So for instance, if a person was, let's take a common example, like the person who has chronic low back pain, but we know that with chronical back pain, often there's anxiety. Often there's grief. Well, there are aspects of yoga that we could use to address the grief or the anxiety. Often when we have ongoing pain, we have the sense of loss of self competence or self efficacy and we could use certain aspects of yoga to address those. Our body tends to get stiff or some muscles, you know, are gripping all the time. And within yoga we can do things to help to release muscles that are gripping or learn how to reengage muscles that seem to be inhibited. And so it's the practice of yoga would be to or yoga therapy would be to go through it and see how this individual is impacted and then see how we could use the different aspects within yoga to put together a plan to address a lot of the changes that are related to ongoing pain. Karen Litzy: 08:12 Yeah. So I think what you're describing may be a little different than what a lot of, perhaps the listeners are seeing. Meaning yoga is more than just handstands on Instagram and you know, doing these impossible moves and making them look so easy because I think that's what a lot of people associate yoga with. And so what we're talking about here is not just going to a yoga class or not just putting something fun up on Instagram, but the yoga therapist being very intentional in their prescription, the type of yoga therapy they feel this person needs. So it's individualized based on a proper evaluation. Neil Pearson: 09:02 Oh, exactly. Yeah. Although the one difference in yoga therapy is that yoga therapy is not diagnostic, right? So the yoga therapist isn't a trained health care professional. So what the yoga therapist is doing is it's actually applying yoga, getting the person to do different aspects of yoga, like meditation or awareness or breathing or movements. And then seeing how the person is limited in that and then working with them to find a way so that they can do that particular technique to help them to change ease of movement of life pain. Karen Litzy: 09:40 Got it. Yeah. And there was, you know, something, we spoke about this a little bit before we went on the air, but there was a sentence within the book, the yoga and science and pain care that I had never heard of this saying before. I mean I'm not immersed in the yoga world, but it's the sentence is expanding our view and even altering our perspective to a Pancha Maya Kosha perspective enhances our understanding that pain physiology is studying the person as much as our biology. So can you talk about that for a little bit because I kind of liked that saying so you could expand on that. Neil Pearson: 10:25 Yeah. So there's sort of the two parts of it is that that studying physiology is about starting the person, not just the biology, but then there's also this Pancha Maya Kosha which all start with that within healthcare we talked about the bio-psychosocial or bio-psychosocial spiritual model, which is intended to be an integrated view of the person that everything biological is going to affect everything psychological, it's going to affect everything social is going to affect the person who has spiritual manner and it's all working together as an integrated unit. So within yoga, the philosophy and the view of yoga is that there are different aspects of the individual, so the individual is integrated and whole, but we can look at the individual from different aspects to understand them better. And so I'm this pantry, my kosher view looks at the individual from a physical perspective, from a more energetic perspective, being Pancha is one of the things they're talking about, which really is life force. Neil Pearson: 11:31 And then it really relates a lot to breath as well. But then there's within yoga to SIM Phi, we could say we look at they often call it the lower mind, but it's really getting at the automatic aspects of the human, all that stuff that runs automatically. And then there's above that or you know, I guess above it. There's this other aspect of us that this about us thinking about what we're thinking and it's about us regulating thoughts and emotions and breath and all that stuff. And then the other aspect of us is more the aspect of his that has more to do with spirit and connectedness to the world and everything. And so yoga already looks at the person from that kind of perspective. And with the idea that any change in one aspect of the individual is going to have an effect on the other aspects of the individual. Neil Pearson: 12:25 So if you have a little back pain, it's going to change the way you breathe. It's going to change the automatic functioning of the body. It's going to change the way you think and emote and it will change your connection with yourself, your community. And that then you'll also have as part of its core belief system is that if a person that had low back pain, you could help the person with low back pain by going through any one of those aspects of the person so that you could help the person by affecting the physical body, by working on breath, by working on the automatic system, by working on thoughts and emotions or community that all those, everything interacts. And so that you could, you know, work at it through any of those aspects of your existence. Karen Litzy: 13:08 Got it. And as someone who has had chronic neck pain for many years, it is very true that the physical pain certainly affects so much else that is happening in your life. It affects your thoughts, it affects your emotions, it affects your relationships, it affects the way you hold your body, the way you relate to your body, the way you see your body. So now I feel like I have a much better idea as to what that sentence means and how yoga can help the individual relate to all of that and kind of put it all together. Cause sometimes when you're in it, you don't see it. Know what I mean? Like you don't see that you're not relating to your body, you don't see that you're moving differently, you don't see that you're breathing differently, you're clenching, you're holding, you just, you don't realize it because it's just the way you are as a result of the pain. Neil Pearson: 14:10 It's so true. And I think one of the key things about what you just said is that the experience of pain often disconnects us from awareness of ourself even so much so that we know now from the science side that sometimes when there's ongoing pain that a person will have a hard time actually feeling the non pain sensations of their physical body. So you know, imagine a person with a low back pain and we asked them to take their attention to the rollback and tell us what they feel there. And typically what a person would do is tell us about their back pain. And then of course I get really sort of funny reaction to people when I say, okay, you told me about your pain. What I want you to do is take your attention back there and tell me the non pain sensations you can feel on your low back. Neil Pearson: 15:02 Which a lot of people, you know, really don't get that. And I say, okay, well you know, just right now take your attention to the feeling of your hands. Your hands are resting. Can you feel your fingers? Can you feel the temperature of your skin in your hands? Can you feel the angle of the knuckles? You probably can feel a whole lot of non pins sensations there and say if you had low back pain, I'd probably say, okay, now take your attention to your upper back, your mid back and notice the non pain sensations. They're just sort of exploring. Scan around. Okay, now what I want you to do is go down to your low back. No, just the pain. Sort of acknowledge it. Now what I'd like you to do is see if you can feel non pain sensations in that same area. Neil Pearson: 15:41 So maybe you need to try to look under the pain or around it or through it. I feel that and it's amazing that some people will say, you know, I really don't experience anything right now except the pain. All I feel there is pain. I can feel my mid back, I can feel my upper back, but my low back, it's pain. That's all there is. And then other people will say, I can sort of feel it, but it feels like it's murky or muddy or hard to feel. And then, you know, we don't often get it with low back pain, but say what was your hand where the pain was? Well often people when they start to do this say, you know, my hand doesn't feel this right shape or size. It feels like it's too big or it feels like it's too small. It feels distorted. Neil Pearson: 16:24 And so it's really interesting is that the practices of yoga specifically get people to take their attention to their physical self to try to reconnect to those sensations. And this is always part of yoga, but in Western science we're finally understanding this. It's really only been in the last five or 10 years where we've paid attention to the distortions of body awareness and body image that are common when pain persists. And, of course this becomes really fascinating to me because the next part is, as a research guy, I get stuck in because I know clinically when a person tells me that, that when I get the person start to work on finding those subtle non pains and sensations of their physical body, that when the person starts to be able to feel those sensations, that there's an associated decrease in their pain. Neil Pearson: 17:20 And then the more the person is able to feel the subtle non-painful sensations of self, the more the pain diminishes. But I can't give you any good scientific explanation for that. You know, we see it clinically, but we can't fully explain it in some sort of, you know, central nervous system or insular cortex or any of those things. We just can't explain it. But to me, that's part of the interesting thing about both the practice of yoga is that it's driven by experience. And yet what the science is now doing is showing is that there's science that says that, you know, the experience of yoga aren't just all in your head. They're actually real measurable changes in the humans biology and physiology. Karen Litzy: 18:08 Yeah, it's really interesting. And I wonder now you have me wondering, well why do people experience that decrease of pain when they start, you know, looking at the painful areas more than just painful. I mean, are they making changes in the sensory cortex? Is it affecting that idea of smudging that maybe they have a clearer outline of what that body part is now in the brain? And that can lead to changes? I don't know, but it's really an interesting concept. Neil Pearson: 18:45 Well, and the thing about that too is that as we start to study more our sense of our physiological state, we start to realize that body awareness and aspect of it is, or a big aspect of is happening, sort of outside the sensory cortex. It's happening more in the insular cortex. And so I know in the last year I saw one research study that was saying that they couldn't find any smudging and people who had altered body awareness, but they were looking at the sensory motor cortex and didn't look at the insular cortex. And so it's another area as the research goes on, is maybe that smudging is happening in a different place or that alteration of brain activity is happening in a different place than we thought, but certainly the person that is experiencing it and if the person is experiencing it, we hope we can be able to find, you know, the correlate in the brain activity. Neil Pearson: 19:45 Of course our, you know, our sciences far beyond or far behind, the experience that the human has, which really gets back to that other aspect of what you're saying is that that statement is when we study physiology, we hope that by studying physiology and pain physiology, that what we start to do is understand the human more rather than, maybe I'll say it this way often when I go to pain society conferences, there's a lot of biochemistry people there and they're talking about their research and at the end of it, they nearly always say, so what the science says is that here's this target for pain care, for pain intervention. And what they're talking about is that, we could give a chemical to the person to target this thing, this gene or this ion channel or whatever it is to change the person's experience of pain. And of course, my question always when I'm there is, so is there anything that the human could do to change that Karen Litzy: 20:48 Outside of something pharmacological? Neil Pearson: 20:50 Well, exactly right. And it would make sense if, if we're getting good effects from different treatments. Like yoga therapy that obviously they must be affecting these same biochemical and genetic and epigenetic things within the human. But they're doing them through the person's own, you know, we can say through their own medicine cabinet. Karen Litzy: 21:13 Right. That medicine cabinet in the brain that David Butler talks about. Neil Pearson: 21:17 Yeah. Yeah. And I think we can expand it into the human right. Because there's a, you know, especially even with the endorphins, cause there seem to be receptors for those all over the body. Karen Litzy: 21:29 Or even, you know, up and coming research into the microbiome and things like that. I think is also an interesting study in pain and how can we alter our diets or can we alter what we put in our system to change the pain experience? Neil Pearson: 21:55 Oh, absolutely. And I think this, you know, when we get to nutrition, the book actually has a chapter on nutrition. And, one of the things that we find one scan clinically is that some people change their diet a lot and really have very little change in their pain or their quality of life. Other people change their diet even just a small amount and get a massive change. And this, once again is part of the thing that is the complexity of pain care is that, we, you know, as an organism, we are a whole bunch of systems together and sometimes you can change one system a little bit and it really, really changes the organism or the person and others times you change that system a ton and you get very, very little change in the human. And that's one scan, part of the trouble of pain care. But part of the advantage of approaches like yoga therapy is because they're sort of okay with that idea is that everyone's fully individual and we don't have everyone should change their diet this way, or everyone should move their back this way, or everyone should, you know, stand this way or, right, right. It's not a linear model at all. Karen Litzy: 23:11 Yeah. No, definitely not. And then when you think about pain and you think about it as an experience, and if we're going off of all the different inputs that can be put into the body, that can have impact over one's pain experience, and you think of all the different ways you can alter those inputs, all of a sudden treating the person with persistent pain goes way beyond just movement. Right? It goes into all of those myriad of inputs that you have ability to alter, whether that be as the yoga therapist, a physical therapist, or let's not forget the person experiencing the pain themselves. Neil Pearson: 23:54 Oh, it's so true. Yeah. And with that last comment, you made, the person experiencing pain, the one thing we were really happy that we did within this book was that's her first chapter. So Julietta Belton wrote the first chapter on the lived experience of pain because we wanted to bring it back to, you know, this is why we're doing this work. It's not, you know, it's not that we're all just trying to understand pain. We're trying to help people. But back to movement, one of the things I think is that physical therapists and yoga therapists, anyone who's doing movement therapy, I think one of the really important things that we can do is start to shift our view of movements as though we can use movement for more than helping a person to be flexible, helping the person to be stronger. Neil Pearson: 24:39 And within yoga therapy, we often do this. We'll say, you know, when you're in this yoga posture, it's not just affecting you on the physical level. It's affecting you on every level. And so we can actually use some of the yoga postures to help with other issues related to pain such as, so I was thinking about, so,one when we do a seated forward bend. So maybe if you have back pain, it's really hard to do it, but you still can get in that kind of position where you're sitting on the floor. Legs were straight or bent in front of you and your trying to reach down towards your knees, your shins, your feet, wherever you get to. The metaphor here is of learning how to let go so you can move forward. Neil Pearson: 25:29 And so, we can use a lot of the different yoga postures like that is that we're thinking. So here's a person who is stuck, right? The person is, you know, maybe it's letting go of the need to have a definitive diagnosis because a lot of times that happens and sometimes to be able to, we see the person clinically that, you know, when we're in this multidisciplinary pain management setting, we say, you know, it seems to be this, one of the big things that stuck for this person, they're stuck believing that they need that to be able to move forward. And so we can use movement or postures to try to address other issues like that. Or as maybe another one that makes a little bit more, is more clear. Often we feel a sense of fragility when we have especially low back pain, pelvic pain. Neil Pearson: 26:19 So if we can get you to come into one of the standing warrior postures, when people, the majority of people in a warrior posture, I'm standing with your arms reaching up or out to the sides. There is a sense of strength and stability and connectedness when you do this. And the really nice thing is we could do those postures from a seated position and people still feel that same kind of thing. And so the idea is could we use movement to effect the person on a psycho-emotional level as well? Could we make that out? One of our goals is this person who doesn't feel strong, feels unstable, feels fragile. Could we use movements not just create physical strength, but to address the other changes that are happening to the person? I think so. Karen Litzy: Yeah. I think so too. And I love that yoga has got that part and I hope that other movement practitioners start to think, well, you don't need yoga to do that. Neil Pearson: 27:16 Right? You can use any, you know, think of any movement that we do and how it makes us feel. Could we address it that way. And then the one other thing that movement has tried to address in one of the chapters in the book is the idea of using movements or yoga therapy as an educational agent. So I know your listeners all know about explain pain and that wonderful work there. And what we're doing with explained pain really is it starts with a cognitive behavioral therapy, right? We're changing auditions to change their behavior. And so for a lot of the people that we work with, they may not have learned how to learn by sitting and listening or reading a book. They may have learned how to learn by doing. And so one of the things we're playing around with is the idea of when a person has ongoing pain, could we get the person to move in a way that could sort of, when the person moves that way they feel an increased sense of ease or they get some increased movements. And then you use that change from the movement as the educational agent. Karen Litzy: 28:21 Saying like, look at what your body can do. Yeah, same thing. Neil Pearson: 28:26 Yeah. Well you can start with, wow, that's awesome. Your pain changed, right? Because that's one of the core messages of explained pain is that right? Changeable. So instead of telling the person that pain is changeable and explaining it to them, if you can get the person to do something and at the end of it, they have less pain or more ease of movement to say, look, it changed. And of course the next step is, and you did it. And so I would then jump into, let's look for all the other things that you could do to actually change this, which is saying to the person your pain is changeable. And you have some influence in it, which is part of what we're trying to do with pain. Karen Litzy: 29:09 Yup. Yeah. It's like giving them the keys to the car. Neil Pearson: 29:13 Exactly. Karen Litzy: 29:13 Right. And having them be in the driver's seat versus feeling like they're the passenger and the pain is in the driver's seat. Neil Pearson: 29:24 Oh yeah. That's a really great way of saying it. And I think clinically what we want to do is both with people we, you know, we want to find a way to integrate these things, but I really, really believe that there's a lot of the people we work with would understand pain better if we got them to experience it. Experience what we're trying to tell them. Karen Litzy: 29:47 Yeah. And we know experiential learning for a lot of people is something that sticks. Neil Pearson: 29:54 Exactly. Yeah. And I think that's the thing is that there were a whole bunch of people that when we explained pain, it changes their cognition, but it immediately they get it, they understand it. It's powerful enough to change their behavior. But then there's other people then some of the research shows this now is that some people have this sort of partial reconceptualization of pain. They understand everything you told them, but they don't apply it to themselves. And so what you're going to need to do at that point is get the person to have the physical experience that matches up with the cognitive experience. And I guess what I'm saying is that what we could do is use the movement practices of yoga or any kind of moving practice for some individuals as the educational agent first and then, I think we need to start to play with that because some people just don't learn well when we talked to them, at least not as well as they do with the physical experience of it. Karen Litzy: 30:58 Yeah. And I think as the therapist that you can kind of get a sense of this after one or two visits that okay. It seems like they understood, but yet they're not able to apply this to themselves or are they kind of come back to you with the same, I don't want to say the same complaints cause that's not right. But with the same maybe problem solving outlook that they did before when you know, you've kind of spoken about pain and maybe how pain works, let's say from explaining pain and they're still coming back to you with this same idea. The same. I did this so I must have done something wrong. And that's why it hurts because I keep doing this to myself. Neil Pearson: 31:55 Exactly right. There was something in what you said too that made me think that it's possible that that person coming back, doesn't have the coping strategies that match up with the new information that they learned. So the person's, you know, coped by being saved, being tough and just sucking up and gritting your teeth and pushing through it or coped by fear avoidance. And so we've given them this new information, but the person that hasn't, when the pain worsens, they go back to the coping strategies that don't match up with the new paradigm. Karen Litzy: 32:29 Right. Yeah. And that was really hard for me to do as well. So what would happen, and I'll give an example of what that means. I think you correct me if I'm wrong, but I used to get a lot of neck pain in my sleep so I'd wake up and kind of feel a pop and then wouldn't be able to move. And what my original coping strategy was hi, I have to call off work today because I need to stay in bed. So I would stay in bed. I used ice, I would use heat but I wouldn't move and that did not do well for me cause like it would help in the short term maybe that day. And then I'd be able to get back into things the next day. But I was still in an awful lot of pain. I mean, maybe I was a nine out of 10 and then I was at seven out of 10 but the seven out of 10 I could function. You know what I mean? Neil Pearson: 33:24 Yeah, absolutely. Karen Litzy: 33:25 Until I started going through explain pain and moving more. So now if I wake up and I feel that pain, my first thought is not, Oh, I better lay in bed. It's okay, let me get up, let me start stretching, let me start moving, let me go to the gym and at least get on a bike. And now, because that's sort of my new shift in thinking that maybe the pain will last only one or two days and not forever. Because before it was this high level of pain with a higher spike. And now it's just little to no pain with a spike or a flare up, if you will, a couple times a year. But knowing the moment I feel that, that I get my butt to the gym and I realized that movement is the thing that helps and that I shouldn't be fearful of that. So for me, that was the input into my system that helped and everyone is different of course, but I think that's a real life example of what you just said. Neil Pearson: 34:27 Yeah. And I think it's great one because what you've said is that what you've found is that you can change the pain and the ease of movement through movements, but also I think what you're saying as well is there's somehow there's a different relationship with your different perspective on it. You're understanding it in a different way. Karen Litzy: 34:48 Yeah. It's less as this sort of monstrous threat that's going to take over my life for the next couple of weeks, days, months versus now. It's like a little annoyance that I know I have the coping skills and the mechanisms at my disposal that I can make a change for myself versus going to a doctor for a quick fix of a pain medication or something, which is what I used to do. Neil Pearson: 35:22 Yeah. Well and what I'd say is, well as within yoga and yoga therapy is that a yoga therapy will offer you more on expanding a number of coping strategies or alternatives. We often think of as making people more flexible in their body, but it actually makes us more flexible in how we adapt or modify things when pain persists. So, you know, you wake up in the middle of the night, maybe one of the things is that I'm laying there and actually taking your attention to the pain and exploring the pain. Actually spending some time doing that or the practice of noticing what's happening to your breath. So now or changing your breath or noticing what's happening in your body tension or changing your body tension too. Within yoga there's many, many different ways that you can try to impact things. We often say we want to do practices that have to do with awareness because awareness practices in and of themselves can be a beneficial when we have ongoing pain. Neil Pearson: 36:28 And then there are other practices that are about regulation. So, you know, getting you to breathe in a certain way or hold your body in a certain way or move your body in a certain way or think a certain way. So with the awareness you can have awareness of your breath or your body or your thoughts or your emotions or your energy or the pain. And the same thing with regulation. You can regulate any of those and start to see what happens when you do either of these things. But then the one other bit you said too was about discernment is what you've learned. You've, you know, you've changed your view of you. You're now when you feel the pain, you can discern more about when the pain is like this, I need to do this. And when the pain's like this, I need to do this. And, I think that's another positive that people can get or the practices of yoga therapy is that you start to actually understand your pain better, right? Be able to discern different aspects of it or different strategies that you need to do at different times where often when we have chronic pain, it's almost like we lose coping, right? Karen Litzy: 37:37 Oh, there's no question. You lose everything. You lose all perspective on yourself as a human being, you know? I mean, even as someone like me who is, I was a physical therapist when I first had all of this pain and you just completely, everything I learned as a PT flew out my brain. It was gone because all you want is for the pain not to be there. And the reason you want the pain not to be there is because you want to have a life with more choices and more possibilities. Whereas when people are in pain, their choices are you get up, you go to work and you come home. If you can even make it to work, those are your choices. That's all you have. You know, have kids, maybe it's struggled to take care of your kids or suffer through taking care of X, Y, Z. Right? Versus when you don't have pain, your options are, I can get up, I can go to the gym, but I can go to work or I can go to the gym, meet up with friends, go on vacation, you know, clean my apartment, go play sports. So all of a sudden you have a life of very little choice and possibilities to an opening of your choices and possibilities. And it's just because you don't have that pain anymore. Neil Pearson: 38:53 Right. And I think that's one of the beauties of the practices that allow us to start to explore are there things that we actually can do for ourselves to try to change this? Or are there things that people can help guide us to be able to do that? Because I think when we're in that huge pain, what we're looking for is, you know, the thing that will just stop it, of course. And you know, we're living in society where the approach mostly is to look externally. And then one of the troubles that people have sometimes when they start to hear about yoga therapy and sort of the self care part is just this idea that it's almost like it's all up to me, right? You're telling me it's all up to me and what we want to say is no, that that doesn't really work well or we want to do is say, what you need is the expertise of a PT or a yoga therapist or an OT who can help to guide you and be there and you know, cheerlead you and coach you and help you through this. Neil Pearson: 39:53 Because this is really, really hard stuff. You know, learning the techniques of yoga, if people really immerse themselves in it, they'll typically say, this is hard to do. Well, it's way harder to do when you're in pain. Right? Karen Litzy: 40:09 Right. And you don't want to think like, Oh, I have one more thing I need to do now. I need to do this. I've got all this pain, now I need to do this. Neil Pearson: 40:17 Yeah, yeah, true. Karen Litzy: 40:19 But yeah, when you position yourself as the guide, you know, I've been reading this book by Donald Miller called the StoryBrand. And in it he talks about the guide who would be, in this case, the yoga therapists and physical therapists and thinking of them as like the Yoda and the student or the hero, he calls them the hero of the story, which would be our patients would be the heroes of our stories are like the Luke Skywalker's. So they're coming to you for guidance, you're helping them, you're giving them the tools, the confidence, in this case, the movement, the education that they need to go out and be the hero of their lives. Karen Litzy: 41:00 So it's not like, Oh, one more thing I have to do. If we can reframe that for those people in pain, it's more like let us guide you so that you have so much to do. Neil Pearson: 41:13 Absolutely. And you know, there's one other piece that I just want to tack on the end because I'm sure you have some people here listening who have ongoing pain is that one of the really difficult things, and I know some, there's been some blogs talking about this recently that has importance is when we work with an individual who has ongoing pain, actually don't know what the outcome is going to be. I think we can be pretty certain that we can help people to be able to move with more ease and to have some less pain and to, you know, get quality of life. But somehow we need to say to people that, you know, when you do these things, you might be the person who says, you know, the pain is mostly gone and I really can do most of what I could do before. Neil Pearson: 41:56 Or he might be the person who says, well, you know, the pain is better, but it's still there. But what you've been able to do is show me how to get back to allowing my life. You know, the pain is less, but I'd be able to get back. And then there's this other group that will say, you know, it doesn't seem like the pain really is changed at all, but you know, if we've been successful with them, the person will say that, you know, even though the pain is there, you've helped me figure out how to live and have pain. Right. And I think that's one of the struggles that people have when they hear us talking about pain management, is the struggle between you're looking for wanting so much the thing that will stop all the pain. But then not really recognize where maybe recognizing the ideas that for some people that's not the outcome. Karen Litzy: 42:50 Right. Yeah. And I try and, you know, and that comes, I think as the therapist, I think that comes, that's something that I think experience helps a lot. The experience of the therapist helps a lot because you kind of have a little more confidence to say to the patient, Hey listen, the goal here is to get you doing the things you want to be doing. You may still have pain doing them, but you can do everything you need to do. Would you be okay if you had a small amount of pain and were still able to do everything you want to do? Cause our goal here is not complete elimination of pain or, I mean, yeah, I guess that is the ultimate goal, but being realistic, we have to tell the patient, Hey listen, this may not happen. What if I told you you could do everything you wanted to do and the pain might be there if doesn't really, you're not suffering. It doesn't bother you that much. Would you be okay with that? And that's a hard conversation to have. Neil Pearson: 43:51 Yeah. Well, you know, in the yoga world is it's somewhat easier because anyone who's a yoga therapist has, I mean that's what we've learned. That's really what yoga says is that we will have pain, we will have suffering in life. And the whole practice of yoga and yoga therapy is to actually learn how to live with it and decrease it. But it's not, you know, it doesn't have the goal of saying there's going to be none. Karen Litzy: 44:21 Yeah. And I think that that's important. It's important to tell patients. And that's the one thing, this is a total rant on my part, so apologize ahead of time. But you know, when you see websites and they're like eliminate your back pain by reading this free resource, well, that drives me bananas and it drives me crazy as a person who did have chronic pain for many years, you're searching for that thing and if someone puts it out there and then you read it and you're like, my pain is the same, I would be like, screw you. It didn't help my pain. It's like a crappy thing to do to someone because I feel like you're praying on very vulnerable people by doing that. And I think that's why. Neil Pearson: 45:08 Yeah, I agree all the way. I mean, it's just not truth. It's a marketing stick. Karen Litzy: 45:14 Right. Neil Pearson: 45:15 I'm like you, it enrages me. It's hard not to be the police though, right? You want to jump on and say, what are you saying then? And we know that, you know, within our professions, really within all the healing professionals or helping professions, there are people who unfortunately use language like that. Hopefully at some point we will be more compassionate. Karen Litzy: 45:40 Yes. Yes. I hope so because, Oh man, that is something that just drives me crazy. But I digress. Let's get back to the book. What do you hope people take away from the book after reading it? Neil Pearson: 46:05 Well, I guess the biggest thing that I want people to take away with is this idea that yoga therapy is something we should consider as a one of the paths when people have ongoing pain. Overall, that's what I want people to do. You know, we don't think that yoga therapy is the answer. But we see it as something that can be integrated within our Western medical world with people with chronic pain and so integrated into that system. But also it allows more access because people usually can get to yoga therapy for less of a cost than they could to medical practitioners. So it's more just to see it as you know, as we've talked about, there's this view of what yoga is. Well, yoga is something different from that. And it actually does make sense as one path to consider when we're working towards recovery when pain persists. Karen Litzy: 47:01 Absolutely. And now before we end, I have one more question for you. And that's knowing where you are now in your life and in your career. What advice would you give to your younger self? Neil Pearson: 47:16 Oh, wow. You know, after I graduated as a physical therapist, I spent the first four and a half years working in hospitals and worked, trauma, ICU. And I worked in a neonatal ICU and cardiac care and all these things. And, the thing that if I were to go back to that spot, I would say, Hey, you're doing the right thing. It's funny because a lot of my colleagues were working, you know, we're stepping right into private practices. And by being in that situation, what I not only did I started working as a physical therapist with this umbrella of protection because there were all these other people who are also working with the same patients in the hospital. But I learned such a humanistic view of what I was doing. Neil Pearson: 48:10 I guess that's because a lot of the stuff we were doing in the hospital had to do with life and death. Now when you're working in a trauma ICU with neonates and so I think you know, cause I know there was a lot of pressure I wanted to work in, you know, sports medicine and in private practice. There was pressure not to be in the hospital. So I guess I'd go back and say you're doing the right thing cause it really helped me to see the person more than the low back or the shoulder or the knee. Karen Litzy: 48:50 Yeah. You know, I worked in a hospital first as well when I first graduated from PT school. Neil Pearson: 49:00 There are some advantages to that. Karen Litzy: 49:04 Yeah. Oh yeah, absolutely. I think it like really increases your empathy and your communication skills. Cause you're like you said you're dealing with pretty sick people. And I wouldn't have traded that for the world. All right, so now where can people find the book? Neil Pearson: 49:28 Well the books on Amazon. Awesome. So that's probably the easiest place to find it. Karen Litzy: 49:34 Yes. So we'll put the link in the show notes. So if people want to go to podcast.healthywealthysmart.com, they can just click on this episode and go straight to the book. Neil Pearson: 49:47 Great. And if people want to learn anything more about the other things that I work on. My website is paincareu.com I'll share that as well with you on there. You can learn about the pain care yoga training that I do and I have a distance professional mentorship that I do for health care professionals as well. Karen Litzy: 50:11 Nice. That's awesome. And because you're up in Canada, right? Neil Pearson: 50:16 Yeah, that's right. If you're in Vancouver and you drove East of it four and a half hours over a couple of mountain ranges, I'm in the Okanogan Valley of British Columbia. Karen Litzy: 50:26 Got it. Kind of. It is so big. Well Neil, thank you so much for coming on. This was a great conversation. I think it's going to give people a lot to think about when they're working with those patients in pain. So thank you so much. And everyone, thanks so much for listening. Have a great couple of days and stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! 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On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Keats Snideman on the show to discuss the non-traditional path to physical therapy school. Keats Snideman is a results-driven Rehab and fitness professional with over 20 years in the Fitness/Athletic Performance and bodywork industry and most recently the field of physical therapy. In this episode, we discuss: -How Keats' background in health and wellness enhanced his learning in PT school -The personal and professional pros and cons of being a non-traditional PT student -The benefits of diversity within a PT cohort -Time and resource management to avoid burnout -And so much more! Resources: Keats Snideman Twitter Keats Snideman Instagram Keats Snideman Facebook Reality Based Fitness Website Email: ksnideman@gmail.com For more information on Keats: Hello, my name is Keats Snideman and I am a results-driven Rehab and fitness professional with over 20 years in the Fitness/Athletic Performance and bodywork industry and most recently the field of physical therapy. My educational background includes a doctorate in physical therapy from Northern Arizona University (PHX Biomedical campus) and a B.Sc in Kinesiology from Arizona State University. Other certifications and titles held include: Certified Strength & Conditioning Coach (CSCS), Certified Orthopedic Manual Therapist (COMT, through OPTIM Manual Therapy), a Strong First Gyra (SFG) Level 1 Kettlebell instructor, a certified Kettlebell Functional Movement Screen Specialist (CK-FMS), a certified neuromuscular therapist (CNMT), and a licensed massage therapist (LMT) in the state of Arizona. Read the full transcript below: Karen Litzy: 00:01 Hi Keats, welcome to the podcast. I'm happy to have you on. So today we're going to be talking about the non traditional path to physical therapy school. And the way we're kind of defining this nontraditional path would be you didn't graduate from high school, go to undergrad and right into physical therapy school. So there was some time off in which you had a completely different career. Well, yeah, a different career and then decided to go into physical therapy school a little later in life. And I use that in quotes when I say that. So what I would love for you to do Keats is can you kind of tell your story to the audience so they get to know you a little bit more? Keats Snideman: 00:45 Yeah, absolutely. So like a lot of PTs, I have a fitness background, I ran some college track, got into working out and decided to become a personal trainer. This was like mid nineties, so quite, quite a long time ago. And that sort of led me down a little bit into the sort of functional fitness was kind of becoming a thing kind of in the 90s. And people who are beginning to use that word function a lot. I have a twin brother also in the fitness world and we got exposed to a gentleman named Paul Chek. He's the guy who kind of popularized the Swiss ball, the physio ball doing the weight training on it, standing on it, doing all that crazy stuff. This was in like 97 to 99. And Paul Chek was also very rehab oriented, not a physical therapist himself, but started opening my eyes to sort of the world of sort of biomechanics and you know, it's sort of high level physiology, and started reading, you know, more technical sort of physical therapy type books and it really interested me and I was like, wow, there's more there than just being a personal trainer. Keats Snideman: 02:00 So I sort of made a decision at that point that I wanted to go on and get, I think it was a masters degree. Most of the programs at that time. But then life happens. Got married, had our first child. I had my own business and eventually I went back to school to finish my bachelor's degree at Arizona state university. And really had the idea of going kind of into PT school pretty quickly after that. Had another child, open up a different location for my business. And time just goes by, you know, very, very quickly. And the next thing I knew it was 2012, 13. I was like, if I don't go to school now, I'm never gonna do it. But all the time through that I ended up getting a massage certification or I got in the early two thousands. Keats Snideman: 02:47 So I started putting my hands on clients who needed it. I started getting some soft tissue clients and basically really trying to find out, you know, what's the best way to use that tool? Cause I wasn't really like a massage person per se. I kind of came into the sort of the manual therapy body work world as more of a fitness person. How could I get somebody out of pain is pretty much the number one thing why people were seeing me so that I could get them more active to get them more mobile, that really fits in to what a lot of physical therapy does. Sort of our modern understanding of pain as it's changing that the therapy is just sort of a, you know, like a brief reset to try to then help, you know, we get that window of opportunity to try to make a change. Keats Snideman: 03:43 And so that, you know, that finally allowed me to make the decision to go to school because I want to be able to do more than just what a massage therapist can do. And more, you know, I wanted to be able to do, if I want to do a joint mobilization or manipulation like a chiropractor could do, you can't do that as a massage therapist. And so that was the final decision. I closed up my shop, I went back to school, I bit the bullet. It was a very challenging road, but even with the family and everything and I got through it, finished a few years ago and here I am. Karen Litzy: 04:18 And I mean that's quite a story and we'll get into some of your words of wisdom and advice for other people who might be in the situation where they have a family, they have children, they don't know if they can do this because it is very time consuming. But before we get to that, I would love to know if you could name a couple of your top struggles during PT school that you were obviously able to overcome. Cause you did graduate, you're now a physical therapist. So give us some of your struggles and what you did to help get over them. Keats Snideman: 04:53 Absolutely. So I would say the first thing that was really, really the hardest for me and my program was at Northern Arizona university. And we were the first class to be sort of accelerated instead of a three year program. It was a two and a half year program. So we didn't get really a lot of breaks. So the coursework I think was condensed a little bit more. And so that meant a little bit higher level of information that we were obtaining. So that first semester was a bit like hazing for me. I've constantly been learning and taking continuing education courses my whole career as a massage therapist, personal trainer, strength coach. But I wasn't quite prepared for the onslaught, sort of the drinking from a fire hose type of thing, if you will, that that first semester did. Keats Snideman: 05:42 And I end up getting a C I think in pathophysiology, which was, it was like in memorizing a thousand PowerPoint slides and two every two weeks. It was brutal. And that put me in academic probation. You can't get a C in PT school. I mean, are you going to get many of them C B's and above? And so that was, you know, I was worried, I thought, man, am I gonna flunk out? You know, I just started after all this, you know, what am I going to tell my family? This is terrible, but I got through it. The rest of my grades were actually quite good after that. But if you haven't been sort of in the academic setting for a while, you've really got to kind of give yourself a little bit of an adjustment time and not be so hard on yourself to the expectations for like getting these great grades needs to be tempered because it's intense. Keats Snideman: 06:35 Obviously you went through it. The amount of information that a physical therapy student will be exposed to is pretty insane. I know medical doctors get a tremendously crazy amount of sort of, you're sort of a general as first, but I think PTs have gotta be some of the broadest sort of scope practitioners out there and me, it was sort of like med school light, you know, a lot of our classes are actually with PAs because we were actually kind of getting sort of the university of Arizona medical curriculum that was given to the PAs at NAU and we were sort of teamed up there with them and some of the occupational therapists as well. So that was my biggest struggle was just the amount of information was just overwhelming. But once I kinda settled in and really focused more on comprehension and learning instead of just getting good grades, I've never been a grade person. I couldn't really care less, unfortunately you need to get good enough grades to pass and then not get kicked out of the program. But I've always been about, I want to understand. So I think if someone who hasn't been in school in awhile, kind of a non traditional student like myself, you've gotta be easy on yourself and you've got to give yourself time to adapt and to adjust to that, just that amazing, wildly overwhelming amount of information that you can get, especially in that first semester, that first year. Karen Litzy: 08:07 And how did you balance the amount of information, the studying the comprehension. And I liked the fact that you said you're there to learn and comprehend, not just memorize, but that was in PowerPoint slides which I think is great advice for anyone. But how did you balance this with a wife and two kids? Keats Snideman: 08:27 It wasn't easy. I wouldn't really say that you can, it's not balanced and you know, the family has to be on board. Obviously my kids are a little bit older. My wife obviously she knew how much this meant to me, so she was very supportive. I wasn't able to be as involved with my kids and their sports and stuff. So there's definitely sacrifices. You can't pass PT school. Even if you're just a single younger person who doesn't have any problems, your life will not be balanced if you are in any doctoral program, especially one like physical therapy. So I wouldn't say I really balanced it, but when I had the time and I needed, because you can't just study, study, study, study, you will literally burn yourself out and there comes to a point, kind of like a sponge that's just saturated with water. Keats Snideman: 09:15 It won't take any more. It just doesn't work. So you have to give yourself little breaks more frequently. And for me, you know, I grew up sort of this ADD never got diagnosed until I was an adult. That's even more important cause I think my executive functioning skills burn out very, very quickly. So I do very well with like the Pomodoro technique where I do like 25 minutes and then take a five minute break or maybe that's 15 minutes, right? Things like that where you do like little mini sprints rather than a marathon of learning. So you give yourself time to get into what's called like a diffuse mode of sort of learning where you have the focus mode, where you're really putting a lot of effort, but then you gotta just walk away, go for a walk, juggle play ping pong. We played a lot of ping pong. If you have a ping pong table and you're like, that really got me through school. I love ping pong. I love it. I have a thing on the table in my house. And just doing something completely different. I'm very much into exercise activities, sprinting, little mini workouts, little mini resets. I feel that helped get me through it. You can't just sit there for hours upon hours and hours. You will just literally just be wasted time. Karen Litzy: 10:35 Yeah, that is wonderful advice and I think that carries over nicely even when you start working as a therapist as well. Great advice. Now let's talk about some of the positives of going back to school as a nontraditional student. Keats Snideman: 10:58 Yeah. Well for me, there's a lot of positives because I had already been working with people for so long as a personal trainer, a strength coach and a massage therapist and sort of a hybrid of all those kind of at the same time that I've been dealing with people for so long. And a lot of these young millennials that are just, you know, like you talked about more traditional which is definitely a good way to do it. Don't get me wrong, I kind of wish I had done that, but they don't have sort of the life experience and the ability to deal, I think with a lot of the psychological and more of the interpersonal issues that will come up when you're dealing with people in pain and dealing. Like once you lived a little bit longer, I feel like you just get it a little bit more. A lot of people in PT, at least sort of in traditional outpatient or even acute, they're a little bit older and I feel like you can relate to them a little bit better. Keats Snideman: 11:51 And it helps me to think about something like soft skills that the professors would talk about and I'd be like, wow, I guess I'm kind of lucky in that respect because I'm older. I kind of already have had to develop those over the years. Those interpersonal communication skills and they would tell, you know, my classmates, these younger sort of millennials that it doesn't really matter what you get. Like, yeah, you got to pass the boards, you gotta pass this, you gotta be smart. But you know, being first in your class, like it doesn't mean you're necessarily gonna be the best therapist. And nobody's going to ask you, Hey, Karen, you know, can you tell me what you got on your NPT boards, et cetera? Oh no, that's too low. I want to work with this person over here. Keats Snideman: 12:36 Or Hey, what'd you get in your patho though? First? Because it doesn't matter, right? You've got to get through it. You can always, you don't need to memorize everything, just you need to know it enough to pass the test. But the most important thing in physical therapy is your ability to empathize, to be empathetic and to deal with another human being that you're dealing with. And I felt like as an older student that was something I kind of already had. So that was like a big plus I think. And when I'm working with my a little bit older clients and patients, I think that helps. So that's a big plus that you can't really get except through time and going through all those different sort of client and patient interactions over the years that will sort of, you know, cause you have these fits sometimes with clients, they don't work well. You don't always buttheads so you develop a certain amount of grit that I think as a bit of an older student you don't have to develop as much as the newer, younger ones. Karen Litzy: 13:45 I think that's a huge positive. I mean experience counts. Experience counts. What other positives did you find even maybe as you were going through the program or looking back on it now? Keats Snideman: 14:03 Well for me with my background and there were other students in there that were like in their thirties. There was one other guy in his forties, you know, it was like the real grandpa. He, you know, he was a little younger than me. But my background was in fitness and in massage. So I had already kind of educated myself a lot on anatomy and physiology. Since we had this sort of medical curriculum. We spent like six weeks or something on the organs and the guts and I didn't really know that too well, so that was pretty hard. But the rest of this stuff sort of with my background wasn't too hard in terms of it's like I felt like I had already prepared myself for that. Contrary to popular belief, you go to PT school more to learn about differential diagnosis and how to not really hurt somebody, you know, it's more like med school light than it is about, like, I'm going to become sort of a mild personal trainer. Like you don't spend a ton of time on the ins and outs of exercises. Keats Snideman: 14:57 They sort of say, well you're going to get that in your rotations. So a lot of people who are more non traditional that had come maybe from like insurance or a different world, they didn't have a much of an exercise background as me. They were really looking for that in school and we didn't get that as much. It's not really what it's about. You get that more on your rotation. So I felt like my previous background had made up for that gap that we weren't going to get in school. I had already sort of gone through the sort of the painstaking self studied it just really sort of figure out like you know, which exercises are appropriate for all the different muscle groups and movements and doing sort of like a needs analysis for the sport or the activity. Keats Snideman: 15:52 Cause that's not really what you're getting in PT school. And I think people don't always understand that they think they're going to learn like everything about exercise. And that's kind of not what it's about. It's more like I keep saying sort of like this being sort of a primary care provider light. You know, and now most States have direct access. So, you know, like taking blood pressures, understanding cardiovascular concerns, understanding pharmacology and like the basics of like protecting, these are real things that are very important that that's what I got out of PT school the most was sort of that thing being sort of, I'm trying marry care provider and the exercise stuff is sort of secondary. Karen Litzy: 16:40 Yeah. So because you had had this other career before you came into PT school, you were able to kind of be on top of your game I guess. And like you said, you were able to fill in some of those gaps in PT school with what'd you already knew. So that is obviously a huge positive. Any other positives that maybe if someone out there is thinking, Hmm, maybe I want to go into PT school, but I'm like over 40 or I'm over 30 or 35, you know, or I'm married, I have kids. Were there any other positives that maybe not even related to physical therapy but maybe spilled over into your home life or your personal life? Keats Snideman: 17:19 Well I think it was good for my teenage boys to see that even as an older adult that, you know, the amount of effort they saw, how much I was putting into it, how much it meant to me to just to show them that if you put in the work at any age, like you can still do some pretty cool things. And, you know, you can teach an old dog new tricks. I mean, I think the younger brain learns a little quicker. I don't think there's a lot of debate about that. You can still do it. So for me, I think the positive was it gave me a sense of belief that if I'm really determined that I can find a way. So gave me like a new level of confidence in myself that I have the grit that I have, that I had to take the GRE three times. Keats Snideman: 18:09 And for those who don't know, that's the graduate record examination that's put on by the people who create the SAT. So it's sort of a SAT for college grads and I hadn't done like high school math, since like 80s and early nineties. So, you know, I did well on those other parts, but I just couldn't remember like basic stuff. I had to get the book. So it gave me sort of a new level of confidence that, you know what, even when things are really tough and you feel like you can't get through, like you can and you know, and you just got to kind of plow through it, like the time will go by anyway. And you just gotta figure it out. How can you work with yourself? To try to, you know, accomplish the goal as challenging as PT school at any age. Keats Snideman: 18:54 It's challenging but definitely harder if you have a family you've been out of sort of that test taking mode. I used a lot of like some of these other like apps where it sort of makes you keep doing the ones that you're not good at. Cause you do have to memorize some stuff for the test. Let's face it. But if you take the time and you're just, you don't be so hard on yourself, you can get through it, you will get through it. Karen Litzy: 19:25 Absolutely. And now again, the question I ask everyone on the show is, and I feel like you kind of just answered it, but I'm going to ask the question anyway because maybe you have a different answer, but what advice would you give to yourself, your pre PT self knowing where you are now in your life and in your business and in your work? What advice would you give to your pre physical therapy school self? Keats Snideman: 19:54 Well I think I was very hard on myself for like initially doing poorly in that first semester especially in that pathophysiology class. But I really thought that I could get through it easier. You know, I just thought like, Oh, this, you know, this is going to be good. I've already sort of learned a lot on my own. I sort of underestimated. So I scheduled my sort of personal training and my sort of my whole clientele in a way that was not realistic. So, you know, working I think is good if you can do it, but giving yourself sort of the permission to say no to certain things that this is an important commitment. And that, you know, not to beat myself up that I'm not earning as much as I could potentially earn by working more because this is an important goal and I need to focus, you need to get it done. Keats Snideman: 20:56 There'll be plenty of time to work after, but I did work throughout my whole schooling. I was trying to bring in a couple thousand dollars a month, you know, for my own clientele. And I did, but that was about probably about a third of what I had originally sort of thought I could do. So I did have to take out a little more loans than I wanted to, but once I sort of realized that it's okay, that sort of like lowered that stress levels for myself, that just is a huge commitment that I've put on myself that I can do, I could commit to all these different elements. And there's only so much time in a day. Like, you know, there's only so much energy you have, you know, sort of like money in a bank. You don't have the, we call it like units of energy. Keats Snideman: 21:40 I don't have a hundred units of energy for school and a hundred units of energy for my family and a hundred and some energy for my clients. I have a hundred units total and that's what I sort of figured out. So I would give myself the advice then manage your units, you know, manage your physical and emotional capital because there's only so much and you just have to be realistic. And I just, I was not realistic with myself with what I thought I could do versus the reality. And once I sort of kind of had that sort of come to Jesus moment, I was better cause I was okay with it. Karen Litzy: 22:13 Well I think that's great advice. So giving yourself permission to prioritize things in your life and doing it all to 100 percent. Excellent advice. Now is there anything else that you wanted to let the listeners know before we sign off about being that nontraditional student in physical therapy school? Keats Snideman: 22:34 I think we need more non traditional students. I mean I think it only helps the programs. I think if any of my classmates that are listening to this, hopefully they are, they can agree. I think a lot of people appreciated me in the class because I would ask the questions. I find if I didn't, interesting kind of being with sort of this younger generation, it's like they're just programmed and it's kind of like robots that just like get the information, figure out how to you know, memorize it, regurgitate it on a test, move on. And it's more about like passing and getting to the next level than it is about mastery and comprehension and not a lot like questions are asked about things that I thought maybe that the teachers explained that were confusing. So I would ask the questions, I'd be like, well what about this and what about that? Keats Snideman: 23:32 And because I'd been in the real world for longer. So I think having that older student and maybe some people thought it was a little bit annoying and that's okay. I'm okay. To me, I'm that guy, because I think it was helpful for the betterment of the class. And when you have somebody who's lived a little bit longer, like you just don't care as much. You just, if something's important to ask, it's important. Like you don't have to go, Oh, I'm not going to ask cause I don't want to like offend anybody or you know what I'm saying? So like having those little more seasoned, non traditional students, I think it spices things up a little bit. And I felt that I kind of provided that for my class and it really sort of, it kinda helps sort of broaden the curriculum by bringing in more real life experience of working with people. Keats Snideman: 24:25 Not that I was a physical therapist, but I was working with people in pain, working with people who had weakness and you know, fitness issues, which is what we do a lot in PT regardless of your setting. So that's my advice is that if you're really, really passionate about helping people in that domain, that we need more nontraditional, a little bit older students in these programs because it really helps to just sort of broaden the scope because of what we can bring with our experience as everybody else in the class. Everyone has their own experiences. Even, I mean young, middle age, older, it's all good. Like to have a variety instead of just everybody being the same. Like I'm all about diversity and I think we should just embrace more diversity. And like I saw something on the news, I think it was the other week on CBS or something and it was some guy like he was like a car mechanic and he went back to school like in his late fifties and he got his medical degree that just like, I love it. That's stuff just like juices me up and he's bringing all his experience to that program. That must have been really neat for the other students. Karen Litzy: 25:37 Yeah, I could not agree with you more. And now where can people find you if they want to chat about your experiences or if they have any questions for you? Keats Snideman: 25:47 Yeah, I'm a pretty Googleable guy. I've got a couple of websites that are sort of in shambles right now, but if you just Google my name, Keats Snideman, I'm on Facebook, I'm on Twitter and Instagram. I think it's a @coachKeats and then I think it's Keith Snideman is what I'm on for Instagram. I'm trying to figure out this whole social media thing. For my own business. I do a combination of PR and work and then just my own, I'm too much of an entrepreneur to work full time for anybody else. But if anybody wants to email me, it's ksnideman@gmail.com. I love helping people who are non traditional to sort of, you know, make the decision. I mean it's not for everybody, but if you're on the fence, I talked to people frequently who sort of find out about me and I would love to talk to you about it. Karen Litzy: 26:43 Awesome. Absolutely, all of that information will be in the show notes for this episode at podcast.healthywealthysmart.com so that people can one click and get to you in any way possible. Perfect. We'll have it all there. So Keith, thank you so much for taking the time out while you're here in New York, dropping your son off at NYU. Keats Snideman: 27:01 I know. Crazy. Yeah, it's been a blast. I'm so glad we got to meet up today. I've always wanted to, you know, talk to some other PTs when I come out here and I'm just, yeah, I'm very, very glad that I was able to get on your show. I've been a big time fan of your podcast when I was a student. I'd share it with my fellow classmates. Your doing an amazing job of just getting amazing people and concepts out into the world. Karen Litzy: 27:26 Well, thank you very much. And, I again, thank you for taking the time today and everyone else have a great couple of days and stay healthy, wealthy and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!

On this week's episode of the Healthy, Wealthy and Smart Podcast, Jenna Kantor guests hosts and interviews Cameron Massumi on new graduate engagement within the American Physical Therapy Association. Cameron Massumi, SPT is the president of APTA's Student Assembly Board of Directors. In this episode, we discuss: -Cameron's passion for new graduate engagement within APTA -Inclusion and diversity within APTA -How to engage in networking events -Ways you can get involved within your professional organization -And so much more! Resources: Cameron Massumi Twitter Outcomes Summit: Use the code LITZY for discount For more information on Cameron: My name is Cameron Massumi, and I am the President of the Student Assembly Board of Directors. I believe that APTA serves an integral role in ensuring the future of our profession through advocacy, public awareness campaigns, and the sharing of a unified vision. However, there is, unfortunately, a marked decline in membership as students graduate from PT school and become active clinicians. It is my goal to stop this from happening and hopefully bring new graduates back into the APTA. My strong background in sales and marketing as well as my leadership experiences prior to entering PT school will allow me to bring a unique skill set to the Board of Directors. I will use these skills as well as my connections to ensure membership and engagement increase so our profession can continue to grow and become stronger. My vision is that through my leadership the student assembly can help promote awareness of the profession, increase diversity, and boost member retention. As a profession we need to collaborate, innovate, and strive for excellence. APTA is the best tool to ensure the success of our profession so that we can #MoveForward, so let's get together and create some real change. After all, we're #BetterTogether! For more information on Jenna: Jenna Kantor (co-founder) is a bubbly and energetic girl who was born and raised in Petaluma, California. Growing up, she trained and performed ballet throughout the United States. After earning a BA in Dance and Drama at the University of California, Irvine, she worked professionally in musical theatre for 15+ years with tours, regional theatres, & overseas (www.jennakantor.com) until she found herself ready to move onto a new chapter in her life – a career in Physical Therapy. Jenna is currently in her 3rd year at Columbia University's Physical Therapy Program. She is also a co-founder of the podcast, "Physiotherapy Performance Perspectives," has an evidence-based monthly youtube series titled "Injury Prevention for Dancers," is a NY SSIG Co-Founder, NYPTA Student Conclave 2017 Development Team, works with the NYPTA Greater New York Legislative Task Force and is the NYPTA Public Policy Committee Student Liaison. Jenna aspires to be a physical therapist for amateur and professional performers to help ensure long, healthy careers. To learn more, please check out her website: www.jennafkantor.wixsite.com/jkpt Read the full transcript below: Jenna Kantor: 00:00 Hello, this is Jenna Kantor with healthy, wealthy and smart. I'm here with Cameron Massumi who is currently the APTA student assembly president, all those things, however you prefer to pronounce it. First of all, Cameron thank you so much for coming on. First of all, it is a joy to interview this gentleman before we go into our topic on new grads. Cameron is one of those rare bulls who has massive stamina where he ran twice to become part of the student assembly. And that alone just shows that if you've seen the movie Rudy where he never gives up on his dream, Cameron, you definitely exemplify that. So thank you for being a person with the stamina to run again. And very, very well represent students at large. Cameron Massumi: 00:49 Oh, thank you for that Jenna. I have to say that I wouldn't say it's a stamina aspect more than it's just perseverance. I think you really learn from your experiences. I did run twice the first time I was unsuccessful. But I'd say that I gained a lot of knowledge from that. You know, you learn a lot about who you are. You really take the time to do some introspection and see what are the areas that you're most passionate about and you find ways to stay motivated and stay involved. I was thankful to the previous board. The students tell me they really helped me find an area in which I could contribute. And so I was a member of the professional advocacy committee and did some work on playing national advocacy centers and then did what I could to stay involved and really kind of figuring out what I would like to work on the next time around when I applied. Jenna Kantor: 01:41 I love that. I love that. All right. Let's now jump into the new Grad stuff now. Why are we talking about new grads? Cause right now you're currently a student. I actually am a new Grad. I'm experiencing what we are going to be discussing. So why do you specifically have a passion for new grads and have some futuristic plans for that, which we will get into in a bit, but why specifically new grads? Cameron Massumi: 02:03 Sure. I think the best way to address this is looking at friends and connections that I've made. I think APTA does a phenomenal job of first of all engaging students and finding a platform for them to have their voices heard and for them to be able to network with other individuals. You know, firsthand that we can make some great lasting friendships. But what the APTA I think struggles that a little bit is retaining some of that engagement when it comes to new grads. We have no secret that we have a decline in our member basis as people transition from students to working professionals. There's a positive in that the trend is moving forward as we are retaining more and more. I think early career started years has incentivized the ability for the association to retain members. Cameron Massumi: 02:51 I think the fact that with our rebranding that we're currently going through as an association, we're finding what matters to its members and really utilizing that to make the association more applicable and more exciting for demonstrating value to members. For me as a person that's about to embark on my own career, transitioning from the role of student to professional it's how do I find a way to stay engaged and how do I find a way to contribute to not only association but my profession. One of the things that most of the feedback that I get from a lot of my friends having graduated is they feel that they're going from a space where they have an existing platform to, you know, share their views and their desires within the profession to one where they don't. So this is a passion project of mine and something that I'm really looking forward to contributing on. And I think APTA's done a commendable job in engaging student voice and looking for collaboration on this. Individually myself, I'm looking at utilizing my state chapter to help with this. But also really pulling students and seeing what we can get collaboratively and seeing where that goes. Jenna Kantor: 04:17 I love that. So regarding new grads, how do they have a voice right now? Cameron Massumi: 04:23 Ah, it's interesting question. I think that ultimately it comes down to you finding your voice. You can use social media. It's a very powerful tool. You can use open floors within APTA. We just had our house of delegates and there's plenty of opportunities for members to get involved there. You can become an active member in your delegation. You can seek leadership opportunities within your chapter, within sections, academies or even at national office. I think that there is a plethora of opportunities for people to utilize. But it ultimately, it comes down to you what level of motivation that the individual has. Jenna Kantor: 05:02 I want to dive a little bit deeper onto the negative specifically for us as new grads and anybody who's listening, not you, you're not a new graduate currently a student. But for being a new Grad, there is definitely a dropoff. There are these opportunities but a lot of it has to do with after five years of experience, doors really do open for getting to apply for some greater leadership positions. And even that when you go, well for me, I specifically experienced this in my state, there is still a level of trust, meaning distrust for me being a new face and energetic face, a creative face, not somebody who's been around to learn the ways of how that specific area wants it to run. So would you mind speaking on that? Where is there a voice for somebody who is still waiting to be trusted? Cameron Massumi: 05:53 Sure. Tough question. Thank you for that. I'd say a lot of that really just comes down to you as an a association, as a profession or as a whole what we are doing to uplift and support individuals. There was a good bit of discussion at house of delegates and at next about diversity, equity and inclusion and for our student assembly meeting at next conference we had a round table and we invited some key panelists as well as students to share their insight and experiences on the topics. And it's interesting because when it became apparent really quickly is how diversity was highlighted almost exclusively at equity and inclusion. I think that as we try to shine more light to that and looking at what equity really means and inclusion and equity, meaning truly leveling the playing field and supporting people and giving them all the tools they need to have equal opportunities. It's not just saying here go, we're really building up individuals and letting them get to a place where they can create change and they can make their mark. And inclusivity is just ensuring that we're doing that with everybody and we're bringing them to that point. Jenna Kantor: 07:29 I just want to express my appreciation for this. With the diversity, equity inclusion coming up in these conversations at this conference, at the house of delegates. It's great, although we do not have a game plan at this moment, which is very clear in this conversation. It's good that it's being brought up on the national level, not just at the state level. I definitely personally represent this being a person with a personality that is out of the norm. Now, if I went to musical theater people, I'm in the norm. My personality blends in and actually Cameron, you would stand out. So I do appreciate that it's beyond just the color of your skin. So I appreciate that the equity and inclusion is also being included in this whole picture with the actual definitions to provide the opportunity that people, so desire. Cameron Massumi: 08:23 So the quote about diversity is being asked to the party and inclusion is being asked to dance. And I think that's a pretty powerful statement if you really break it down and you know, I commend APTA for their effort in or renewed effort in ensuring that we move forward with this as a profession. But it's really interesting. You know I see a very diverse group of people that come to these conferences and in my program back at Virginia, I see a vast diversity within our student population. Inclusion is one of those ones that's a little bit harder to utilize. Because you can't really force somebody to do something. You have to elevate them and promote a way in which they can take that opportunity to really get their voice out there and heard. And, and I think that we're moving in the right direction and it's exciting times and I can't wait to see where it goes. Jenna Kantor: 09:24 Yeah, yeah, for sure. I think I really liked that you gave that definition. It was worth the wait. It was worth it. So for me, I was just at house of delegates to share a little bit and I'm new. It was my first time at house of delegates. So as a new Grad I went there and I was not voted in as a delegate, an elected delegate. But I was an alternate delegate and with that I was able to attend and sit in the gallery, which is in the very back in order to just listen and learn, which is very valuable during the breaks I am very extroverted. Jenna Kantor: 10:05 And where for you Cameron, I mean you are present so people want to talk to you. You have that. It's amazing for me. I want to meet people. So I did find regarding specifically inclusion, which is why I wanted to, I was like oh I thought of this. I'm like, oh this'll be a great one with Cameron cause this is where your passion lies. I found myself in the room, you know when you see two people bonding that, oh they know who I am so I'm going to stand on the side and wait until you know you're kind of like smiling awkwardly on the side, you know, so I can get in the conversation and maybe have some bonding time. I think maybe one time, the whole time was it actually successful with me standing on the side because people were so focused in on their individual conversations. Jenna Kantor: 10:46 So I did not get any networking at all in at house of delegates, which was a shame. And, as you are saying right now about that, inclusion is hard because you can't force anybody. I think what I experienced would be a perfect example of a very, very eager beaver wanting to meet people. Cause that's the thing. You need to meet people. You need to gain that trust and you develop those relationships. And I'm not important enough. That's what I'm assuming where they would go, oh wait, Jenna's here, let's include give eye contact, equal eye contact in the conversation where you can somehow become a part of it even as the new person. So I really like how you're bringing that up, the individual. What are ways that we as the APTA team members where we could start thinking outside of the box outside of our own world to maybe pay attention to when we are actively being exclusionary because of the own world that we live in. Cameron Massumi: 11:46 Well first I like to say I'm sorry that you were made to feel that way. The House of Delegates is definitely crazy, especially this year when we had over 70 motions to get through. So you have a shorter amount of time and always so much to really get some of those meaty discussions out of the way that can present quite a problem to be able to communicate and network, I guess. Jenna Kantor: 12:09 Oh, for sure. But these are half hour breaks. Cameron Massumi: 12:12 Well my suggestion, I mean this really goes down to what are you doing to engage in conversation. You know, I recommend that if it's something that you're passionate about to find alternative means of starting dialogue, you know, it's fine to use the tact where you're kind of standing by respectfully and waiting, but there are other times where it may be more appropriate to interrupt but to you know, find a way to segway into the conversation and say, you know, I was just standing by and I really heard you discussing this. You know, it's actually something that I'm really passionate about. Would you mind if I shared my input? Or you know, maybe ahead of time, reach out and say, Hey, I know I'm a member of your delegation or I am a constituent and this is a passion area of mine I'd love to be involved in discussing this. Cameron Massumi: 13:10 There's all sorts of different ways that you can approach individuals and it's going to vary based on your personality and the personality of who you're trying to reach out to. So that's where I'd say it took to really start and just find ways to do it. I mean, I'm a very extroverted person. I have no problem really walking up and saying, hey, you know, I would love to engage in some dialogue, but there's other people that are more timid and you just have to find different ways of doing it. I don't think that it is plausible to really expect people to just notice you at all times and be like, Hey, like I see you over there, come on in. And I don't think that that is an issue with inclusivity, more so than the fact that there's just a lot of things going on. So, it's important for people to take more active roles to get involved with things that they're passionate about. Jenna Kantor: 14:09 This is really helpful. I mean and you make a very good point here Cameron, on just like seeing the real big picture of like the barriers, even though we may be all be in the same room of just the chaos that goes on in the rooms. And this isn't just like one thing. I mean we have these annual wonderful events, CSM, NEXT, we have the national student conclave. We had these other events which are also other opportunities and then of course the local opportunities as well. So for you, what are your future plans that you want to explore with the new grads? Because I remember us talking at Graham sessions, I believe. No, Federal Advocacy Forum. We're like plugging all these places everywhere, by the way, attend all these things at the federal advocacy forum. And you were talking about your passions, some things that you might want to develop one day for new grads. Would you mind starting to go into that? Cameron Massumi: 15:04 I'm sure I don't have any true plans at this point. All I know is that I feel that the new Grad, early career professionals population is kind of a lost area. And what I mean by that is that there's no formal engagement targeting that group. And that's unfortunate in my mind. So I'd really like to see more active participation engagements available for that demographic. And currently myself, you know, I'm looking to kind of transition from the current role that I'm in and to more of one focused on my local chapter level for a little bit as I also work to you know, further my own practicing career and then really just find a final way to increase involvement and engagement with that population. So there's a good number of early career professionals that I'm friends with that live in my home state. So I would just want to collaborate with them and see what we can get off the ground going. Jenna Kantor: 16:13 I love that. And for those who don't know, Cameron's a champ. I cannot express enough how this is somebody you do want to meet. You do want to have in your life in some capacity because of just he is a person who really speaks his truth but really from the heart and has so much love for others and seeing everybody really have the ideal professional career that they so desire. And we had a great bonding moment at federal advocacy forum talking about this and though I have most definitely put you in the hot seat, but for reasons to really help identify that there is and what you just said, there is a gap on the support that's available right now. It's not the APTA is ignoring it, they see it, but it's still there. It's one thing to see it and then figure out exactly how can action be taken. That would be exactly what people need. It's definitely been discussed. So I really appreciate and I'm honestly happy and excited for people in your area to be getting your wisdom and you even just like figuring out what you can do. That's very powerful. So just honestly, thank you for that. Cameron Massumi: 17:25 Oh, thank you Jenna. I'm just one person, you know, and I'll speak in, like you said, from the heart, and these are just my own thoughts, but I really think that that the heart of it is collaborative efforts. You know, people from various backgrounds are gonna be able to come together and really problem solve a lot. And then as far as APTA goes, I think that they do a terrific job of acknowledging areas for improvement. And they are really actively trying to pursue avenues in which they can rectify some things and improve existing methods. I don't think that they do a bad job by any means with early career professionals, but I just don't think that it's where it needs to. I don't think that where it currently is where it needs to be. But you know, everything's a learning process and as we continue to grow as a profession, things will inevitably improve. Jenna Kantor: 18:18 Oh, for sure. I was looking at things like that as opportunities. I'm like, oh look, we have more opportunities. And I think, it is really good at looking at things as opportunities and you have to look at it in a positive light. So for anybody who might be listening and being like, ah, you know, waiting for us to say something bad. Like what is it going to, how in this particular conversation right now where we're really trying to reach out and pull in the new Grad audience, like, is it gonna do us any good to sit here and bad mouth or to actually acknowledge what the APTA is doing and how they're regularly acknowledging things. So that way it gives you a rightful reason to hope and believe in an organization that has the power to make a huge difference. They have a huge audience. Jenna Kantor: 19:02 They have a huge following. Even if right now in June 2019 just for when this goes forward, and time passes, there's one third of the population. There's no denying. Even for nonmembers they have a huge, huge audience. So it is very important. Even if you don't currently believe are not currently a member which join if you're not currently a member, you cannot deny the outreach that they have. So what is very good news? You want to hear that they're talking about it. You want to hear that it's on their mind. You want to hear that they're seeing the opportunities and are trying their best to explore it to the right thing because you know, as soon as they take action on it, they got to stick with it to see if it works, you know, and get that feedback. Well Cameron, thank you so much for coming on here. Thank you for dedicating this time. You've been in meetings this whole time and I was able to fortunately schedule you here at NEXT 2019 and I could not appreciate it enough. Do you have any final words you would like to say? You're like Mic drop to people who are new Grad physical therapists or even soon to be. Cameron Massumi: 20:14 Thank you Jenna for the opportunity. I think the biggest thing is just be an advocate for the profession and for yourself in whatever capacity that is. The APTA provides a lot of platforms for you to be able to get involved, for you to be able to get your voice out there and heard, support your PAC. You know, that's how we get things done legislatively. How we improve things regulatory too. As an example from a student perspective, you know, lots of lobbying has allowed for legislation to be enacted to help with student loan forgiveness. That's massive. You know, that helps not only students, but early career professionals and we're relieving a lot of their financial burden. Stuff like that is really powerful. Don't underestimate your voice. You have much more volume, your actions and your voice speak volumes and just find a way to get involved. Jenna Kantor: I love it. Thank you so much. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Michelle Collie on the show to discuss the importance of outcomes and how they can make a difference in your practice. Michelle became the owner of Performance Physical Therapy. Under Michelle's leadership, Performance has grown to a practice with 13 locations in Rhode Island and Massachusetts and over 200 employees. In this episode, we discuss: What is the definition of outcomes as it relates to physical therapy. How to use patient outcomes and business outcomes to drive your business forward Using outcomes data to increase your referrals A sneak peek into Michelle's keynote speech at The Outcomes Summit And so much more! Resources: The Outcomes Summit: Use the discount code LITZY Performance Physical Therapy Performance PT on Facebook Performance PT on Twitter Performance PT on Instagram For More on Dr. Collie: Born and raised on a sheep farm in New Zealand, Dr Michelle Collie spent her childhood years training pet sheep, riding motorbikes, and eating enough lamb to last a lifetime. She earned her bachelor's degree in Physiotherapy from the University of Otago in 1994 then moved to Rhode Island due to the United States Physical Therapy shortage. In 2003 while pursuing a Master of Science and Doctorate of Physical Therapy from Massachusetts General Hospital's Institute of Health Care Professionals, Michelle became the owner of Performance Physical Therapy. Under Michelle's leadership, Performance has grown to a practice with 13 locations in Rhode Island and Massachusetts and over 200 employees. Michelle is an APTA member and serves as the chair of the private practice PR and Marketing committee. Performance Physical Therapy has received a number of awards over the years for its business success and philanthropy, the highlight being the recipient of the 2014 Jane L Snyder, Private Practice of the Year. She is a board-certified Orthopedic Clinical Specialist Read the full transcript below: Karen: 00:00 Hey Michelle, welcome back to the cloud cast. I'm happy to have you back. Michelle: 00:04 It's great to be here. Karen, thank you for having me. Karen: 00:07 Of course. So today we're going to talk about outcomes, specifically outcomes within your clinic and with your patients. But I think before we get into the meat of this talk, I would love to hear from you what your definition of outcomes is. Michelle: 00:24 Well, um, hopefully I'm not quoted by the Webster dictionary or anyone else out there, but for me in my practice is a physical therapist. To me, outcomes of the results that are numbers and they could mean practice management outcomes such as how many patients we see visits in an episode in here. They could be outcomes related to patient satisfaction such as your net promoter score or how many Google reviews did you get. Or they could also be clinical outcomes based on such things as the specific clinical outcomes means, Mitt measures that we use, whether it's related to the Oswestry or a disability scales. So those are just examples of some of the outcomes. But I think outcomes are like the results, tangible numbers of behind them. So you can actually give some, um, objective measures behind what these outcomes are. Karen: 01:19 Right. And you S uh, I like that you kind of put those outcomes into different categories because when I hear outcomes I just get incredibly overwhelmed and think, well there's, there could be so many. Right? So thanks. No. So now we kind of have a defined how do we measure outcomes within our practice? And maybe you can give some examples of what you guys do, but is there, do you have any standardized ways that you are measuring these different outcomes? Michelle: 01:50 So again, we can classify it into different ways and I will bring out one, one methodology actually is when it comes to practice management outcomes, that's something you hear often, especially with the benchmarking program that happens through the private practice section. We start looking at outcomes and using numbers to benchmark against each other. And those are things such as, um, how many, how many visits in an episode of care or how much revenue do you gain per patient visit? So these are things that are very much financial and operational defined and how you figure out business wise how well you're doing. So that's one side I'm going to flip to the other side, which I think is much more exciting to talk about for most people and that's actually our clinical outcomes. How good a job or how well are we doing when it comes to treating our patients? Michelle: 02:47 And there's such a drive now to looking at our outcomes as far as our clinical outcomes and what does that truly mean? Does that mean that my practice or Misa physical therapists get someone better and less visits or at least amount of time or with more intervention or different combination when, how much better do we get someone? So the outcomes to me relate around time, which could also be actual number of visits or encounters and also is how much bitter someone gets. If I'm treating a runner and they, our goal is, Hey, I want to run a marathon in four hours, am I being sucks? Can I get them back to being able to do that? And can I do that just as well as not just the next physical therapist, but other fitness, health care provider, whoever that is. And how can these outcomes? Michelle: 03:42 So how do measuring outcomes help to drive your practice? So I guess this is a really, what you're counting down to was the why. Why bother doing this? And so yeah, this is getting to the why, which is the most fundamental part is by measuring our outcomes and helps us differentiate. Now when we can differentiate ourselves, it makes it easier to do marketing and that marketing can, it can impact us in different ways. We can use it to market to get more patients. We can use it to negotiate, which is marketing messaging with a payer, whether that's an insurance company or whether someone's paying cash for services that we now have outcomes, which is data to help him messaging and differentiate, here's what I can do or my practice can do. Um, so I think there's many different levels, um, that it relates to, but it's all comes back to marketing and messaging and being able to differentiate and communicate to the consumer and will the payer about what our services can provide. Michelle: 04:54 And can you give an example of how you, you and your practice might use your outcomes to market and you can choose if you want to market to a payer market to the general public, I'll let you choose. So we've done a whole bunch of things that our practice and hit a lot of success. Um, one is marketing and this is probably the easiest one for people to understand marketing to physicians. So with the data that we have, I can go to a physician [inaudible] physician group and say, Hey, here are end results. If you, when you refer a patient to us, we're going to get them this much theatre and here's what the national benchmarks are. So we're actually proving to you that we're going to get the results that you want and guess what? I can and we're actually gonna do it at least visits and what the national standards are. Michelle: 05:51 Now I can compare as cells to um, we, I compare as to practice nationally or regionally or even over time. Look, we put these new systems in place or we started try needling or using this new blood flow restrictive therapy or whatever modalities or treatment methodologies we're using and say, because of this, now we're now we have the data to show how much better we're getting patients. And then for us it's actually really helped to Provo provide actually data to referral sources and they can actually say, Oh, so we're going to seam patients to you because you're actually going to provide solutions and get our patients better. It's not just about the fact that Oh, you've got more clinics or you are open on Saturday mornings and no one else is, or you had fancy equipment. I mean these are true differentiators, not just things we can do to make ourselves look better. Michelle: 06:50 I think that's the big thing. I think, you know, years ago I always used to think that marketing and promoting your practice was just simply about relationships. And if people like you, they'll send you patients and patients like you, they'll come back to see you and all those. Although those things are true too a little bit when you've actually got the data behind you and really meant, helps you tell a story and say, Hey, this is why we should be treating your patients or to the general public. This is why you should be coming to physical therapy to help with your back pain or your ankle sprain or your pelvic health problem or your dizziness. You've got the numbers to show that we will get you better. Karen: 07:31 Yeah, and I think it's great to use numbers because these are our facts, right? You're not fudging these numbers. This is the actual data that is coming out of your clinic. So I think it's great to be able to then instead of just have the data and say, Oh great, look what we did. But you want to use those outcomes in order to market your clinic. Michelle: 07:56 Exactly. And I think the other nice side about it as when you're using the data to market, it actually changes the culture within your clinic and within your practice. Karen: 08:07 That was literally my next question was how did outcomes affect that people working day to day in your practice? Michelle: 08:13 Yeah, well I think it's really helped to make us practice and every visit make all of our clinicians and their patient care coordinators and our assistance and our exercise specialists realize, yes, we're very concerned about customer service and giving, um, you know, having beautiful clinics and all of these other aspects. But at the end of the day, we need to make sure that every moment we're spending with patients is designed to get them back to be doing the things they want to do in this got a show in the data. Yeah. And I think it's helped to really drive our clinic and the kind of care that we're providing. So it's not just about, Oh, I'll collect the data and now I'm going to get paid more by an insurance company. Or now people are going to come and see us or doctors or refer. It actually drives the culture within a clinic to ensure that you, I always feel like we've got rid of complacency which can sometimes creep and practices. Yeah. And how do, Karen: 09:14 how do you use this, the outcomes data to kind of align with your vision or the or the mission of your practice? What would you say to other clinicians when it comes to aligning the data with the mission and vision? Michelle: 09:30 Well, I think that's really a great point you bring up because people often say, well how do you know what to measure and why are you doing this? And I think it always starts with your strategic plan and figuring out, first of all, what is your purpose? Which is like your greater good. Why do you, why you in practice and what's it all about? And then thinking, okay, well then what's their, what's their mission, what are EMV values? And once you figured those things out, then you can challenge yourself and say, well how am I going to prove it and how am I going to measure it? So that when someone says to me, Oh, your purpose is about having a healthy, fulfilling the film happy community, and you're helping your community to be in that way, how are you going to truly measure that? Michelle: 10:13 That's what you're doing? So I think you have to start with that strategic over powering, look at your vision, your mission, your values and names going on. How am I going to measure that and not the other way round. Mmm. We see like, yes, we're going to look after our community and then we're going to use innovative results given here and now it's like, well, how are we going to prove that? I'm like, the only way you can prove that you're getting results driven, innovative care is by showing the data because otherwise it's just talk [inaudible]. Karen: 10:48 Yeah, yeah. No, that's great. As you're saying this, I'm thinking about my mission for my company and like, Hmm, yeah, okay, Michelle: 10:59 how am I going to measure this now? And it's not, you're not going to come up with it overnight and there's no perfect way to do it because this is quite a new area for physical therapists or we're only just part of this evolving healthcare environment where payments changing and with payment changes the messaging of how we're promoting what we do, but it is turning into much more a shift away from fee for service and much more to say like we're paying for the outcomes or the experience, not how many visits or how many units of charge per visit or how many visits and an episodic here we should be advocating improving our stamps for our outcomes. Neat. Good. The only way we can do that as some health, pulling out what clinical outcomes and how we're gonna measure those and basic jet. Karen: 11:50 Yeah. And how do your outcomes from clinic aligned with Michelle: 11:54 your vision and your mission? Like what is the mission of your clinic and how do you, how do your outcomes revolve around that? The way our mission is about providing innovative, results-driven, physical therapy services for a community. And the way that we measure the outcomes is that our goal is to get, use the hashtag better, faster. So we're all about getting people better, more better, and doing it in the least number of visits we possibly can. Now it's interesting because there's many practices out there, and I'm often challenged by this and this is where I butt heads with media, other people in private practice and like, but we get paid per visit. Why would you want to see people enlist visits? And I've had some really fun heated debates with some colleagues and peers over this Mike. But if we can do it and least visits, isn't that the right thing to do? Michelle: 12:45 And then doesn't then allow us to advocate and, and, and prove ourselves and our value. And they're like, what? How can you afford to do that? Because you're basically sacrificing money because you're going to do it and least visits. So it's been a fun debate to have because we've had it now for many years. And I think the ties of changing, because I've been now in a position to actually go to payers and insurance companies and actually hit the data and say, look, we are doing at least visits. So let's talk about how we do some cost sharings. Let's talk about different ways to reimburse because we're doing it and at least visits and uncles to go to the outcomes to show that we're getting people just as bitter or more. That's really poor English with that. So I came up here. Yeah, that's okay. We get the gist of it. Michelle: 13:35 So one of your outcome measures might be how many visits are in an episode of care? So we had the keys that we use, we use visits in an episode of care and the other one we use is the clinical more clinical um, change. So traditionally we've used photo focused on therapeutic outcomes of your system. Um, which has been great because that will, that will differentiate patients based on payer, um, diagnosis, body part, all of these things. So we can say, Hey, for a bag spine or all the Pedic on Euro or upper extremity, here's how, here's the change that we're getting in function and we can actually beat back and compare ourselves to other practices both in our region and nationally as well. You can do, it's an interesting time because now with MIPS and again I realized the assaults and people out there who don't know if MIPS are going to happen and we still don't have a lot of final rules, but again, we're still in with Mets. We're still using different, um, standardized clinical outcome tools that we're all very familiar with and I'm looking at opportunities to benchmark not just against it within their own practices, but between each other's practices as well. Karen: 14:54 Yeah, I think that's great. I love looking at it that way of, of figuring out your mission and then how are you going to measure it and then taking those measurements and using it for a whole bunch of different things. Michelle: 15:07 Well, I think that to me that's been the most interesting thing in our practice. It's, we've got this mission and a vision, which is what you have to start with. And your purpose. We've created the tools to measure it well. We've figured out what tools and how to measure it and it's, it's really helped evolve the culture of that practice. It's helped us with how we onboard our staff. It's helped us with how we recruit new people. It's helped us when we take on students. So it's had a big impact on every part of their practice. And, um, rather than just, you know, how just rather than just how we treat a patient, an everything embodied bodied, everything. Karen: 15:47 That's awesome. And now you had mentioned photo and coming up in October, October 23rd to the 25th, and Knoxville, Tennessee is the outcomes summit. Uh, and you are one of the keynote speakers. So can you give us just a little sneak peek, a little taste of what your keynote speech is going to be about? Michelle: 16:07 Well, so the keynote speak is all about on marketing with outcomes data, helping people understand the value, um, for outcomes data. When marketing your practice, I'll use my personal story because I think it helps to show that I'm, you know, really at the end of the day, just a little farm girl from a very remote part of the world. And um, so if, if I can use data to Mark it with anybody can, and I also like to talk a lot about the fear because I think there's a lot of fear out there. PTs are often scared. One of my deck data doesn't show what I want it to show. Karen: 16:44 Right? Then what happens Michelle: 16:46 then what happens? So yeah, that's like the million dollar question. And then what happens is people run away from fear and then they don't do it and so they're not moving forward. So I definitely had plenty of fears when I first started put up though the date and say what a for not as good as we think we are. Well, I find it interesting that it's really abandoned teach and if you're following what your purpose and your mission is and the results are going to happen because this changes all of the messaging and it impacts your entire culture. But I think it's a journey of how to address the fear of what if my data isn't as good as what I think it can be. Because when it comes to marketing, yeah, I can have beautiful brushers and amazing weird site. I can be open all different hours and think those things are going to differentiate me and they will a little bit. Michelle: 17:37 But at the end of the day, I do think it comes back to data is the real differentiator and if you want to get serious about marketing and messaging what your practice does, and I think this goes, now I'm going to get on a, and this goes for our app proficiency as a whole and list were privy. At least we're proving that we really are the base caregivers for muscular skeletal and your a muscular disorders and diseases. Then we, you know, we're still lists, we're just not doing a good job, but at the moment like how do we differentiate ourselves from the other healthcare providers and fitness people out there who also say we'll take care of someone's back pain or help them get trained for a five K. so again, we have to, as a profession, as a whole, use that data and be comfortable using it to prove proven value. Karen: 18:31 I love it and it sounds like it's going to be a great talk. So all of the people who are going to the outcomes, the clinical outcomes summit are in for real treat. Um, so that's awesome. Now, uh, before we, and here I have a one more question and that's what advice would you give to yourself as a new graduate? Fresh out of PT school. So that farm girl from New Zealand, she just graduated from PT school. What advice, knowing where you are now in your life and career, would you give yourself back then? Michelle: 19:11 Oh my God, it's so much advice I would give. I think it would be about the key advice I would say is that your, we all have fear. We're all nervous of things. Whether it's, Oh, I'm going to make a mistake when I treat a patient or I'm going to have a practice that's not successful, or I'm going to open my mouth and sound like an idiot, but we're all gonna do it in. That's fine. And the only way to conquer those fears is just push through it and just keep, keep moving forward. So I think it would just be letting myself know at that shy Tinder age in my early twenties that, um, all the challenges that I had, just the same of everyone else's. And so yeah, just put on your big girl panties. They would say base the fears and move forward. Sorry. Karen: 19:57 Great advice. And now where can people find you, whether it be on social media and or your clinic? Michelle: 20:04 Um, so we have a multi clinic practice based out of Rhode Island with some clinics in Massachusetts as well. So performance ptri.com is our website and all their social media handles all reflect their performance. ptr.com P t@ptri.com. So, um, feel free to check out her website and we are you on Instagram, Facebook, Twitter, all of those, all of those places. Karen: 20:30 Awesome. Well, Michelle, thank you so much for coming back onto the podcast. I appreciate it. You gave me a lot to think about, so thanks so much. Thanks very much, Karen and everyone, thanks so much for tuning in. Have a great couple of days and stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!

On this episode of the Healthy, Wealthy and Smart Podcast, I welcome Dr. Stephanie Gray on the show to discuss bone health. Dr. Stephanie Gray, DNP, MS, ARNP, ANP-C, GNP-C, ABAAHP, FAARFM, is a functional medicine provider who helps men and women build sustainable and optimal health and longevity so that they can focus on what matters most to them. She is co-founder of Your Longevity Blueprint nutraceuticals with her husband, Eric. They own the Integrative Health and Hormone Clinic in Hiawatha, Iowa. In this episode, we discuss: -What is functional medicine and integrative medicine? -Hormones that impact your bone density as you age and how to find your deficiencies -The difference between natural and synthetic hormones -Your Longevity Blueprint: a guide to mastering each of your body systems -And so much more! Resources: Integrative Health and Hormone Clinic Website Your Longevity Blueprint Free gift: 10% off using code healthy10 Stephanie Gray Facebook Integrative Health and Hormone Clinic Facebook Stephanie Gray Instagram Your Longevity Blueprint Instagram Stephanie Gray Twitter Your Longevity Blueprint Youtube For more information on Dr. Gray Stephanie Gray, DNP, MS, ARNP, ANP-C, GNP-C, ABAAHP, FAARFM, is a functional medicine provider who helps men and women build sustainable and optimal health and longevity so that they can focus on what matters most to them! She has been working as a nurse practitioner since 2009. She completed her doctorate focusing on estrogen metabolism from the University of Iowa in 2011. Additionally, she has a Masters in Metabolic Nutritional Medicine from the University of South Florida's Medical School. Her expertise lies within integrative, anti-aging, and functional medicine. She is arguably one of the midwest's' most credentialed female healthcare providers combining many certifications and trainings. She completed an Advanced fellowship in Anti-Aging Regenerative and Functional medicine in 2013. She became the first BioTe certified provider in Iowa to administer hormone pellets also in 2013. She is the author of the FNP Mastery App and an Amazon best-selling author of her book Your Longevity Blueprint. She is co-founder of Your Longevity Blueprint nutraceuticals with her husband, Eric. They own the Integrative Health and Hormone Clinic in Hiawatha, Iowa. Read the full transcript below: Karen Litzy: 00:01 Hi, Dr. Stephanie Gray. Welcome to the podcast. I'm happy to finally have you on. This is taken forever between the two of our schedules. Stephanie Gray: 00:09 Thank you for having me on. I'm excited to speak with you today. Karen Litzy: 00:12 Yeah, I'm very excited. And we had met, Gosh, last year, maybe Stephanie Gray: 00:17 October. Karen Litzy: 00:18 Yeah, October of last year. Holy Cow. Yes. Well, I'm very excited to have you on because when we met at unfair advantage and I remember hearing your story and hearing you speak and I thought I need to talk to this woman because I think she's doing some really great work, so I'm happy to have you on and share all about what you're doing. We'll talk about your book, the longevity blueprint in a little bit, but first, can you let the audience know a little bit about your journey from your BS to your MS in nursing to doctorate to all these certifications and how that happened in the why behind it? Stephanie Gray: 00:58 Sure. Well, maybe the short version is that I was born and raised in the Midwest and I grew up in a very healthy family and I wasn't quite sure what I wanted to do with my life as many people are I'm sure. My parents always took us to see a chiropractor, not a regular doctor. They were self employed, had a really high deductible. So they wanted to keep us healthy and growing up, I wanted to get into medicine. I kind of grew up wanting to be a doctor. I'd play with my doctor Kit, but I didn't necessarily want to prescribe drugs. And so I thought, well maybe I'll go into nursing. Right? So I went through the nursing program at University of Iowa and I love nurses, man, they're so important. We have a shortage, we need more nurses. But I thought I wanted to have more autonomy and more independence and I wanted to still be able to diagnose and treat patients. Stephanie Gray: 01:43 And so I did continue on to become a nurse practitioner and I ended up going through the master's and then the doctorate program. And I still was a little unsatisfied. I felt like, man, there's gotta be more to life than prescribing medications. Right? Nursing is a more holistic approach in general. And that's why I'm biased to nurse practitioners as primary care providers because I think they do provide a more holistic approach. I wanted some additional trainings so that I could incorporate nutrition, that I would have some credentials behind recommending things other than drugs. So I did also then pursue a master's in metabolic nutritional medicine, which taught me a lot about, you know, using supplements and herbs and whatnot, which I heavily applied in my practice. And then I also did complete the advanced fellowship in anti-aging, regenerative and functional medicine which helped me tremendously. I learned a lot about use of bioidentical hormones as well. And I really just became on fire for integrative and functional medicine and thought, this is it. This is what, especially my community in Iowa needs, because there weren't a lot of providers offering this sort of care. So that's, I guess that's kind of my story. Karen Litzy: 02:50 Well, that's a great story. I love it. Now you mentioned functional medicine and Integrative Medicine. Can you kind of help us out and talk about what those branches of medicine are? Stephanie Gray: 03:01 Sure. So integrative medicine combines or integrates conventional medicine with natural, uneven, complimentary forms of medicine. It's not, I'll say functional medicine also really more works to get to the root cause of the problem. That's kind of more of the definition of functional medicine. And I use both in my practice. I use functional medicine to kind of discover the why, but I also use integrative medicine because there is a time and place for medication use. Sometimes patients do need antibiotics or surgery. I've had to partake in them myself. But I want to provide my patients with the best of all worlds combined. So do I think chiropractic is important? Yes. Acupuncture? Yes. Use of supplements. Yes. Medications, all of the above. I think the major difference in the analogy I use with my patients that I did not create a colleague, Patrick, he mentions conventional medicine as being more of the fire department approach. Right? We need conventional medicine. If you have a big bad ugly tumor or whatnot, you need the fire department to put that out to remove it. But conventional medicines tools are drugs and surgery. Functional medicine is a little different. We described that in my practice as being more of like a carpenter approach and that's what I describe in my book. Really helping to repair and rebuild the body, figure out why the fire happened in the first place and try to get to that root cause of the problem, not just provide a bandaid approach. Karen Litzy: 04:16 Right. And that's a great analogy. Thank you for that. That's definitely clear. It makes functional and integrative medicine a little bit clearer for everyone. Hopefully. So now I mentioned the book longevity blueprint and again we'll talk about that a little bit later, but there's a chapter in the book, Chapter Four where you discuss the importance of fixing nutritional deficiencies and specifically when it comes to our bones. So as mainly women, we all know as we get older and as we go through menopause, our hormones change and bone density can change along with that. So what nutrients I guess are specifically important for our bones? Stephanie Gray: 05:09 So I'll discuss several nutrients. So many women think calcium is a number one most important nutrient for their bones. And the truth is that your bones need a lot more than calcium. So vitamin D, magnesium, vitamin K2 and strontium are all nutrients that I recommend to my patients. I mentioned vitamin D in several different chapters of my book and that as many people know, helps your body absorb calcium and phosphorus from the foods you eat. And it helps with bone remodeling. Maybe I don't know how deep we should get into that. Maybe you shouldn't, but without enough magnesium though calcium can also collect in the wrong places in soft tissues and cause arthritis. And so magnesium is just as important as calcium. There have been several studies of women with Osteopenia or osteoporosis showing they're actually not deficient in calcium deficient, they're deficient in magnesium yet. Stephanie Gray: 05:58 What's the number one most prescribed supplement? Menopausal woman. Again, it's calcium. I personally have had a kidney stone and they are not fun. So calcium can not only gain weight, it can cause bone spurs, but it can cause kidney stones. It can calcify our arteries. We don't want it getting absorbed in to the wrong places of our body. And that's where vitamin K2 comes in also. So vitaminK is really overlooked nutrient. It's one of the four fat soluble nutrients. So it really helps prevent calcium from accumulating in our vessels. And it can even, some people believe can help remove dangerous calcifications too. We know that low levels of k2 can directly be related to poor bone mineral density. So I like analogy. Stephanie Gray: 06:45 So here's another analogy on what vitamin K2 really does, and vitamin D. So vitamin D is the doorman that opens the door for calcium to enter the bloodstream. But once it's in the bloodstream, it could go anywhere. So I think if K2 is being that usher that's going to direct the calcium from the lobby, if we think of a hotel or whatnot, directing him to the appropriate seat in our bone matrix. So do we need vitamin D? Yes. Do we need magnesium? Yes. We also need vitaminK2. So there are different sort or different types of vitamin K. So vitaminK is broken down to K1 and K2. So if you are purchasing a supplement, if it just says vitaminK , you don't necessarily know what you're getting. Stephanie Gray: 07:26 You want to make sure that the label is really differentiating if specifying what is in that product. So vitamin K1 isn't as much needed to be supplemented. It's the deficiency is pretty rare. It's found in leafy Greens. Hopefully you're all getting your leafy Greens. But vitamin K2 comes from very specific foods and also bacterial synthesis. So think of it. Think of yourself as you know, if you don't have a healthy gut, unfortunately your body's not going to be able to convert. K1 to K2 in the gut if you've taken antibiotics, whatnot, if you have a lot of food sensitivities and gut inflammation. And so you really want to think about consuming foods with K2 and possibly supplementing in that as well. So vitamin K2 comes from fermented soybeans, which many of us probably are not consuming and also from the fat milk and organs of grass fed animals. Stephanie Gray: 08:16 So things like egg yolk, butter, and even liver with why we're coming, we're becoming more vitamin K deficient is that you are where you're what you eat, eat. So if you've heard of what Michael Poland has said, and I think that's really true with K2. So when we removed animals from the pasture, right? If we don't eat animals that are eating greens, they're not getting the K2 themselves and then we're not getting it from our products. So you want to make sure you are eating grass fed animals and think of wild game. Wild game is really what's can usually consuming the ingredients. So try to consume more pheasant, duck rabbit, venison, elk, or wild Turkey. I mean these are things that we don't all have access to, but that would actually help increase our K2 levels. So if you can't get some of those foods into your diet, then you could consider supplementing that. Stephanie Gray: 09:06 It could literally again consume the fermented soy beans. But MK7 has a pretty long half life, longer than MK4. So I recommend my patients take MK7, MK4 is actually extracted from a tobacco plant, which I don't like either, sometimes will come from fermented soybeans, geranium or chickpea. And the source that we use for our production is chickpea. It has a longer half life, so a single daily dose can provide longer protection. So many of my patients, we're putting on 45 90 or even 180 micrograms of MK7 per day. It's great to incorporate foods that have, you know, consumed grass Greens. You hit the chlorophyll to get the vitamin K and to have a great healthy gut that convert can indicate too, but if you can't, and supplementing with MK7 is what I recommend. Karen Litzy: 09:56 Yeah. And, just so people know, are you doing blood tests on people to find these levels? I just want to point that out so that people listening are like, well, I'm just going to go buy all this stuff, but you have to go and be evaluated first. Stephanie Gray: 10:15 Yeah. So in my book in chapter four I talk about, well, every chapter of the book discusses a functional medicine testing option that's available. And chapter four is all about examining micronutrient deficiencies. Which even my patients who eat organic, who grow their own food in their backyard are still nutritionally deficient because our food sources are just not as nutrient dense as they used to be. I mean, the magnesium content in our foods has been on a decline since the 1950s. It keeps going down and down and down, which is very sad. But because of that, we can see that evidenced on a test that we run on our patients. So one of the first tests for my patients with osteoporosis or Penia that we would run is this nutritional analysis, which is looking at vitamin, mineral, amino acid, antioxidant, and even Omega levels. And if you have the access to a functional medicine practitioner, definitely I would recommend getting this test because then you don't have to guess how much magnesium, how much do I need? It's better to really get the test to see what you need. Karen Litzy: 11:12 Right. Yeah, no, that makes a lot of sense. And I just wanted to point that out to people so that they know. I guess also, are there any dangers of taking these vitamins if you don't need them? Stephanie Gray: 11:28 So vitaminK to a high dose just can cause blood thinning. So if patients are taking anticoagulants, if they're on medications like Warfarin, you know, Coumadin, then this could potentiate those effects at really high dosages. So if you're listening to this and you want to take some K2, you probably need it. But talk to your doctor or nurse just so that they know so that they can monitor your levels. So that would the biggest, biggest side effects. Stephanie Gray: 12:04 The last nutrient for bone mineral density that I recommend to my patients is strontium. This was one of the first minerals that I really learned about for bone density. So I heavily used it initially even before I learned about the importance of K2. There have been randomized double blind placebo controlled clinical trials showing that strontium in a dose of about one gram per day could be equally as effective as a lot of the bisphosphonate medications without getting those nasty side effects. But I have seen this be effective in my patients too. Granted, I'm recommending they take minerals, optimize their hormones, reduce their stress, exercise, right? So all of those interventions are going to have an additive effect for improving bone density. But strontium can be very, very helpful for bone density as well. Karen Litzy: 12:48 Nice. All right, so we have vitamin D, vitaminK2, strontium and magnesium. Stephanie Gray: 12:56 And then calcium of course calcium. I don't put calcium on the top of the list, but yes. Karen Litzy: 13:01 But it's there. Okay. All right. Now you mentioned hormones for a quick second there, but is there value in optimizing hormones for bone density? Stephanie Gray: 13:13 You Bet. So about 25 well, I think it's 27% of women over 50 can have osteoporosis, right? Like a fourth of those patients of that population, which is pretty scary. Yeah. And I'll go 40% have osteopenia. There's also, I'm referencing women over 50 so what's the other common dominator for women over 50 usually you're going through menopause around that declining and this, the danger here is that this can increase risk for fractures. Of course, Osteoporosis Foundation says at 24% of those with hip fractures die within a year. That's, that's terrible. Very cool. So absolutely, I run a hormone clinic and I strongly believe that improving estrogen, progesterone, and even testosterone levels in women can help with bone density. And I can talk a little, I can go into depth with each of those hormones. Karen Litzy: 14:06 Yeah, I think I would like a little bit more in depth conversation on that and also the difference between synthetic and natural hormones. Stephanie Gray: 14:15 Sure, sure. So maybe first we'll talk a little bit about estrogen. So estrogen literally helps with a proper bone remodeling process. Progesterone helps promote osteoblastic activity. So osteoblast help build your bones while osteoclast break it down, right? So progesterone is going to help with the bone builders and testosterone has been proven to actually stimulate new bone growth and inhibit or block the osteoclastic that breaking down activity. Progesterone, I've even been heard called one time I heard it called a bone trophic hormone. Like it literally seems to promote bone formation, which is wonderful. So it's one of the first hormones I'll start my patients on even before their menopausal many peri-menopausal or younger are taking progesterone. And when I mentioned testosterone for women, some women kind of look at me sideways like, well I don't want to grow a beard or I don't think I need to. Stephanie Gray: 15:12 But actually it's extremely important if you even think of how testosterone helps with muscle mass, it can help strengthen the patient also, right? To improve balance, to minimize falls. Testosterone is great for many reasons. In my book I actually mentioned a study. I feel so strongly about how important testosterone can help really because of the study, because I've seen this, testosterone has shown an 8.3% improvement in bone mineral density, which is like unheard of. It's just dramatic. I've had patients who have received hormone replacement therapy, not overnight, but over a year, go from having osteoporosis, Osteopenia to even having normal bone density because after a year, their bones are improving and that is amazing. But conventional medicine, many times putting patients on drugs, we're just hoping that they don't have a decline. We're just hoping that they stabilize, not that they actually build bone density and hormones can really help do that. Stephanie Gray: 16:08 But in reference to your other question, anytime we talk about hormones, the cancer word is going to come up. So that's where I can differentiate between the synthetics and the naturals. And in my book in chapter six actually show the molecular structure of synthetic hormones like I synthetic progestin and natural progesterone aesthetic is faster on molecule and natural testosterone cause the hormones really need to fit like a key fitting in a key hole, right? And that's what the molecular structure of natural or bioidentical hormones are. I mean, they should fit like a key fitting in and thus caused your side effects. So most of the studies that showed hormones cause cancer were studies like the women's health initiative study, which was done on a lot of women, but they use synthetic horse urine and they use Premarin. Stephanie Gray: 16:54 That's literally what Premarin stands for, pregnant Mare's urine. So naturally I try to not replicate what was done in that study with my patients. I don't want to use synthetic hormones. I don't want to use oral estrogen either. That means estrogen taken by mouth in a pill form, right? Which is going to have to be cleared through the gut and the liver. So who was trained through, I should say in addition to the fellowship program that I went through was bio t, they're a hormone pellet company. They're the biggest hormone pellet company in the nation who very well trained their providers and their practitioners and they keep us up to date on all the current research and what's happening in Europe as well with hormones. And so they strongly believe that hormone is given an appellate version, which is an actual subcutaneous little implant that we put under the fatty tissue, kind of in the lower back. Stephanie Gray: 17:44 Upper bottom area is by far the safest. And that's what we're going for with our patients, right? We want to improve on density. We want them feeling better. We want to give them the safest version of the safest dosage. And so pellet therapy specifically is what can improve bone density the most. But again, we're using natural hormones that are plant-based, not synthetic. They should bind to your hormone receptors appropriately. And therefore the risks of, you know, what were shown in the women's health initiative study just can't be compared to what practitioners like myself use. Cause we're using natural hormones, not the synthetics and not by mouth. Karen Litzy: 18:19 And so what are the side effects or the downside of using these natural hormones versus a synthetic? Stephanie Gray: 18:26 Sure. So all of us are already making, well we should be making hormones, right? Which when we grow up we go through adolescence, our hormones peak and then in our twenties and thirties and forties and 50s we start seeing this decline. So really if hormones are dosed appropriately, patients shouldn't have side effects. However, if you think of younger women when they're cycling, sometimes before bleeding they may have some fluid retention or a little bit of breast tenderness or whatnot. And sometimes those symptoms can reoccur as we give patients hormones. The goal is that those would be very short lived. They wouldn't last once we refined the dose. But too much of estrogen can definitely cause fluid retention, breast tenderness, potentially some weight gain. Too much testosterone could cause acne, oily skin, hair growth. Too much. Progesterone can make you feel a little tired. Most menopausal women need help sleeping. So they like that effect, kind of calms them down. Or if women are real PMSing they need or have anxiety, they need some progesterone to calm them down. But we don't want to overdose patients. Right? We don't want to get them to high levels of the hormones, but we want to give them high enough levels that will protect their bones, that will help them sleep. Right. That will provide benefit. Karen Litzy: 19:34 Are there instances of cancer with the natural hormones? Stephanie Gray: 19:41 So there are always instances of cancer? I can't say definitively that. No, I've never seen it. I'd never had a patient ever have cancer. But from my experience, they're very rare. And Bio T are great to have as a resource because they track all of that. I mean, they're tracking all these hundreds and hundreds of thousands of patients with pellets and they're tracking the rights and if they confidently say the rates are extremely low. Karen Litzy: 20:07 Well, you know, cause we wanna give the listeners sort of like a balanced view of everything. So we want to give the, you know, as you know, and I'm sure this is the exact questions that your patients probably ask you. Stephanie Gray: 20:23 Yes. Karen Litzy: 20:25 Or hopefully that's what they ask you. Let's put it that way, So now talking about these hormones, how would one know if they are low on these hormones? Stephanie Gray: 20:37 Good question. Really get tested. Does every postmenopause woman with osteoporosis need testosterone? No, I can't say that I'm speaking to what has helped my patients. But the beauty of functional integrated medicine is that we personalize treatment, right? We test hormone levels to see what our patients need and we test them at the beginning of therapy and through the therapy and annually, right. To make sure we're not under or overdosing our patients. So, I recommend that women, even young women, and I should say men too, but we're kind of speaking to women today, get their hormone levels tested in their twenties, thirties, forties. Right? So they can get a baseline. They can track changes. So they start to feel different, start to feel something has gone awry, we can compare to see where their hormones were before. I think that's really important. But basic blood tests can tell you where your hormone levels are. Stephanie Gray: 21:27 And now that's for postmenopausal women and for men. Now if you're younger, another test that I utilize in my practice is saliva hormone testing. So for younger women whose hormones fluctuate, whose hormones fluctuate on a daily basis, many times I'll have them spit into a tube every couple of days over the course of a month so we can really see what's happening. Maybe they're getting headaches for population or maybe they're getting headaches before bleeding or having pms or whatnot. If we can correlate their labs with their symptoms, then we know exactly what's happening, which hormones fluctuation is triggering that, and then we can intervene appropriately. So that's the beauty of testing and not guessing. Really being able to examine on paper what's happening and match it with what the patient's plan. Karen Litzy: 22:09 And with osteoporosis or Osteopenia, let's say you are getting tested when you're younger to find out, you know, what are you deficient in vitamin or mineral wise and where are your hormones levels at? Can you through this process help to let's say ward off osteoporosis or Osteopenia even if it's a genetic thing within your family. Stephanie Gray: 22:40 I guess the easy answer there would be sure. That would be the goal of course. So we want to ward off all chronic disease. Karen Litzy: 22:47 Yeah, exactly. Stephanie Gray: 22:49 I'm sure there could be some rare genetic disorder. I'm not aware of that. Maybe, you know, we couldn't influence, but yes, that would absolutely be the goal is intervene soon. Absolutely. Karen Litzy: 23:03 Got It. And is there anything else when you're seeing patients coming to you with Osteopenia, osteoporosis, anything else that you're looking at or any other treatments that you may suggest? So that if anyone is listening to this, and let's say they are concerned that maybe they have osteoporosis or Osteopenia or they are post-menopausal or reaching that post-menopausal phase and they want to go to their doctor and they want to ask them about these tests, is there anything else aside from what we've already talked about that you would suggest? Stephanie Gray: 23:37 Oh, all kinds of things. So I'm back to the micronutrient deficiency possibility. Well, especially if that occurs, we're going to be looking at diet with the patient, right? I had a young woman my age who was drinking like six or seven cups of coffee per day. And I said, you know, that's just basically leaching minerals from your bones, right? It's a diuretic. It's essentially robbing you of all important nutrients, even nutrients you're supplementing with. So you still need to examine diet with all of our patients and make sure that we're eating well. Right? And not just drinking tons of carbonated beverages or caffeine or whatnot. So definitely looking at diet is important. Sometimes we do look at heavy metal toxicity with our patients, with these patients specifically. I don't want to say it's rare, but it's much more common and more easy to treat the patients, you know, by fixing the nutritional deficiencies and the hormones. Stephanie Gray: 24:32 But there are times where it is really important to look at heavy metals as well. And then I definitely always ask my patients about their stress, right? So if they have low hormone levels, that's part of that's natural, right? Your hormones are going to decline as you age, but you're super stressed out. Stress is your body's biggest hormone, hijacker stresses not helping your situation or your bombs. So we do need to think about lifestyle and really getting stressed under control, deep breathing, Yoga, meditation, and then examine if they're doing weight bearing activity as well. Yeah, of course. Needs to start really young, right? You build your phone mineral density in your 20s. So know that needs to start at a very young age. But I do want to make sure my patients are exercising as well. Karen Litzy: 25:20 Awesome. Well, I think that gives us a really nice holistic view of kind of looking at Osteopenia and osteoporosis from sort of bridging the gap really between that functional medicine and traditional medicine. As a physical therapist, I often get patients referred to me for osteoporosis to do those exactly what you said, those weight bearing exercises, stress reduction, things like that. And so it's good to know that as a physical therapist that we can team up with other healthcare professionals with our patient's wellbeing at the center. Stephanie Gray: 25:54 Absolutely, I would say that that's also a belief for functional medicine, that we need interdisciplinary care for our patients. You know, I don't have time during my visits to teach patients exercise for strength and balance. We have our own strengths, but we can work together as a team and really have a multidisciplinary approach for our patients, which is going to provide them with better outcomes. Karen Litzy: 26:17 Yeah, no question. I agree 100%. And now we had mentioned the book a little bit, it's called the longevity blueprint, can you tell the listeners a little bit more about the book and where they can find it? Stephanie Gray: 26:30 Maybe I'll go off on a little tangent here and just say why I wrote the book first. I think sometimes patients or consumers may think, oh, so-and-so just wrote a book, but she doesn't know because she hasn't experienced such and such or whatnot. And I'm definitely a provider who has gone through my own health challenges, unfortunately. But fortunately I've used them to my advantage to write this book. So I personally, I've struggled with a lot of things. The most challenging really was fast heart rate or a tachnocardic episodes, which, landed me at Mayo Clinic actually, well, firstly to be in the emergency room, but I eventually landed me at Mayo and conventional medicine's approach to my issue was to take a medication to control my heart rate. And although that could have worked and could have helped, I thought I need to figure out what's happening to me. Stephanie Gray: 27:25 I needed to figure out why my body's gonna ride, right, why my heart is racing like this. And so around the same time, my husband is actually our office manager at our clinic. We have integrated health clinic in Iowa and he said, you know, you should really use this to try to streamline the process as far as what we recommend to our patients. Can you outline all of what we offer? Because sometimes patients would come see a functional medicine practitioner who only offered gut health or only offered hormone health or detoxing or whatnot. And we really offered the whole Shebang. And so he said, why don't we try to create some sort of analogy to outline all of what we can offer patients really to provide them hope. And so I created this blueprint outlining a functional medicine and all the different principles of what we can offer patients with every organ system of the body. Stephanie Gray: 28:14 And then I kind of laced through my personal story as well as far as what I had to utilize to regain back my health. And so what I'm doing with the book is I'm trying to at least create this analogy between how we maintain our homes and the compare that to our body, right? So with our home, we have, well I have hair in my drain, right? I don't want hair clogging my drain. You probably mow your lawn. If you have a lawn, you probably change the furnace filters on your home right there. Just things you'd have, you know, you have to do to maintain your home. But we don't always know how to maintain our body. We don't know how to rebuild our body if we're sick or build that health period. And so I'm taking a room in each of our homes, right? Stephanie Gray: 28:55 And I'm comparing that to an organ system in the body. So chapter one is all about gut health because I believe that gut is the most important piece of our health, most important organ system that we have. And I'm comparing that to the foundation of the home. You have to have the strong foundation upon which to build good health. So then I go chapter by chapter. I'm comparing, you know, organ system. So we were talking a lot about chapter four today and chapter six, chapter six I'm comparing the heating and cooling in your home, right? And you don't want to be too cold, you want to be too hot, you have to have a good thermostat there. But I'm comparing that to the endocrine system in the body. And so I try to help patients rebuild their body, rebuild every organ system using functional medicine principles. So I talk about the tests that are important. I talk about the nutrients that are important and offer patients resources as well. Karen Litzy: 29:42 That's awesome and that's really great for patients. And just so everyone knows, we'll have a link to the book in the show notes over at podcast.healthywealthysmart.com. So if you're interested and you can go over, click a link and it'll take you right to Stephanie's books, you can read more about it and see if it's for you. And now, Stephanie, I ask everyone this question at the end of the podcast and that is knowing where you are now in your life and in your business, what advice would you give to yourself and in your case, since you have a plethora of degrees, let's say right after your bachelor degree, after you graduated with that bachelor's in nursing. Stephanie Gray: 30:26 Okay, so that's tough. I think what part of what I've learned through my health situation, I had to change my diet and nutrition and what not, but I also had to reduce stress big time. And so I think one I really recommend to all, well everyone but including the youth, I wish I would have as happy I as I am to be where I am and to have the knowledge I have so that I can ultimately help others. My health suffered along the way and so I could have, you know, done this over a longer period of time and instead of jamming it into fewer years, I think the advice to myself would be to physically set time in my calendar to deep breathe. Deep breathing has been extremely important to me to calm my nervous system. I'm obviously a fast talker and I needed to set aside time for my body to just mend and relax, rest and digest. So I think that's what my advice would be to take time for myself. As hard as it would've been, it probably would've been very difficult for me to do yoga. I probably couldn't have sat still, but I needed it. Yeah. That's probably the advice to just slow down, breathe slowly, take time. Karen Litzy: 31:39 Yeah. And that's great advice and it's advice that I give to a good majority of my patients as well. And so now is there anything else, I know that you had mentioned that you have an offer for listeners. Do you want to share that now? Stephanie Gray: 31:54 Sure. So if you're hearing about functional medicine for the first time today, I'd highly recommend you check out my book just because I think that it could provide you hope or hope for a loved one. I think many patients are just so dissatisfied, they keep going to the doctor, they keep being told that everything's normal and they know they don't feel normal and they know there are answers out there and there's a good potential that a functional medicine provider could help you. So I would definitely recommend grab a copy of my book, which is loaded with resources but also look for a functional medicine practitioner in your area. So the code on our website that can be used to purchase the book, although it's available at Barnes and noble and Amazon and everywhere books are sold is yourlongevityblueprint.com. So if you use the code healthy10, you can get 10% off order on the book or any of the supplements like vitamin K2 or anything you feel like you need. But after, you know, when you think of a home being built, there's always a contractor overseeing that process. And, that's what the last chapter of my book is about. Finding your contractor to help you personally as a community build your health. The book can help, but you do need a guide. You need a contractor. Karen Litzy: 33:01 Well thank you so much. This was great. I love learning different ways to kind of keep myself healthy and as I get older and I start, I mean I think I have a little while left, but kind of entering the phase of my life where a lot of this stuff is going to be very pertinent to me. So I thank you for sharing it all. Stephanie Gray: 33:25 Well, thank you for having me on. I hope this helps many of your viewers Karen Litzy: 33:28 And I think it will. Thank you so much Stephanie and everyone out there listening. Thanks so much. Have a great couple of days and stay healthy, wealthy, and smart. Thanks for listening and subscribing to the podcast! Make sure to connect with me on twitter, instagram and facebook to stay updated on all of the latest! Show your support for the show by leaving a rating and review on iTunes!